4D Digital Subtraction Angiography for the Temporal Flow Visualization of Intracranial Aneurysms and Vascular Malformations

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105327Get rights and content

Abstract

Purpose

To assess the benefit and radiation dose of four-dimensional (4D) digital subtraction angiography (DSA) - a time resolved three-dimensional (3D) DSA application - to evaluate the flow and architecture of aneurysms and vascular malformations.

Methods

All patients with cerebrovascular disease were considered who underwent 4D-DSA at our institution between January 2015 and February 2016. For the aneurysm patients, we evaluated the image quality in terms of the visualization of contrast flow in the aneurysm on a 3-point scale (excellent, fair and poor). Interrater agreement between two raters was estimated using Cohen's Kappa statistics. For the shunt disease patients, the additional information obtained from the 4D-DSA was described for each disease. The median radiation dose and volume of contrast medium required for the acquisitions were estimated.

Results

A total of 173 patients underwent 4D-DSA; 126 intracranial aneurysms, 10 arteriovenous malformations (AVM), 15 dural arteriovenous fistula (dAVF) and 22 other diseases. For aneurysm patients, excellent and fair visualization of the intra-aneurysmal flow was observed in 27.7%, 72.3%, and excellent (κ = 0.9) agreement between the raters was found. For AVM and dAVF patients, 4D-DSA clarified the complex vasculature by viewing the discrete time phase of contrast filling. Median radiation dose for intracranial lesions was 79.6 mGy for 6s 4D-DSA, and 175 mGy for 12s 4D-DSA. The median amount of contrast medium used was 18.0 ml for 6s 4D-DSA and 21.0 ml for 12s 4D-DSA.

Conclusions

4D-DSA provided additional information regarding intra-aneurysmal flow and contributed to detect different component of nidus or shunt points.

Introduction

Four-dimensional digital subtraction angiography (4D-DSA) is a recently developed application that allows for the reconstruction of a modified three (3D) DSA acquisition into a series of fully time-resolved 3D-DSA volumes at frame rates of up to 30/s. It has been reported that 4D-DSA provides higher temporal and spatial resolution than currently available MR angiography or CT angiography.1,2 Recent studies have indicated that 4D-DSA facilitated the evaluation of complex vascular lesions such as arteriovenous malformations (AVM) or dural arteriovenous fistulas (dAVFs).3, 4, 5, 6, 7 However, little is known about the potential efficacy of this new imaging technology for other neurovascular diseases, e.g. intracranial aneurysms, spinal vascular diseases and acute ischemic stroke. For instance, whether 4D-DSA can detect the intra-aneurysmal flow patterns (e.g. inflow / outflow) or not remains unknown.

The purpose of this study was to review the 4D-DSA images for different types of neuro vascular diseases and to evaluate the benefits of this novel imaging technology in the clinical settings. The radiation dose and contrast medium dose required for the acquisition were also evaluated.

Section snippets

Patient population

The study was approved by the institutional review board (IRB) of our hospital (27-236(8121)). Between January 2015 and February 2016, patients that were diagnosed with any type of cerebrovascular disease and underwent 4D-DSA were included in this study. Informed consents for procedures were obtained from all patients. The IRB waived specific informed consent for this study, because the data were obtained from routine procedures and analyzed retrospectively. However, the IRB requested that we

Patient demographics

For all 173 patients (66 male and 107 female), 4D-DSA was successfully performed. The median age was 62 (range 14–84 years). 126 patients were diagnosed with intracranial aneurysms, 10 with AVMs and 15 with dAVFs. The others 22 patients presented with 6 ischemic strokes, 6 spinal vascular malformations, 7 stenosis of intracranial arteries, 2 intracerebral hemorrhages and 1 tumor. 6s 4D-DSA was performed on 138 patients (120 with aneurysms, 4 with AVMs/dAVFs, and 14 with others). 12s 4D-DSA was

Additional information obtained from the time resolved 3D-DSA

The clinical applications of 4D-DSA have been reported mainly for the evaluation of intracranial AVMs.3,4,6,7 Our initial experience of 4D-DSA indicated that the clinical application of this new imaging technology can be further expanded to the evaluation of intracranial aneurysms. Additional information provided by the time resolved 3D-DSA includes the visually appreciated speed and direction of the blood flow in the target vessel. For instance, 27.7% of the aneurysm cases examined in this

Conclusions

4D-DSA helps understanding the complex vascular structures and flow dynamics in different types of neurovascular diseases.

Declaration of Interest

This study was partially supported by a research grant (ID C00221023) from Siemens Healthcare K.K. C.D. and K.O. are employees of Sie mens Healthcare K.K. The other authors report no conflicts of interest.

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Research Institute: Department of Neurosurgery, The Jikei University School of Medicine Tokyo.

Grant Support: This study was partially supported by a research grant (ID C00221023) from Siemens Healthcare K.K.

1

These authors contributed equally to this work.

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