Bologna XIX Symposium Neuroradiologicum
Bologna XIX Symposium Neuroradiologicum
Follow Up of Coiled Intracranial Aneurysms:
MRA vs. DSA
XIX Symposium NeuroradiologicumBologna
Dr. Stefan Celedin
Klagenfurt / Austria
Bologna XIX Symposium Neuroradiologicum
How to Check if the Mine is Still Defused
Bologna XIX Symposium Neuroradiologicum
Follow Up in Austria
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Bologna XIX Symposium Neuroradiologicum
DSA vs. MRA
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Bologna XIX Symposium Neuroradiologicum
DSA vs. MRA
Flat – Panel – DetectorMatrix
5 Standard Projections
3D – Rotational - Angio
2 Standard Projections
Matrix / TECoil-Type / Stent
3 Tesla
1,5 Tesla
K-Space
2D Time of Flight
+/- contrast
Ce-MRAFirst Pass
Steady State with Blood Pool
3D Time of Flight
+/- contrast
MOTSAMultiple Overlapping Thin Slab Acquisition
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Bologna XIX Symposium Neuroradiologicum
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Bologna XIX Symposium Neuroradiologicum
Smaller Methodologically Heterogeneous
Single-Center-Studies➔Buhk et al: No Advantage of time-of-flight magnetic resonance angiography at 3 Tesla coompared to 1,5 Tesla in follow-up after endovascular treatment of cerebral aneurysms: Neuroradiology 2008;50(10):855-861➔Deutschmann et al: Diagnostic accuracy of 3D time-of-flight MR angiography compared with digital subtraction angiography for follow-up of coiled intracranial aneurysms: influence of aneurysm size. AJNR 2007;28(4):628-634➔Ferré et al: Time-of-Flight MR angiography at 3T versus digital subraction angiography in the imaging follow-up of 51 intracranial aneurysms treated with coils. EurJRadiol 2009;72(3):365-369➔Gauvrit et al: Intracranial Aneurysms treated with Guglielmi detachable coils: long-term imaging follow up with contrast enhanced magnetic resonsnce angiography. J Neurosurg 2008;108(3):443-449➔Kwee et al: MR angiography in the follow up of intracraniel aneurysms treated with gulielmi detachable coils: systematic review and meta-analysis. Neuroradiology 2007;49(9):703-713➔Urbach et al: Three-dimensional time-of-flight MR angiography at 3T compared to digital substraction angiography in the follow-up of ruptured and coiled intracraniel aneurysms: a prospective study. Neuroradiology 2008;50(5)383-389➔Wong et al: Assessment of brain aneurysms by using high-resolution magnetic resonsnce angiography after endovascular coil delivery. J Neurosurg 2007;107(2):283-289
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Bologna XIX Symposium Neuroradiologicum
Meta – Analysis I
Kwee T: MR angiography in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils: systematic review and meta-analysis. Neuroradiology. 2007;49(9):703-13
Included 16 Studies
Detection of Residual Flow TOF:
Sensitivity: 83,3% (95% CI 70.3 – 91,3%)
Specificity: 90,6% (95% CI 80.4 – 95.8%)
Detection of Residual Flow ceMRA:
Sensitivity: 86,8% (95% CI 71,4 – 94,5%)
Specificity: 91,9% (95% CI 79.8 - 97.0%)
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Bologna XIX Symposium Neuroradiologicum
Conclusion Kwee:
Both TOF-MRA and ce-MRA achieve a moderate to high diagnostic performance.
Studies of moderate methodological quality
Pooled estimates subject to heterogeneity.
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Bologna XIX Symposium Neuroradiologicum
Meta – Analysis II
Weng HH: Meta-analysis on diagnostic accuracy of MR Angiography in follow-up of residual intracranial aneurysms treated with Gulielmi detachable coils. Interv Neuroradiol. 2008;14 Suppl2:53-63
Included 16 Studies
Detection of Residual Flow TOF:
Sensitivity: 90% (95% CI 79 – 95%)
Specificity: 95% (95% CI 88 – 98%)
Detection of Residual Flow ceMRA:
Sensitivity: 92% (95% CI 79 – 97%)
Specificity: 96 (95% CI 91 - 98%)
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Bologna XIX Symposium Neuroradiologicum
Conclusion Weng:
The diagnostic accuracy of TOF-MRA and ce-MRA tests offer comparable and equal results and may obviate the invasive DS
angiography
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Bologna XIX Symposium Neuroradiologicum
Intracranial Aneurysms Treated with Coil Placement:
Test Characteristics of Follow-up MR Angiography-Multicenter Study
Schaafsma Joanna et al
Radiology July 2010
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Bologna XIX Symposium Neuroradiologicum
M & M
4 University Hospitals
311 pat, 343 aneurysms
DSA: 3 Projections (AP, LV, OPT)
MRA: 3D-TOF, ceMRA (1st pass)
2 Neuroradiologists (1 Intervent.)
Occlusion Class I-III (Roy)
Occlusion Class: I&II vs. III
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MM
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MM
Complete Subtotal Incomplete
Bologna XIX Symposium Neuroradiologicum
Image Evaluation:
MRA:
1 Aneur. (platinum-iridium coils) excluded
2 Aneur. not interpretable in TOF (thombus/orientation) → ceMRA only
6 Aneur. not interpretable in ceMRA (orientation/timing/contras t)→ TOF only
DSA:
3 Aneur. not interpretable → excluded
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MM
image
Bologna XIX Symposium Neuroradiologicum
Image Evaluation:
Incomplete Occlusion:DSA: 25% patients (76; 95%CI 20-29%)
23% examinations (88; 95%CI 19-27%)
Interobserver Agreement:
DSA: κ 0,62 (95%CI 0,56-0,69)
MRA: κ 0,64 (95%CI 0,57-0,70)
INR: κ 0,61 (95%CI 0,54-0,68)
INR/NINR: κ 0,65 (95%CI 0,60-0,71)
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MM
image
Bologna XIX Symposium Neuroradiologicum
Discrepancies
16 (88) incomplete Occlusion (III°) in DSA:
1 total Occlusion in MRA (coil artifacts)
15 subtotal (II°) Occlusions in MR
32 incomplete Occlusions in MRA:
20 subtotal in DSA
12 totally occluded in DSA
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image
discrep.
Bologna XIX Symposium Neuroradiologicum
Discrepancies
Accuracy: 0,89
Accuracy for 1,5T and 3T were comparable.
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MM
image
discrep.
Bologna XIX Symposium Neuroradiologicum
ceMRA
Change of Classification in 6% (n=21)
9 Change = DSA
1 overstimated Degree of Occlusion
11 underestimated Degree of Occlusion
Accuracy: TOF (0,86) and ceMRA (0,85) similar
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MM
image
Discrep.
ceMRA
Bologna XIX Symposium Neuroradiologicum
Coil Artifacts
Platinum-Iridium coils with nitinol Core Excluded.
Artifacts impeded interpretation in 29 Aneurysms (8%)
22 @ TOF
1 @ ceMRA
6 @ both
1 MRA I°, DSA III°
8 MRA II°, DSA I°
20 MRA = DSA
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MM
image
Discrep.
CeMRA
coils
Bologna XIX Symposium Neuroradiologicum
Associated with Discrepancy
Small Residual LumenSuboptimal projection in DSA
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MM
image
Discrep.
CeMRA
coils
Bologna XIX Symposium Neuroradiologicum
Discussion
TOF & ceMRA @ 1,5 and 3,0T high NPV for Aneurysm Recurrence.
MRA showed all III° Occlusions that required treatment.
No additional value of ceMRA over TOF
Is Incomplete Occlusion in MRA but not in DSA false poitive?
Imperfect reference test?
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MM
image
Discrep.
CeMRA
Coild
discuss
Bologna XIX Symposium Neuroradiologicum
Discussion
Results favor the use of MRA at 1,5T or 3,0T instead of DSA.
When MRA shows I or II° occlusion, DSA is likely not required.
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MM
image
Discrep.
CeMRA
Coild
discuss
Bologna XIX Symposium Neuroradiologicum
Conclusion Schaafsma et al
The diagnostic performance of
MR angiography in patients treated with coil placement is
likely to be sufficient for it
to replace routine follow-up intraarterial digital subtraction angiography,
even though evaluation of
costs and health benefitsfor both modalities is still needed.
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MM
image
Discrep.
CeMRA
Coild
Discuss
conclude
Bologna XIX Symposium Neuroradiologicum
The End
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MM
image
Discrep.
CeMRA
Coild
Discuss
ConcludeEND