Bologna XIX Symposium Neuroradiologicum

Bologna XIX Symposium Neuroradiologicum


Follow Up of Coiled Intracranial Aneurysms:

MRA vs. DSA

XIX Symposium NeuroradiologicumBologna

Dr. Stefan CeledinKlagenfurt / Austria


How to Check if the Mine is Still Defused


Follow Up in Austria

F/U in Austria


DSA vs. MRA

F/U in AustriaGold Standard


DSA vs. MRA

Flat – Panel – DetectorMatrix

5 Standard Projections3D – Rotational - Angio

2 Standard Projections

Matrix / TECoil-Type / Stent

3 Tesla1,5 Tesla

K-Space

2D Time of Flight+/- contrast

Ce-MRAFirst PassSteady State with Blood Pool

3D Time of Flight+/- contrast

MOTSAMultiple Overlapping Thin Slab Acquisition

F/U in AustriaGold StandardLiterature




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



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 StudiesDetection 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%)

F/U in AustriaGold StandardLiteraturMeta-Analysis


Conclusion Kwee:

Both TOF-MRA and ce-MRA achieve a moderate to high diagnostic performance.

Studies of moderate methodological qualityPooled estimates subject to heterogeneity.

F/U in AustriaGold StandardLiteratureMeta-Analysis


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 StudiesDetection 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%)



Conclusion Weng:

The diagnostic accuracy of TOF-MRA and ce-MRA tests offer comparable and equal results and may obviate the invasive DS

angiography



Intracranial Aneurysms Treated with Coil Placement:

Test Characteristics of Follow-up MR Angiography-Multicenter Study

Schaafsma Joanna et al

Radiology July 2010

F/U in AustriaGold StandardLiteratureMeta-AnalysisSchaafsma


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


MM


MM

Complete Subtotal Incomplete


Image Evaluation:

MRA:1 Aneur. (platinum-iridium coils) excluded2 Aneur. not interpretable in TOF (thombus/orientation) → ceMRA only6 Aneur. not interpretable in ceMRA (orientation/timing/contras t)→ TOF only

DSA:3 Aneur. not interpretable → excluded


MM

image


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)


MM

image


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 DSA12 totally occluded in DSA


MM

image

discrep.


Discrepancies

Accuracy: 0,89Accuracy for 1,5T and 3T were comparable.


MM

image

discrep.


ceMRA

Change of Classification in 6% (n=21)

9 Change = DSA1 overstimated Degree of Occlusion11 underestimated Degree of Occlusion

Accuracy: TOF (0,86) and ceMRA (0,85) similar


MM

image

Discrep.

ceMRA


Coil Artifacts

Platinum-Iridium coils with nitinol Core Excluded.

Artifacts impeded interpretation in 29 Aneurysms (8%)22 @ TOF1 @ ceMRA6 @ both

1 MRA I°, DSA III° 8 MRA II°, DSA I°20 MRA = DSA


MM

image

Discrep.

CeMRA

coils


Associated with Discrepancy

Small Residual LumenSuboptimal projection in DSA


MM

image

Discrep.

CeMRA

coils


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?


MM

image

Discrep.

CeMRA

Coild

discuss


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.


MM

image

Discrep.

CeMRA

Coild

discuss


Conclusion Schaafsma et al

The diagnostic performance ofMR angiography

in patients treated with coil placement islikely to be sufficient

for itto replace routine follow-up intraarterial digital

subtraction angiography,even though evaluation of

costs and health benefitsfor both modalities is still needed.


MM

image

Discrep.

CeMRA

Coild

Discuss

conclude


The End


MM

image

Discrep.

CeMRA

Coild

Discuss

ConcludeEND

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Bologna XIX Symposium Neuroradiologicum