"Real-world" comparison of non-invasive imaging to conventional catheter angiography in the diagnosis of cerebral aneurysms

Abstract

Background:Based on numerous reports citing high sensitivity and specificity of non-invasive imaging [e.g. computed tomography angiography (CTA) or magnetic resonance angiography (MRA)] in the detection of intracranial aneurysms, it has become increasingly difficult to justify the role of conventional angiography [digital subtraction angiography (DSA)] for diagnostic purposes. The current literature, however, largely fails to demonstrate the practical application of these technologies within the context of a “real-world” neurosurgical practice. We sought to determine the proportion of patients for whom the additional information gleaned from 3D rotational DSA (3DRA) led to a change in treatment.Methods:We analyzed the medical records of the last 361 consecutive patients referred to a neurosurgeon at our institution for evaluation of “possible intracranial aneurysm” or subarachnoid hemorrhage (SAH). Only those who underwent non-invasive vascular imaging within 3 months prior to DSA were included in the study. For asymptomatic patients without a history of SAH, aneurysms less than 5 mm were followed conservatively. Treatment was advocated for patients with unruptured, non-cavernous aneurysms measuring 5 mm or larger and for any non-cavernous aneurysm in the setting of acute SAH.Results:For those who underwent CTA or MRA, the treatment plan was changed in 17/90 (18.9%) and 22/73 (30.1%), respectively, based on subsequent information gleaned from DSA. Several reasons exist for the change in the treatment plan, including size and location discrepancies (e.g. cavernous versus supraclinoid), or detection of a benign vascular variant rather than a true aneurysm.Conclusions:In a “real-world” analysis of intracranial aneurysms, DSA continues to play an important role in determining the optimal management strategy.

Detection of unruptured intracranial aneurysms on noninvasive imaging. Is there still a role for digital subtraction angiography?

“…The sensitivity and specificity of noninvasive CTA/MRA imaging in the detection of UIA have been previously described in the literature. [ 3 5 8 10 11 12 13 14 17 18 19 ] This data is variable and sometimes even contradictory as a result of varied quality of noninvasive imaging. An earlier meta-analysis reported that the accuracy of CTA/MRA is about 90%.…”

“…The differences in the detection of UIA by DSA as compared to MRA and CTA have been previously documented by studies that focused primarily on the overall accuracy and reliability of detection, rather than on FP findings in current practice. [ 11 13 14 ] Since the follow-up of patients with untreated UIA involves serial imaging, eliminating FPs diagnosed noninvasively is essential. In this retrospective study, we aimed to determine if there is still a diagnostic role for DSA in patients referred with UIA detected by noninvasive imaging in the current era.…”

Azygos anterior cerebral artery shield masquerading as an aneurysm

“…MR angiography (MRA) has several advantages over CTA including the lack of radiation exposure and a high sensitivity up to 93% even for the aneurysms less than 3 mm. 10 Some limitations of MRA include the longer acquisition time and greater likelihood of motion and other artifacts. 8 The high sensitivity and absence of radiation make MRA a preferred imaging study for the outpatient evaluation of cerebral aneurysms at many centers.…”