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Comparison of Aortic Arch and Intravenous Contrast Injection Techniques for C-arm Cone Beam CT

Posted Mar 31, 2013 Updated Apr 10, 2023
By Jesse M. Klostranec MD PhD , Tina Ehtiati PhD , Swati Rao BSc , Martin G. Radvany MD
10 min read

Rationale and Objectives

The ability to perform cerebral perfusion imaging (CPI) in the angiography suite has provided a new tool for diagnosis and treatment of neurovascular patients but requires comparable contrast perfusion to each cerebral hemisphere. In the angiography suite, contrast injection may be performed via an intra-arterial or intravenous (IV) route. The purpose of this study was to investigate whether a difference exists between contrast injection in the aortic arch (AA) and a peripheral vein (IV), particularly in the setting of stroke.

Materials and Methods

Using three canines, both AA and IV injection protocols compatible with CPI were performed prospectively at three time points after creation of a stroke. The common carotid arteries in the resulting image data sets were segmented and the means and distributions of corresponding pixel intensities analyzed with Student’s t -test. Using similar techniques, the internal carotid arteries of three patients (one female, two males, ages 69, 29, and 20) undergoing AA contrast injection with cone beam computed tomography (CBCT) cerebral imaging were analyzed and compared retrospectively with those of three random patients (one female, two males, ages 19, 57, and 35) undergoing standard head CT scans using IV contrast administration. All acquisitions followed institutionally approved protocols and informed consent.

Results

No statistical significance ( P < .05) was found when mean values for the right and left carotid artery pixel intensities were compared in the canine model or the clinical studies in which patients underwent imaging after AA or IV contrast administration.

Conclusions

No statistically significant difference exists between right and left carotid artery filling density using either AA or IV contrast injection methods, making both suitable for CPI in the angiography suite.

Conventional digital subtraction angiography (DSA) highlights abnormalities in vascular anatomy that may be pathologic, whereas advances in technology and medical knowledge have led to the development of imaging techniques that yield clinically useful physiologic information . Examples of the latter include positron emission tomography, functional magnetic resonance imaging (fMRI), and perfusion computed tomography (CT). In cerebral perfusion imaging (CPI), measurements of cerebral blood volume (CBV), mean transit time (MTT), and cerebral blood flow (CBF) make up parameters used to describe the physiologic tissue perfusion of the brain. Such information is very helpful in assessing patients suffering acute stroke, vasospasm, and intracranial tumors . In fact, perfusion CT and perfusion MRI techniques are being considered as tools to extend the window for thrombolysis in acute stroke .

There exist several endovascular treatment options for acute stroke in the angiography suite, including intra-arterial (IA) thrombolysis and mechanical embolectomy . With these treatment methods available in the angiography suite and the strong inverse correlation between time to treatment and good outcomes, clearly it would be advantageous to have the multimodal imaging capabilities for stroke work up in the same room where therapy can take place. With the advent of Food and Drug Administration–approved C-arm-mounted flat-panel detectors in angiography suites (Artis zee biplane, Siemens Healthcare, Germany), the ability to acquire three-dimensional cone beam computed tomography (CBCT) images in addition to traditional angiographic images from standard C-arm systems inside the angiography suite is now being incorporated into routine angiography protocols . These systems are capable of producing CBV maps in ischemic stroke models comparable to conventional perfusion CT and, with some alterations to image acquisition protocols, are even able to provide comparable temporal MTT and CBF information .

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Materials and methods

Canine Model

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Canine CBCT Image Acquisition

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Figure 1, Schematics for contrast injection and data acquisition protocols. Important time points are shown on plots of contrast concentration (arbitrary units for cone beam computed tomography) in the superior sagittal sinus versus time using ascending aorta intra-arterial (a) and antecubital fossa intravenous (b) contrast injection sites. Also highlighted are the periods of acquisition of the mask and fill runs routinely used to produce digital subtraction images.

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Human CBCT Image Acquisition

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Human Standard Head CT with Contrast

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Image Analysis

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Figure 2, Examples of common carotid artery segmentation of canine images. Shown are images from the mask run (a,d) , fill run (b,e) , and fill run with red outlines of the segmentation areas (c,f) for canine 1 at the 1 hour after infarction time point. The top row images use an ascending aorta intra-arterial contrast injection (a–c) ; the bottom row use an antecubital fossa intravenous injection site (d–f) .

Table 1

Segmented Mean Data, Percentage Differences, and P Values for Three Canine Stroke Models at Different Time Points after Infarction

Mean(SD−standarddeviation)[n−numberofpixels/animals] Mean

(

SD

−

standard

deviation

)

[

n

−

number

of

pixels

/

animals

] Time after infarction 1 hour 2 hours 3 hours Contrast route AA IV AA IV AA IV Canine 1 RCC 431 (28.8) [851] 101 (28.9) [825] 344 (36.0) [892] 328 (51.8) [789] 407 (36.9) [899] 399 (41.5) [899] LCC 449 (37.2) [851] 123 (21.8) [785] 355 (33.6) [756] 337 (42.4) [893] 437 (33.6) [957] 438 (34.8) [899] % difference 4.17 20.0 3.15 2.85 7.17 9.34 Canine 2 RCC 620 (55.0) [740] 316 (49.4) [777] 522 (44.9) [740] 389 (33.8) [740] 726 (52.6) [777] 463 (36.2) [740] LCC 533 (53.5) [740] 335 (36.8) [777] 509 (34.0) [740] 430 (29.0) [740] 669 (44.4) [777] 519 (35.7) [740] % difference 15.0 6.03 2.5 10.1 8.17 11.3 Canine 3 RCC 495 (59.3) [724] 212 (57.7) [491] 538 (34.6) [315] 475 (90.8) [402] 487 (28.1) [348] 464 (48.1) [340] LCC 508 (38.3) [820] 315 (74.7) [693] 563 (24.5) [378] 512 (76.8) [527] 528 (26.0) [464] 501 (54.4) [525] % difference 2.65 39.0 4.45 7.40 7.89 7.63 Average RCC 511 (96.1) [3] 207 (108) [3] 443 (108) [3] 382 (74.0) [3] 554 (166) [3] 434 (37.4) [3] LCC 495 (43.1) [3] 255 (117) [3] 458 (108) [3] 412 (87.2) [3] 538 (117) [3] 481 (42.5) [3]P value .78 .63 .93 .68 .97 .25

AA, aortic arch; IV, intravenous; LCC, left common carotid artery; RCC, right common carotid artery.

Table 2

Segmented Mean Data for Patients Imaged Using C-arm CBCT and Standard Head CT with Contrast

Mean(SD−standarddeviation)[n−numberofpixels/animals] Mean

(

SD

−

standard

deviation

)

[

n

−

number

of

pixels

/

animals

] C-arm CBCT Standard Head CT with Contrast (AA Injection) (IV Injection) Patient 1 RIC 1120 (61.1) [1947] 1200 (19.4) [513] LIC 1130 (63.4) [1966] 1180 (19.0) [537] % difference 13.5 9.33 Patient 2 RIC 1180 (74.4) [1457] 1180 (14.0) [430] LIC 1190 (89.6) [1209] 1190 (12.0) [578] % difference 7.20 4.49 Patient 3 RIC 1100 (70.5) [1335] 1190 (18.9) [671] LIC 1200 (59.3) [1527] 1190 (18.2) [671] % difference 8.03 2.33 Average RIC 1133 (42.0) [3] 1190 (10.0) [3] LIC 1176 (38.8) [3] 1186 (3.5) [3]P value .29 .65

AA, aortic arch; IV, intravenous; LIC, left internal carotid artery; RIC, right internal carotid artery.

Figure 3, Sample histogram (a) and mean pixel intensity results (b) for the canine experiments. Canine images were segmented with respect to the right common carotid (RCC) and left common carotid (LCC) arteries. Histograms were then produced from the image segmentations of the aortic arch (AA) and intravenous (IV) contrast injection acquisitions with the results for canine 2 3 hours after infarction shown in (a) . (b) Results from when the trials of all three animals are averaged for the different time points after infarction. The mean pixel values are given for each injection method at each time point with the error bars representing the 95% confidence interval of the mean ( n = 3). AU, arbitrary units.

Figure 4, Comparison of right internal carotid (RIC) and left internal carotid (LIC) artery contrast filling in human patients via aortic arch (AA) and intravenous (IV) contrast injection sites. A sample cone beam computed tomography (CT) image with AA injection is given in (a) with the regions of interest (ROIs) used for segmentation outlined in red in (b) . The resulting histograms from the segmentation comparing RIC and LIC contrast filling densities for three patients are shown in (c–e) . Similarly, a sample standard head CT with contrast image taken following intravenous contrast administration is given in (f) with the ROIs used outlined in red in (g) . Histograms comparing RIC and LIC contrast filling densities for these three patients are shown (h–j) . The mean pixel intensities for the RIC and LIC after averaging the means from each set of three patients are demonstrated in (k) with the error bars representing the 95% confidence level of the true mean ( n = 3). AU, arbitrary units.

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Results

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Discussion

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Conclusion

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Acknowledgments

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Appendix A

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Academic Radiology, Volume 20, Issue 4
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