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Usefulness of 3D DSA-MR Fusion Imaging in the Pretreatment Evaluation of Brain Arteriovenous Malformations

Posted Oct 31, 2012 Updated Apr 10, 2023
By Satoru Ide MD , Toshinori Hirai MD , Motohiro Morioka MD , Yutaka Kai MD , Shigetoshi Yano MD , Takayuki Kawano MD , Shuichi Tochihara RT , Yoshinori Shigematsu MD , Hiroyuki Uetani MD , Yu Murakami MD , Keita Watanabe MD , Yasuyuki Yamashita MD
10 min read

Rationale and Objectives

For the evaluation of patients scheduled for the treatment of brain arteriovenous malformations (AVMs), accurate anatomical information is essential. The purpose of this study was to assess the usefulness of three-dimensional (3D) digital subtraction angiography (DSA)-magnetic resonance (MR) fusion imaging for the pretreatment evaluation of AVMs.

Materials and Methods

The study population consisted of 11 consecutive patients (7 males, 4 females; age 10–72 years; mean 45 years) with brain AVMs. All prospectively underwent pretreatment MR imaging (MRI), MR angiography (MRA), and two-dimensional (2D) and 3D DSA. The 3D DSA and MR images were semiautomatically fused with fusion software on a workstation. In the delineation of AVM nidus, feeder, drainer, and relationship between AVM and the adjacent brain structures, two radiologists independently evaluated MRA and MRI, three-dimensional (3D) DSA, and MRI, and 3D DSA-MR fusion images using a 4-point scoring system. The referring neurosurgeons were asked whether the information provided by 3D DSA-MR fusion images was helpful for treatment decisions.

Results

For all four items, the delineation was significantly better with the 3D DSA/MRI or 3D DSA-MR fusion images than the MRA/MRI images. Although the delineation for the nidus, feeder, and drainer were not significantly different between the 3D DSA/MRI and 3D DSA-MR fusion images, 3D DSA-MR fusion imaging were significantly better for the relationship between AVM and the adjacent brain structures than 3D DSA/MR imaging ( P = .0047). The information provided by 3D DSA-MR fusion images was helpful for treatment decisions in all cases.

Conclusion

3D DSA-MR fusion images are useful for the pretreatment evaluation of brain AVMs.

At the pretreatment assessment of brain arteriovenous malformations (AVMs), the precise relationship between the nidus, feeders, and drainers and the adjacent hematoma and/or brain structures must be recognized. Intra-arterial two-dimensional (2D) digital subtraction angiography (DSA) is the standard reference procedure for the diagnosis and follow-up of brain AVMs because of its high temporal and spatial resolution . However, it does not provide three-dimensional (3D) information on the vasculature and adjacent brain tissues. On conventional magnetic resonance imaging (MRI) and MR angiography (MRA), including source and multiplanar reconstruction images, the intracranial vasculature and brain tissues are visualized; therefore, these techniques are valuable for the pretreatment and follow-up evaluation of brain AVMs .

Image fusion techniques consisting of the registration of different kinds of images are widely used for diagnostic purposes and pretreatment planning . The fusion of 3D DSA and MR images yields useful information on the vasculature (eg, perforating arteries, aneurysms) and brain tissues . Although it is expected to be useful for the evaluation of brain AVMs, the report regarding the utility of 3D DSA-MR fusion imaging in patients with brain AVMs is limited . The usefulness of this technique for the pretreatment evaluation of brain AVMs has not been systematically investigated. The purpose of this study was to systematically assess the usefulness of 3D DSA-MR fusion imaging in conjunction with 2D DSA for the pretreatment evaluation of brain AVMs.

Materials and methods

Subjects

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Table 1

Summary of Patients and Lesion Characteristics

Case No. Age/Gender Maximum Diameter of Nidus (cm) Nidus Site Depth of AVM Nidus (Spetzler-Martin Scores) Feeders Drainers 1 10/male 0.5 PO Deep (1) P SCVs 2 39/male 1.0 Frontal Deep (1) M SCVs 3 19/female 1.6 Temporal Deep (2) P Tent, T 4 61/female 2.3 Temporal Deep (2) ACh Gal, TS 5 69/male 2.4 Frontal Superficial (2) A SCVs, BV 6 ∗,† 53/male 2.5 FP S& D (2) A, M, P SCVs 7 35/female 2.7 BG Deep (2) MS, ACh BV 8 † 70/male 2.8 FP Deep (3) A, P SCVs, StS 9 † 72/female 3.0 Frontal Superficial (4) M SCVs, BV 10 11/male 3.5 PO S& D (2) A, M, P SCVs 11 † 58/male 5.0 FP S& D (3) A, M, P SCVs

A, anterior cerebral artery; ACh, anterior choroidal artery; AVM, brain arteriovenous malformation; BG, basal ganglia; BV, basal vein; F, female; FP, frontoparietal; Gal, the vein of Galen; ICV, internal cerebral vein; M, middle cerebral artery; MS, medial striate artery; P, posterior cerebral artery; PO, parieto-occipital; SCVs, superficial cerebral veins; StS, straight sinus; T, transverse sinus; Tent, tentorial sinus; TS, transverse-sigmoid sinus.

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2D and 3D DSA

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MR Imaging and MR Angiography

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3D DSA-MR Fusion

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Figure 1, Fused three-dimensional (3D) digital subtraction angiography (DSA) and magnetic resonance (MR) image displayed on a monitor. Based on the overlap of the carotid bifurcation on the 3D DSA and MR images, under the guidance of one experienced neuroradiologist, one experienced technologist semiautomatically fused the images using commercially available image fusion software on a workstation.

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Image Analysis

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Statistical Analyses

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Results

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Table 2

AVM Delineation at MRI/MRA, 3D DSA/MRI and 3D DSA-MR Fusion Images in 9 Patients Who Underwent Surgery

Delineation Score MRA/MRI 3D DSA/MRI 3D DSA-MR Fusion Nidus Feeder Drainer Relation Nidus Feeder Drainer Relation Nidus Feeder Drainer Relation +2 2 (22) 1 (11) 2 (22) 0 (0) 9 (100) 9 (100) 7 (78) 3 (33) 9 (100) 9 (100) 7 (78) 9 (100) +1 5 (56) 6 (67) 4 (44) 7 (78) 0 (0) 0 (0) 2 (22) 6 (67) 0 (0) 0 (0) 2 (22) 0 (0) 0 2 (22) 2 (22) 3 (33) 2 (22) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) −1 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Mean score 1.00 0.89 0.89 0.78 2.00 2.00 1.78 1.33 2.00 2.00 1.78 2.00 ±SD 0.71 0.60 0.78 0.44 0 0 0.44 0.50 0 0 0.44 0

AVM, brain arteriovenous malformation; relation, relationship between AVM and the adjacent brain structures including hematoma; SD, standard deviation; +2, sufficient visualization; +1, ambiguous visualization; 0, poor visualization; −1, misinterpretation.

Data are number of AVMs. Numbers in parentheses are percentages.

Figure 2, A 10-year-old boy (case 1) with a left parietooccipital arteriovenous malformation (AVM) and hemorrhage. Anteroposterior (a) and axial (b) maximal-intensity-projection magnetic resonance angiography (MRA) images show a hyperintense hematoma; no AVM is visualized. The MRA source image (c) does not clearly depict any abnormal vessel structures. For the AVM nidus, feeder, drainer, and the relationship to the brain and hematoma on MRA/MR imaging (MRI), the two observers scaled as poor visualization (grade 0). Anteroposterior views of DSA (d) and three-dimensional (3D) DSA (e) from the left vertebral artery show an arteriovenous shunt with a small nidus ( arrow ). Axial (f) and sagittal (g) 3D DSA-MR fusion images reveal a small nidus ( arrow ) inferomedial to the hematoma. For the AVM nidus, feeder, and drainer, the two observers classified as sufficient visualization (grade 2) on the combination of 3D DSA and MRI (3D DSA/MRI) and 3D DSA-MR fusion images. In the spatial relationship to the brain and hematoma, they scaled as ambiguous visualization (grade 1) for 3D DSA/MRI and as sufficient visualization (grade 2) for 3D DSA-MR fusion images. According to this finding, neurosurgeons made a decision to remove the hematoma first and then the adjacent feeders and nidus during surgery. This information was highly helpful for the selection of the surgical approach (grade 2).

Figure 3, A 39-year-old man (case 2) with a left frontal arteriovenous malformation (AVM) and hemorrhage. The magnetic resonance angiography (MRA) image (a) shows a large hyperintense hematoma; it does not depict the AVM lesion. The contrast-enhanced three-dimensional (3D) turbo field echo (TFE) image (b) does not show the AVM structures. For the AVM nidus, feeder, drainer, and the relationship to the brain and hematoma on MRA/MR imaging (MRI), the two observers scaled as grade 0. Left oblique views of digital subtraction angiography (DSA) (c) and 3D DSA (d) from the left internal carotid artery reveal a small AVM ( arrow ). Axial (e) and coronal (f) 3D DSA-MR fused images show a small nidus ( arrow ) inferolateral to the hematoma. For the AVM nidus, feeder, and drainer, the two observers classified as grade 2 on 3D DSA/MRI and 3D DSA-MR fusion images. In the spatial relationship to the brain and hematoma, they scaled as grade 1 for 3D DSA/MRI and as grade 2 for 3D DSA-MR fusion images. According to this finding, neurosurgeons made a decision to remove the hematoma first and then the adjacent feeders and nidus during surgery. This information was very helpful for choosing the surgical approach (grade 2).

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Figure 4, An 11-year-old boy (case 10) with a left parieto-occipital brain arteriovenous malformations (AVM) and hemorrhage. The fluid-attenuated inversion recovery (FLAIR) image (a) shows a hypointense hematoma ( arrowhead ) with a flow-void lesion corresponding to the AVM nidus ( arrow ). Magnetic resonance angiography (MRA) (b) depicts the AVM lesion ( arrow ) in the left parieto-occipital region. The MRA source image (c) shows hyperintense vessel structures in the nidus ( arrow ) and surrounding hematoma. For the AVM nidus, feeder, drainer, and the relationship to the brain and hematoma on MRA/MR imaging, the two observers scaled as grade 1. Anteroposterior views of digital subtraction angiography (DSA) (d,e) and three-dimensional (3D) DSA (f,g) from the left internal carotid and vertebral arteries show an AVM nidus fed by the left middle and the posterior cerebral artery, respectively. The anterior cerebral artery feeds the nidus slightly. The 3D DSA-MR image fused with 3D DSA from the left internal carotid artery (h) reveals two feeders ( arrows ) and the posterolateral part of the nidus adjacent to the hematoma. The 3D DSA-MR image fused with 3D DSA from the left vertebral artery (i) shows the feeders ( arrow ) and the anteromedial part of the nidus. Compared with MRI/MRA and 3D DSA/MRI, the 3D DSA-MR fusion images provided more precise information about the spatial relationship between the nidus and the feeders from each pedicle. The two observers classified the 3D DSA-MR fusion images as grade 2. This information was highly helpful for the early localization and management of the feeding arteries during surgery (grade 2).

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Discussion

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Conclusion

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References

  • 1. Nüssel F., Wegmüller H., Huber P.: Comparison of magnetic resonance angiography, magnetic resonance imaging and conventional angiography in cerebral arteriovenous malformation. Neuroradiology 1991; 33: pp. 56-61.

  • 2. Mukherji S.K., Quisling R.G., Kubilis P.S., et. al.: Intracranial arteriovenous malformations: Quantitative analysis of magnitude contrast MR angiography versus gradient-echo MR imaging versus conventional angiography. Radiology 1995; 196: pp. 187-193.

  • 3. Fasulakis S., Andronikou S.: Comparison of MR angiography and conventional angiography in the investigation of intracranial arteriovenous malformations and aneurysms in children. Pediatr Radiol 2003; 33: pp. 378-384.

  • 4. Heidenreich J.O., Schilling A.M., Unterharnscheidt F., et. al.: Assessment of 3D-TOF-MRA at 3.0 Tesla in the characterization of the angioarchitecture of cerebral arteriovenous malformations: a preliminary study. Acta Radiol 2007; 48: pp. 678-686.

  • 5. Hamm K.D., Klisch J., Surber G., et. al.: Special aspects of diagnostic imaging for radiosurgery of arteriovenous malformations. Neurosurgery 2008; 62: pp. A44-A52.

  • 6. Utsunomiya D., Shiraishi S., Imuta M., et. al.: Added value of SPECT/CT fusion in assessing suspected bone metastasis: comparison with scintigraphy alone and nonfused scintigraphy and CT. Radiology 2006; 238: pp. 264-271.

  • 7. Stancanello J., Cavedon C., Francescon P., et. al.: BOLD fMRI integration into radiosurgery treatment planning of cerebral vascular malformations. Med Phys 2007; 34: pp. 1176-1184.

  • 8. Boss A., Bisdas S., Kolb A., et. al.: Hybrid PET/MRI of intracranial masses: initial experiences and comparison to PET/CT. J Nucl Med 2010; 51: pp. 1198-1205.

  • 9. Shimizu S., Suzuki H., Maki H., et. al.: A novel image fusion visualizes the angioarchitecture of the perforating arteries in the brain. AJNR Am J Neuroradiol 2003; 24: pp. 2011-2014.

  • 10. Suzuki H., Maki H., Maeda M., et. al.: Visualization of the intracisternal angioarchitecture at the posterior fossa by use of image fusion. Neurosurgery 2005; 56: pp. 335-342.

  • 11. Suzuki H., Shimizu S., Maki H., et. al.: Role of image fusion combining three-dimensional digital subtraction angiography with magnetic resonance imaging in evaluation of unruptured cerebral aneurysms. Neurol Res 2007; 29: pp. 58-63.

  • 12. Suzuki H., Maki H., Taki W.: Evaluation of cerebral arteriovenous malformations using image fusion combining three-dimensional digital subtraction angiography with magnetic resonance imaging. Turk Neurosurg 2012; 22: pp. 341-345.

  • 13. Johnston J.L., Johnston I.H.: The surgical treatment of small deep intracranial arteriovenous malformations: a report of 85 cases. J Clin Neurosci 1996; 3: pp. 338-345.

  • 14. Spetzler R.F., Martin N.A.: A proposed grading system for arteriovenous malformations. J Neurosurg 1986; 65: pp. 476-483.

  • 15. Ruijters D., Homan R., Mielekamp P., et. al.: Validation of 3D multimodality roadmapping in interventional neuroradiology. Phys Med Biol 2011; 56: pp. 5335-5354.

  • 16. Muacevic A., Steiger H.J.: Computer-assisted resection of cerebral arteriovenous malformations. Neurosurgery 1999; 45: pp. 1164-1170.

  • 17. Schaller C., Urbach H., Schramm J., et. al.: Role of venous drainage in cerebral arteriovenous malformation surgery, as related to the development of postoperative hyperperfusion injury. Neurosurgery 2002; 51: pp. 921-927.

  • 18. Du R., Young W.L., Lawton M.T.: “Tangential” resection of medial temporal lobe arteriovenous malformations with the orbitozygomatic approach. Neurosurgery 2004; 54: pp. 645-651.

  • 19. Hashimoto N., Nozaki K., Takagi Y., et. al.: Surgery of cerebral arteriovenous malformations. Neurosurgery 2007; 61: pp. 375-387.

  • 20. Sanelli P.C., Mifsud M.J., Stieg P.E.: Role of CT angiography in guiding management decisions of newly diagnosed and residual arteriovenous malformations. AJR Am J Roentgenol 2004; 183: pp. 1123-1126.

  • 21. Matsumoto M., Kodama N., Sakuma J., et. al.: 3D-CT arteriography and 3D-CT venography: the separate demonstration of arterial-phase and venous-phase on 3D-CT angiography in a single procedure. AJNR Am J Neuroradiol 2005; 26: pp. 635-641.

  • 22. Hirai T., Korogi Y., Suginohara K., et. al.: Clinical usefulness of unsubtracted 3D digital angiography compared with rotational digital angiography in the pretreatment evaluation of intracranial aneurysms. AJNR Am J Neuroradiol 2003; 24: pp. 1067-1074.

  • 23. Hadizadeh D.R., von Falkenhausen M., Gieseke J.: Cerebral arteriovenous malformation: Spetzler-Martin classification at subsecond-temporal-resolution four-dimensional MR angiography compared with that at DSA. Radiology 2008; 246: pp. 205-213.

Academic Radiology, Volume 19, Issue 11
Journals General Radiology
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