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Research ArticleInterventional

Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device

H. Oishi, T. Fujii, M. Suzuki, N. Takano, K. Teranishi, K. Yatomi, T. Kitamura, M. Yamamoto, S. Aoki and H. Arai
American Journal of Neuroradiology May 2019, 40 (5) 808-814; DOI: https://doi.org/10.3174/ajnr.A6047
H. Oishi
aFrom the Departments of Neuroendovascular Therapy (H.O., T.F., T.K.)
bNeurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
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T. Fujii
aFrom the Departments of Neuroendovascular Therapy (H.O., T.F., T.K.)
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M. Suzuki
cRadiology (M.S., N.T., S.A.), Juntendo University Faculty of Medicine, Tokyo, Japan.
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N. Takano
cRadiology (M.S., N.T., S.A.), Juntendo University Faculty of Medicine, Tokyo, Japan.
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K. Teranishi
bNeurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
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K. Yatomi
bNeurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
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T. Kitamura
aFrom the Departments of Neuroendovascular Therapy (H.O., T.F., T.K.)
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M. Yamamoto
bNeurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
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S. Aoki
cRadiology (M.S., N.T., S.A.), Juntendo University Faculty of Medicine, Tokyo, Japan.
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H. Arai
bNeurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
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Article Figures & Data

Figures

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  • Fig 1.
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    Fig 1.

    A flowchart of eligible patients assessed by Silent MR angiography after Pipeline Flex placement for intracranial aneurysms.

  • Fig 2.
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    Fig 2.

    A, An 82-year-old woman. Flow-diverter placement in the left internal carotid artery cavernous segment aneurysm (20.1 × 6.3 mm) was performed with the Pipeline Flex (4.5 × 25 mm). B, Digital subtraction angiography shows the location of the Pipeline Flex by conebeam CT. C, The 6-month follow-up DSA shows complete occlusion of the aneurysm. D, This Silent MRA shows an excellent signal flow in the Pipeline Flex (arrow) but no intra-aneurysmal signal. E, This time-of-flight MRA almost lost the signal in the Pipeline Flex (double arrows) and has a faint signal in the aneurysm. The scores of the Silent MRA by 3 observers were 4, 3, and 4, and those of the TOF-MRA were 2, 2, and 2.

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    Fig 3.

    A 75-year-old woman. A, The aneurysm (26.2 × 6.1 mm) was located in the left internal carotid artery paraclinoid segment. B, A 6-month follow-up DSA shows almost complete occlusion of the aneurysm. C, The MRA T1-weighted image immediately after the operation shows an intra-aneurysmal isointensity signal (arrow). D and E, Both Silent MRA and TOF-MRA show an intra-aneurysmal signal that had a negative influence on the parent artery assessment. F, A 6-month follow-up T1-weighted image shows an intra-aneurysmal high-intensity signal, which means thrombosis (double arrows). G, A 6-month follow-up, Silent MRA shows excellent signal flow in the Pipeline Flex. H, A 6-month follow-up TOF-MRA shows that the image could not be assessed by the intra-aneurysmal thrombosed signal. I, The 1-year follow-up T1-weighted MR image shows a lower intra-aneurysmal high-intensity signal decrease than at the 6-month follow-up (triple arrows). J, The 1-year follow-up findings on the Silent MRA signal flow were the same as at the 6-month follow-up. K, The 1-year follow-up on TOF-MRA shows a better signal flow than at the 6-month follow-up TOF-MRA (arrowhead) by improvement of the thrombosed aneurysm (double arrowheads), but the signal flow on the Silent MRA is better than that on the TOF-MRA. The scores of the 6-month follow-up Silent MRA by 3 independent observers were 4, 4, and 4. The scores of the TOF-MRA were 1, 1, and 1.

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    Fig 4.

    A–C, A 62-year-old woman. A, The 6-month follow-up DSA shows complete occlusion and good patency in the Pipeline Flex. B and C, The 6-month follow-up Silent MRA shows a worse signal flow than the TOF-MRA due to artifacts caused by the left denture (arrow). The Silent MRA scores by 3 independent observers were 2, 1, and 2, while the TOF-MRA scores were 3, 2, and 3. D–F, A 73-year-old woman. D, The 6-month follow-up DSA shows reduction of intra-aneurysmal flow. E and F, The 6-month follow-up Silent MRA shows a poor signal caused by motion artifacts because the patient was claustrophobic and moved during the procedure, and TOF-MRA also shows a poor signal flow caused by an intra-aneurysmal thrombosis after the Pipeline Flex placement (double arrows). The scores of Silent MRA by 3 independent observers were 3, 3, and 3. The scores of TOF-MRA were 2, 3, and 4.

Tables

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    Table 1:

    Characteristics of the patients assessed by DSA, Silent MRA, and TOF-MRA after placement of flow-diverter devices

    ParametersData
    Age (mean) (range) (yr)61.4 ± 13.3 (19–82)
    Sex (M/F)6:72
    Side (R/L)36:42
    Location (cavernous segment/paraclinoid segment)52:26
    Aneurysmal size (mean) (range) (mm)14.8 ± 5.5 (10.0–32.5)
    Aneurysmal neck diameter (mean) (range) (mm)6.5 ± 2.2 (2.8–15.3)
    Symptomatic cases (No.) (%)23 (29.5%)
    Additional coiling (No.) (%)39 (50%)
    Pipeline diameter (mean) (range) (mm)4.2 ± 0.6 (3–5)
    Pipeline length (mean) (range) (mm)21.8 ± 6.3 (16–35)
    In-stent percutaneous transluminal angioplasty (No.) (%)52 (66.7%)
    In-stent stenosis (No.) (%)
        None (0%)28 (38.9%)
        Mild (0–25%)41 (52.6%)
        Moderate (≥25%)9 (11.5%)
    Duration of follow-up (mean) (range) (mo)6.1 ± 0.6 (4–8)
    • Note:—R indicates right; L, left.

    • View popup
    Table 2:

    Comparison of correlations between Silent MRA and TOF-MRA from the viewpoint of all parameters for Silent MRA (3.18 ± 0.72)

    High Score (>2, n = 66)Low Score (≤2, n = 12)P Value
    Aneurysmal size (mean) (mm)14.8 ± 5.415.0 ± 6.6.91
    Aneurysmal neck diameter (mean) (mm)6.5 ± 2.26.4 ± 2.3.79
    Pipeline diameter (mean) (mm)4.3 ± 0.64.1 ± 0.6.27
    Pipeline length (mean) (mm)21.7 ± 6.322.0 ± 6.8.90
    In-stent stenosis (No.) (%)42/66 (63.6%)8/12 (66.7%).84
    Location (paraclinoid/cavernous)44:228:41.00
    Additional coiling (No.) (%)33/66 (50.0%)7/12 (58.3%).60
    • View popup
    Table 3:

    Comparison of correlations between Silent MRA and TOF-MRA from the viewpoint of all parameters for TOF-MRA (2.31 ± 0.86)

    High Score (>2, n = 44)Low Score (≤2, n = 34)P Value
    Aneurysmal size (mean) (mm)13.5 ± 4.316.6 ± 6.5<.05
    Aneurysmal neck diameter (mean) (mm)6.0 ± 1.67.2 ± 2.7<.05
    Pipeline diameter (mean) (mm)4.2 ± 0.64.3 ± 0.5.61
    Pipeline length (mean) (mm)20.8 ± 5.823.0 ± 6.9.13
    In-stent stenosis (No.) (%)28/44 (63.6%)22/34 (65.9%).92
    Location (paraclinoid/cavernous)35:917:17<.01
    Additional coiling (No.) (%)26/44 (59.1%)14/34 (41.2%).12
    • View popup
    Table 4:

    Comparison of correlation between Silent MRA and TOF-MRA from the viewpoint of intra-aneurysmal thrombosis after flow-diverter device placement

    Intra-Aneurysmal Thrombosis (+) (n = 13)Intra-Aneurysmal Thrombosis (−) (n = 65)P Value
    Location (paraclinoid segment/cavernous segment)2:1163:2<.01
    Aneurysmal size (mean) (range) (mm)21.7 ± 5.3 (12.6–32.5)13.4 ± 4.4 (8.1–28.7)<.01
    Aneurysmal neck diameter (mean) (range) (mm)7.8 ± 3.1 (2.8–15.3)6.3 ± 1.9 (3.3–13.9)<.05
    Additional coiling (No.) (%)2 (15.4%)37 (56.9%)<.01
    Pipeline diameter (mean) (range) (mm)4.21 ± 0.5 (3–5)4.23 ± 0.6 (3–5).91
    Pipeline length (mean) (range) (mm)27.5 ± 7.2 (18–35)20.6 ± 5.4 (16–35)<.01
    Silent MRA score (mean)3.5 ± 0.53.1 ± 0.7.10
    TOF-MRA score (mean)2.0 ± 0.82.3 ± 0.8.20
    • Note:—+ indicates present; −, absent.

    • View popup
    Table 5:

    Comparison of embolization assessment among DSA, Silent MRA, and TOF-MRA after flow-diverter device placement

    DSA
    CO (n = 55)IO (n = 23)
    Silent MRACO (n = 58)535
    IO (n = 20)218
    TOF-MRACO (n = 52)477
    IO (n = 26)816
    • Note:—CO indicates complete occlusion; IO, incomplete occlusion.

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American Journal of Neuroradiology: 40 (5)
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H. Oishi, T. Fujii, M. Suzuki, N. Takano, K. Teranishi, K. Yatomi, T. Kitamura, M. Yamamoto, S. Aoki, H. Arai
Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device
American Journal of Neuroradiology May 2019, 40 (5) 808-814; DOI: 10.3174/ajnr.A6047

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Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device
H. Oishi, T. Fujii, M. Suzuki, N. Takano, K. Teranishi, K. Yatomi, T. Kitamura, M. Yamamoto, S. Aoki, H. Arai
American Journal of Neuroradiology May 2019, 40 (5) 808-814; DOI: 10.3174/ajnr.A6047
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