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AJNR Awards, New Junior Editors, and more. Read the latest AJNR updates

Research ArticleNeurointervention

Dual-Energy CTA Iodine Map Reconstructions Improve Visualization of Residual Cerebral Aneurysms following Endovascular Coiling

Dylan N. Wolman, Gabriella Kuraitis, Eric Sussman, Benjamin Pulli, Anke Wouters, Jia Wang, Adam Wang, Maarten G. Lansberg and Jeremy J. Heit
American Journal of Neuroradiology August 2024, DOI: https://doi.org/10.3174/ajnr.A8305
Dylan N. Wolman
aFrom the Department of Diagnostic Imaging (D.N.W.), The Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, Rhode Island
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  • ORCID record for Dylan N. Wolman
Gabriella Kuraitis
bDepartment of Radiology (G.K., B.P., A.Wouters, J.W., A.Wang, J.J.H.), Neuroimaging and Neurointervention Section, Stanford University Hospital, Palo Alto, California
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Eric Sussman
cDepartment of Neurosurgery (E.S.), Hartford Hospital, Ayer Neuroscience Institute, Hartford, Connecticut
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Benjamin Pulli
bDepartment of Radiology (G.K., B.P., A.Wouters, J.W., A.Wang, J.J.H.), Neuroimaging and Neurointervention Section, Stanford University Hospital, Palo Alto, California
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Anke Wouters
bDepartment of Radiology (G.K., B.P., A.Wouters, J.W., A.Wang, J.J.H.), Neuroimaging and Neurointervention Section, Stanford University Hospital, Palo Alto, California
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Jia Wang
bDepartment of Radiology (G.K., B.P., A.Wouters, J.W., A.Wang, J.J.H.), Neuroimaging and Neurointervention Section, Stanford University Hospital, Palo Alto, California
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Adam Wang
bDepartment of Radiology (G.K., B.P., A.Wouters, J.W., A.Wang, J.J.H.), Neuroimaging and Neurointervention Section, Stanford University Hospital, Palo Alto, California
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Maarten G. Lansberg
dDepartment of Neurology (M.G.L.), Stanford University Hospital, Palo Alto, California
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Jeremy J. Heit
bDepartment of Radiology (G.K., B.P., A.Wouters, J.W., A.Wang, J.J.H.), Neuroimaging and Neurointervention Section, Stanford University Hospital, Palo Alto, California
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  • FIG 1.
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    FIG 1.

    Example cases of residual aneurysms. A-D, Example case of a residual left middle cerebral artery bifurcation aneurysm after prior primary coil embolization. A, Single arterial phase anteroposterior cranial view on follow-up diagnostic cerebral angiogram demonstrates an aneurysm residual following coil compaction. B, Axial CCTA image at the level of the aneurysm neck. C, Axial IM-DECTA image at the level of the aneurysm neck. D, Axial MIP IM-DECTA image at the level of the aneurysm neck. Arrows indicate the location of the residual aneurysm. E-H, Example case of a residual left posterior inferior cerebellar artery aneurysm after prior primary coil embolization. E, Upper panel: arterial phase anteroposterior cranial view on follow-up diagnostic cerebral angiogram demonstrating small residual aneurysm inferior to the coil mass. Lower panel: early and midarterial phase lateral cranial views demonstrate the residual aneurysm inferior to the coil mass. F, Axial CCTA image at the level of the aneurysm neck. G, Axial IM-DECTA image at the level of the aneurysm neck demonstrating volume averaging between the artifactually “dark” inferior aspect of the coil mass and the small opacified residual aneurysm. H, Axial MIP IM-DECTA image at the level of the aneurysm neck effectively subtracting the coil mass to better delineate the small residual aneurysm.

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    FIG 2.

    Metallic spectral analysis graph. Mass attenuation coefficients (cm2/g) of the material basis pair used in iodine map reconstructions (iodine and water) and of platinum, plotted against beam energy (keV) within the CT imaging range. The energy spectrum of platinum demonstrates a k-edge at 78.4 keV with a resultant attenuation spike within the reconstruction range of the material basis pairs, resulting in artifactual subtraction by the reconstruction software. Spectral data acquired from the NIST Standard Reference Database 126; DOI: 10.18434/T4D01F.

Tables

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    Table 1:

    Baseline aneurysm characteristics

    Aneurysm location
     Anterior communicating artery6/25 (24%)
     Posterior communicating artery3/25 (12%)
     Supraclinoid internal carotid artery5/25 (20%)
     Middle cerebral artery bifurcation3/25 (12%)
     Basilar apex4/25 (16%)
     Proximal vertebrobasilar system4/25 (16%)
    Ruptured on presentation22/25 (88%)
    Mean aneurysm size (maximal diameter)6.3 ± 3.9 mm (2–17 mm)
    Mean residual aneurysm size (maximal diameter)2.7 ± 1.1 mm (1.4–5.4 mm)
    Mean coil mass size (maximal diameter)6.6 ± 2.7 mm (2.7–14 mm)
    Mean coil-to-aneurysm size ratio3.0 ± 1.4 (1.6-5.3)
    Mean time from DECTA to follow-up DSA286 ± 212 days (22–683 days)
    Follow-up DSA mRRC
     mRRC 114/25 (56%)
     mRRC 23/25 (12%)
     mRRC 3a5/25 (20%)
     mRRC 3b3/25 (12%)
    • Note:—Summary of baseline aneurysm characteristics. Mean aneurysm size is derived from initial DSA and mean residual aneurysm size and coil-to-aneurysm size ratio is derived from follow-up DSA. Mean coil mass size is derived from bone kernel noncontrast head CT images. Sizes are expressed as mean±SD (range) in mm.

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    Table 2:

    Detection of residual aneurysms

    Binary Residual Aneurysm Detection
     SensitivitySpecificityAccuracyAgreementP-Value
    CCTA0%86%23%−0.18<.01
    50-keV CTA31%88%52%0.33<.01
    70-keV CTA20%100%52%0.41<.01
    IM-DECTA75%93%85%0.51.31
    MIP IM-DECTA83%92%88%0.51.97
    • Note:—Sensitivity, specificity, accuracy, and reader agreement (expressed as the Pearson correlation coefficient) for residual aneurysm detection is expressed relative to reference DSA, therefore nonsignificant P-values indicate greater agreement with the reference standard.

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    Table 3:

    Residual aneurysm occlusion classification

    Agreement with mRRC by DSA
     Pearson Correlationκ AgreementP-Value
    CCTA−0.040.34<.01
    50-keV CTA0.580.34<.01
    70-keV CTA0.50.44<.01
    IM-DECTA0.580.55.09
    MIP IM-DECTA0.670.58.93
    • Note:—Pearson correlation coefficient and κ interreader variability for mRRC scoring is expressed relative to reference DSA, therefore nonsignificant P-values indicate greater agreement with the reference standard.

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    Table 4:

    Quantitative image noise assessment

     Mean HUSD HUSEMP-Value
    CCTA445103.213.3 
    50-keV CTA42478.110.1.06
    70-keV CTA765129.616.7.07
    IM-DECTA13027.93.6<.01
    MIP IM-DECTA16026.83.5<.01
    • Note:—Quantitative image noise assessment data as compared against reference CCTA, with the mean standard deviation HU values acquired by ROI placement within the parent vessel adjacent to each aneurysm neck used as a surrogate for beam-hardening artifact, with higher mean standard deviation values reflecting more extensive artifact.

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    Table 5:

    Qualitative image noise assessment and interpretability

    IQ1IQ2IQ3ModeκNeck Visualization
    CCTA14/25 (56%)11/25 (44%)0/25 (0%)00.3411/25 (44%)
    50-keV CTA3/25 (12%)16/25 (64%)6/25 (24%)10.2318/25 (72%)
    70-keV CTA5/25 (20%)16/25 (64%)4/25 (16%)10.2720/25 (80%)
    IM-DECTA0/25 (0%)8/25 (32%)17/25 (68%)20.4924/25 (96%)
    MIP IM-DECTA0/25 (0%)6/25 (24%)19/25 (76%)20.5824/25 (96%)
    • Note:—Qualitative image noise assessment based on Likert-style scale reader scores for each CTA series, with interreader agreement assessed by Cohen κ and reported neck visualization for each series. All series demonstrated a significant improvement in neck visualization over reference CCTA as assessed by the nonparameteric Kruskal-Wallis test.

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Dylan N. Wolman, Gabriella Kuraitis, Eric Sussman, Benjamin Pulli, Anke Wouters, Jia Wang, Adam Wang, Maarten G. Lansberg, Jeremy J. Heit
Dual-Energy CTA Iodine Map Reconstructions Improve Visualization of Residual Cerebral Aneurysms following Endovascular Coiling
American Journal of Neuroradiology Aug 2024, DOI: 10.3174/ajnr.A8305

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Dual-Energy CTA Iodine Map Reconstructions Improve Visualization of Residual Cerebral Aneurysms following Endovascular Coiling
Dylan N. Wolman, Gabriella Kuraitis, Eric Sussman, Benjamin Pulli, Anke Wouters, Jia Wang, Adam Wang, Maarten G. Lansberg, Jeremy J. Heit
American Journal of Neuroradiology Aug 2024, DOI: 10.3174/ajnr.A8305
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