Comparison of Standard- and Low-Tube Voltage 320-Detector Row Volume CT Angiography in Detection of Intracranial Aneurysms with Digital Subtraction Angiography as Gold Standard

doi:10.1016/j.acra.2011.11.004

Academic Radiology

Volume 19, Issue 3, March 2012, Pages 281-288

https://doi.org/10.1016/j.acra.2011.11.004 Get rights and content

Rationale and Objectives

The aim of this study was to prospectively assess the effect of low–tube voltage (80 kVp) 320–detector row volume computed tomographic (CT) angiography (L-VCTA) in the detection of intracranial aneurysms, with three-dimensional (3D) spin digital subtraction angiography (DSA) as the gold standard.

Materials and Methods

Forty-eight patients with clinically suspected subarachnoid hemorrhages were divided into two groups. One group underwent L-VCTA and DSA, while the other group underwent conventional–tube voltage (120 kVp) volume CT angiography (C-VCTA) and DSA. Vascular enhancement, image quality, detection accuracy of aneurysms, and radiation dose were compared between the two groups.

Results

For objective image quality, the L-VCTA group had higher mean vessel attenuation, correlated with higher image noise and lower signal-to-noise ratio, than the C-VCTA group. For subjective image quality, there were no significant differences between the two groups regarding scores for arterial enhancement, depiction of small arterial detail, interference of venous structures, and overall image quality scores. The mean effective dose for the L-VCTA group was significantly lower than for the C-VCTA group (0.56 ± 0.25 vs 1.84 ± 0.002 mSv), with a reduction of radiation dose of 69.73%. With 3D DSA as the reference standard, the sensitivity, specificity, and accuracy in the L-VCTA and C-VCTA groups were 94.12%, 100%, 94.4% and 100%, 100%, and 100%, respectively. In both groups, there were significant correlations for maximum aneurysm diameter measurements between volume CT angiography and 3D DSA; no statistical difference in the mean maximum diameter of each aneurysm was measured between volume CT angiography and 3D DSA.

Conclusions

L-VCTA is helpful in detecting intracranial aneurysms, with results similar to those of 3D DSA, but at a lower radiation dose than C-VCTA.

Section snippets

Patients

Between January 2009 and August 2010, a total of 48 patients were enrolled in this prospective study. The inclusion criterion was an indication for CTA and DSA because of acute suspicion of a ruptured intracranial aneurysm. This prospective study was approved by the institutional ethics review board. Informed consent was obtained from all participating patients.

The patients were randomly assigned to undergo L-VCTA (n = 24) or C-VCTA (n = 24), using a computer-generated list to ensure

Image Quality

In the quantitative ROI analysis of Hounsfield units (HU), absolute values tended to be higher for the L-VCTA group than for the C-VCTA group. The mean attenuation and noise values are shown in Table 1. The average differences in mean attenuation were 125.5 HU in the largest vessel, 99.92 HU in the second segment of the middle cerebral artery, and 129.49 HU in the basilar artery trunk (P < .001). These data indicated a 42% to 58% increase in arterial attenuation at 80 kVp compared to arterial

Discussion

In the acute setting of suspected intracranial aneurysmal subarachnoid hemorrhage, therapeutic decision making requires rapid and accurate assessment of the presence of an aneurysm. Although DSA has remained the gold standard for the detection of intracranial aneurysms, it has several disadvantages: it is invasive and time consuming, it requires highly experienced operators, and it carries procedural risks such as cerebral ischemia with persistent neurologic deficits 17, 18. The advances in

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Both SNR and CNR were significantly higher with temporal averaging compared to CTA, increasing by 104% and 113%, respectively (p<0.001).
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Diagnosis and Treatment of Intracranial Aneurysms with 320-Detector Row Volumetric Computed Tomography Angiography
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Recent clinical innovations include a 320-detector row computed tomography (CT) featuring a 16-cm-wide scanner.3 The scanner enables full brain coverage in a single gantry rotation, enabling the acquisition of combined volumetric angiographic data after the injection of a single contrast material.13,14 Because subtracted 320-detector row volume-computed tomography angiography (VCTA) has been shown to be comparable with DSA for the detection of intracranial aneurysms,15 the present study was designed to evaluate the diagnostic accuracy of the 320-detector row VCTA for intracranial aneurysms and determine its clinical utility.
The objective of the study was to determine the clinical utility of 320-detector row volume-computed tomographic angiography (VCTA) in the management of intracranial aneurysms.
Between February 2011 and May 2015, 550 patients successfully underwent 320-detector row VCTA for suspected intracranial aneurysms. Three-dimensional (3D) digital subtraction angiography (DSA) was used as the ultimate reference standard, and the sensitivity, specificity, and accuracy of both nonsubtracted and subtracted VCTA in identifying aneurysms were analyzed.
Nonsubtracted VCTA identified 417 aneurysms (2 false-positive readings, 12 false-negative readings). The diagnostic sensitivity, specificity, and accuracy of non-subtracted VCTA, on a per-aneurysm basis, were 97.2%, 99.0%, and 97.6%, respectively. Subtracted VCTA identified 426 aneurysms (2 false-positive readings, 3 false-negative readings). The sensitivity, specificity, and accuracy of subtracted VCTA, on a per-aneurysm basis, were 99.3%, 99.0%, and 99.2%, respectively. No differences in diagnostic accuracy were found between subtracted VCTA and 3D DSA. Nonsubtracted VCTA, however, was observed to be significantly less sensitive than 3D DSA and subtracted VCTA. Twenty-six aneurysm cases were referred for surgical treatment based on VCTA imaging. All aneurysms were deemed completely occluded during surgical clipping. On the basis of VCTA imaging, 299 aneurysms were found suitable for endovascular coiling, of which 293 aneurysms (98%) were treated successfully.
The 320-detector row subtracted VCTA technique is an effective, first-line diagnostic imaging modality for surgical and endovascular treatment of aneurysms. The nonsubtracted VCTA was less accurate than the subtracted VCTA, especially for intracranial aneurysms adjoining bone tissue.
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Moreover, Sun et al.14 assessed the effect of low-tube voltage (80 kVp) 320-detector row volume CTA (L-VCTA) in the detection of intracranial aneurysms and found that the sensitivity in the L-VCTA (94.12%) was in inferior to the conventional tube voltage (120 kVp) volume CTA (C-VCTA) groups (100%). However, L-VCTA was superior to C-VCTA in objective image quality and at a lower radiation dose.14 Initial studies with single-detector CTA reported sensitivities between 62 and 100%, and specificities between 98 and 100% for the detection of intracranial aneurysms.15,16
To compare the diagnostic performance of 320-detector row computed tomographic angiography (CTA) with digital subtraction angiography (DSA) for the detection and characterization of intracranial aneurysms.
Fifty-two consecutive patients with non-traumatic subarachnoid haemorrhage (SAH) and suspected intracranial aneurysms were evaluated from January 2009 to October 2011. All underwent both 320-detector row volume CTA examination and DSA. CTA volume data were transmitted to a VITREA workstation and two physicians with experience in diagnostic imaging of the nervous system independently carried out image post-processing and assessed the results. The three-dimensional (3D) CTA and DSA images were assessed using intraoperative findings as the reference standard.
In 52 patients, 54 aneurysms were detected; 48 patients underwent surgery for 50 aneurysms. The overall sensitivity, specificity, and accuracy of 3D CTA were 96.3, 100, and 94.6%, respectively. Meanwhile, the overall sensitivity, specificity, and accuracy of DSA were 98.1, 98.1, and 95.1%, respectively. For aneurysms less than 3 mm, the sensitivity, specificity, and accuracy of 3D CTA were 81.8, 100, and 93.3%, respectively. The sensitivity, specificity, and accuracy of DSA for small aneurysms were 90.9, 100, and 96.2%, respectively. 3D CTA was superior to DSA in demonstrating aneurysmal calcification, parent artery, and surrounding vascular anatomy.
3D CTA is a highly sensitive, specific, and non-invasive imaging method for diagnosis and evaluation of intracranial aneurysms. It also allows for precise depiction of aneurysm morphology. Therefore, 320-detector row CTA may be used as an alternative to DSA as a first-line imaging technique in patients with SAH.
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Original investigationComparison of Standard- and Low-Tube Voltage 320-Detector Row Volume CT Angiography in Detection of Intracranial Aneurysms with Digital Subtraction Angiography as Gold Standard

Rationale and Objectives

Materials and Methods

Results

Conclusions

Section snippets

Patients

Image Quality

Discussion

Eur J Radiol

Acad Radiol

Time trends in outcome of subarachnoid hemorrhage: population-based study and systematic review

Neurology

Declining mortality from subarachnoid hemorrhage: changes in incidence and case fatality from 1985 through 2000

Stroke

Intracranial aneurysms: clinical value of 3D digital subtraction angiography in the therapeutic decision and endovascular treatment

Radiology

Detection of intracranial aneurysms: multi-detector row CT angiography compared with DSA

Radiology

Dual-energy direct bone removal CT angiography for evaluation of intracranial aneurysm or stenosis: comparison with conventional digital subtraction angiography

Eur Radiol

Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysms, and arteriovenous malformations: a meta-analysis

Stroke

Dual-energy CT angiography in the evaluation of intracranial aneurysms: image quality, radiation dose, and comparison with 3D rotational DSA

AJR Am J Roentgenol

320-slice CT neuroimaging: initial clinical experience and image quality evaluation

Br J Radiol

Effect of low doses of ionizing radiation in infancy on cognitive function in adulthood: Swedish population based cohort study

BMJ

Dose exposure of patients undergoing comprehensive stroke imaging by multidetector-row CT: comparison of 320-detector row and 64-detector row CT scanners

AJNR Am J Neuroradiol

Dynamic CT angiography and CT perfusion employing a 320-detector row CT

Clin Neuroradiol

Multi-detector row CT angiography of the brain at various kilovoltage settings

Radiology

Original investigation
Comparison of Standard- and Low-Tube Voltage 320-Detector Row Volume CT Angiography in Detection of Intracranial Aneurysms with Digital Subtraction Angiography as Gold Standard