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El Naamani K, Mastorakos P, Adeeb N, Lan M, Castiglione J, Khanna O, Diestro JDB, McLellan RM, Dibas M, Vranic JE, Aslan A, Cuellar-Saenz HH, Guenego A, Carnevale J, Saliou G, Ulfert C, Möhlenbruch M, Foreman PM, Vachhani JA, Hafeez MU, Waqas M, Tutino VM, Rabinov JD, Ren Y, Michelozzi C, Spears J, Panni P, Griessenauer CJ, Asadi H, Regenhardt RW, Stapleton CJ, Ghozy S, Siddiqui A, Patel NJ, Kan P, Boddu S, Knopman J, Aziz-Sultan MA, Zanaty M, Ghosh R, Abbas R, Amllay A, Tjoumakaris SI, Gooch MR, Cancelliere NM, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Pereira VM, Patel AB, Jabbour P, Dmytriw AA. Long-Term Follow-Up of Cerebral Aneurysms Completely Occluded at 6 Months After Intervention with the Woven EndoBridge (WEB) Device: a Retrospective Multicenter Observational Study. Transl Stroke Res 2024; 15:591-598. [PMID: 37165289 DOI: 10.1007/s12975-023-01153-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 05/12/2023]
Abstract
The Woven EndoBridge (WEB) device has been widely used to treat intracranial wide neck bifurcation aneurysms. Initial studies have demonstrated that approximately 90% of patients have same or improved long-term aneurysm occlusion after the initial 6-month follow up. The aim of this study is to assess the long-term follow-up in aneurysms that have achieved complete occlusion at 6 months. We also compared the predictive value of different imaging modalities used. This is an analysis of a prospectively maintained database across 13 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB device who achieved complete occlusion at first follow-up and had available long-term follow-up. A total of 95 patients with a mean age of 61.6 ± 11.9 years were studied. The mean neck diameter and height were 3.9 ± 1.3 mm and 6.0 ± 1.8 mm, respectively. The mean time to first and last follow-up was 5.4 ± 1.8 and 14.1 ± 12.9 months, respectively. Out of all the aneurysms that were completely occluded at 6 months, 84 (90.3%) showed complete occlusion at the final follow-up, and 11(11.5%) patients did not achieve complete occlusion. The positive predictive value (PPV) of complete occlusion at first follow was 88.4%. Importantly, this did not differ between digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomography angiography (CTA). This study underlines the importance of repeat imaging in patients treated with the WEB device even if complete occlusion is achieved short term. Follow-up can be performed using DSA, MRA or CTA with no difference in positive predictive value.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Panagiotis Mastorakos
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nimer Adeeb
- Departement of Neurosurgery and Neurointerventional Surgery, Louisiana State University, Shreveport, LA, USA
| | - Mathews Lan
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James Castiglione
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose Danilo Bengzon Diestro
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Rachel M McLellan
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mahmoud Dibas
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Justin E Vranic
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Assala Aslan
- Departement of Neurosurgery and Neurointerventional Surgery, Louisiana State University, Shreveport, LA, USA
| | - Hugo H Cuellar-Saenz
- Departement of Neurosurgery and Neurointerventional Surgery, Louisiana State University, Shreveport, LA, USA
| | - Adrien Guenego
- Service de Neuroradiologie Interventionnelle, Hôpital Universitaire Erasme, Brussels, Belgium
| | - Joseph Carnevale
- Neurosurgery & Interventional Neuroradiology, Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Guillaume Saliou
- Service de Radiodiagnostic et Radiologie Interventionnelle, Centre Hospitalier Vaudois de Lausanne, Lausanne, Switzerland
| | - Christian Ulfert
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Markus Möhlenbruch
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Paul M Foreman
- Neurosurgery Department, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, FL, USA
| | - Jay A Vachhani
- Neurosurgery Department, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, FL, USA
| | - Muhammad U Hafeez
- Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, TX, USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Vincent M Tutino
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yifan Ren
- Interventional Radiology and Neurointerventional Services, Department of Radiology, Austin Health, Melbourne, VIC, Australia
| | | | - Julian Spears
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Pietro Panni
- Interventional Neuroradiology and Neurosurgery, San Raffaele University Hospital, Milan, Italy
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Salzburg, Austria
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamed Asadi
- Interventional Radiology and Neurointerventional Services, Department of Radiology, Austin Health, Melbourne, VIC, Australia
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sherief Ghozy
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Nirav J Patel
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kan
- Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, TX, USA
| | - Srikanth Boddu
- Neurosurgery & Interventional Neuroradiology, Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Jared Knopman
- Neurosurgery & Interventional Neuroradiology, Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mohammad A Aziz-Sultan
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mario Zanaty
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ritam Ghosh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Adam A Dmytriw
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Peng F, Xu B, Xia J, Chen X, Liu A. Association Between Serum Homocysteine Concentration, Aneurysm Wall Inflammation, and Aneurysm Symptoms in Intracranial Fusiform Aneurysm. Acad Radiol 2024; 31:168-179. [PMID: 37211477 DOI: 10.1016/j.acra.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 05/23/2023]
Abstract
RATIONALE AND OBJECTIVES The pathophysiology of fusiform intracranial aneurysm (FIA) involves inflammatory processes, and homocysteine plays a role in the inflammatory processes in the vessel wall. Moreover, aneurysm wall enhancement (AWE) has emerged as a new imaging biomarker of aneurysm wall inflammatory pathologies. To investigate the pathophysiological mechanisms of aneurysm wall inflammation and FIA instability, we aimed to determine the associations between the homocysteine concentration, AWE, and FIAs' related symptoms. MATERIALS AND METHODS We retrospectively reviewed the data of 53 patients with FIA who underwent both high-resolution magnetic resonance imaging and serum homocysteine concentration measurement. FIAs' related symptoms were defined as ischemic stroke or transient ischemic attack, cranial nerve compression, brainstem compression, and acute headache. The contrast ratio of the signal intensity of the aneurysm wall to the pituitary stalk (CRstalk) was used to indicate AWE. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were performed to determine how well the independent factors could predict FIAs' related symptoms. Predictors of CRstalk were also investigated. Spearman's correlation coefficient was used to identify the potential associations between these predictors. RESULTS Fifty-three patients were included, of whom 23 (43.4%) presented with FIAs' related symptoms. After adjusting for baseline differences in the multivariate logistic regression analysis, the CRstalk (odds ratio [OR]=3.207, P = .023) and homocysteine concentration (OR=1.344, P = .015) independently predicted FIAs' related symptoms. The CRstalk was able to differentiate between FIAs with and without symptoms (area under the ROC curve [AUC]=0.805), with an optimal cutoff value of 0.76. The homocysteine concentration could also differentiate between FIAs with and without symptoms (AUC=0.788), with an optimal cutoff value of 13.13. The combination of the CRstalk and homocysteine concentration had a better ability to identify symptomatic FIAs (AUC=0.857). Male sex (OR=0.536, P = .018), FIAs' related symptoms (OR=1.292, P = .038), and homocysteine concentration (OR=1.254, P = .045) independently predicted the CRstalk. CONCLUSION A higher serum homocysteine concentration and greater AWE indicate FIA instability. Serum homocysteine concentration may be a useful biomarker of FIA instability; however, this needs to be verified in future studies.
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Affiliation(s)
- Fei Peng
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China (F.P., B.X., J.X., X.C., A.L.)
| | - Boya Xu
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China (F.P., B.X., J.X., X.C., A.L.)
| | - Jiaxiang Xia
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China (F.P., B.X., J.X., X.C., A.L.)
| | - Xuge Chen
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China (F.P., B.X., J.X., X.C., A.L.)
| | - Aihua Liu
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China (F.P., B.X., J.X., X.C., A.L.).
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Ma P, Li Y, Feng Y, Wu G, Li B, Wu H. The Application of Multiple Magnetic Resonance Scanning Techniques in Evaluating the Stability of Intracranial Aneurysms. Int J Gen Med 2023; 16:2003-2011. [PMID: 37256082 PMCID: PMC10225275 DOI: 10.2147/ijgm.s402255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/28/2023] [Indexed: 06/01/2023] Open
Abstract
Purpose To evaluate the stability of unruptured intracranial aneurysm (UIA) with high-resolution magnetic resonance imaging of the vessel wall (HR-VWI). Materials and Methods A total of 92 UIA patients were enrolled. After MRA, HR-VWI imaging, the reconstruction of volume rendering (VR) and maximum intensity projection (MIP) were performed to observe the location and size of aneurysms, AR value (ratio of aneurysm height to aneurysmal diameter), SR value (ratio of maximum tumor depth to proximal parent artery diameter), and signal intensity were measured. Results There were 7 aneurysms with UIA located in the anterior cerebral artery, 31 aneurysms with UIA in the middle cerebral artery, 1 aneurysm with UIA in the posterior cerebral artery, 18 aneurysms with UIA in the anterior communication, 5 aneurysms with UIA in the posterior communication, 34 aneurysms with UIA in the intracranial segment of the internal carotid artery and 3 aneurysms with UIA in the vertebral artery. Among them, 8 patients had more than two multiple aneurysms. The lesion size was 2-38mm (6.3 ± 5.09). There are 46 aneurysms with wall enhancement: the maximum SR value was 7.03 and the minimum 1.2, and the maximum AR value was 7.5 and the minimum 1.0. Fifty-five aneurysms showed no enhancement of the tumor wall. The maximum SR value was 4.55 and the minimum 0.58, and the maximum AR value was 4.0 and the minimum 0.6, respectively. Patients were divided into a stable group and an unstable group according to the aneurysm wall. The enhancement rate, SR value, and AR value in the stable aneurysm group were significantly lower than those in the unstable aneurysm group (P < 0.05). Conclusion MRA and HR-VWI can objectively reflect the stability of aneurysms by judging the morphology, SR value, and signal enhancement of UIA, and can provide a certain basis for diagnosis and treatment, which has become routine examination.
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Affiliation(s)
- Pengcheng Ma
- Department of Radiology, Kunming Yan ‘an Hospital, Kunming, 650000, People’s Republic of China
| | - Yadi Li
- Department of Ophthalmology, Affiliated Hospital of Yunnan University, Kunming, 650000, People’s Republic of China
| | - Yusen Feng
- Department of Radiology, Kunming Yan ‘an Hospital, Kunming, 650000, People’s Republic of China
| | - Gang Wu
- Department of Neurology, Kunming Yan ‘an Hospital, Kunming, 650000, People’s Republic of China
| | - Bin Li
- Department of Neurosurgery, Kunming Yan ‘an Hospital, Kunming, 650000, People’s Republic of China
| | - Haiyan Wu
- Department of Cardiovascular, Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650000, People’s Republic of China
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Shahrouki P, Gupta R, Belani P, Chien A, Doshi AH, De Leacy R, Fifi JT, Mocco J, Nael K. Differential Subsampling with Cartesian Ordering-MRA for Classifying Residual Treated Aneurysms. AJNR Am J Neuroradiol 2022; 43:887-892. [PMID: 35672082 DOI: 10.3174/ajnr.a7532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 04/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Differential Subsampling with Cartesian Ordering (DISCO), an ultrafast high-spatial-resolution head MRA, has been introduced. We aimed to determine the diagnostic performance of DISCO-MRA in grading residual aneurysm in comparison with TOF-MRA in patients with treated intracranial aneurysms. MATERIALS AND METHODS Patients with endovascular treatment and having undergone DISCO-MRA, TOF-MRA, and DSA were included for review. The voxel size and acquisition time were 0.75 × 0.75 × 1 mm3/6 seconds for DISCO-MRA and 0.6 × 0.6 × 1 mm3/6 minutes for TOF-MRA. Residual aneurysms were determined using the Modified Raymond-Roy Classification on TOF-MRA and DISCO-MRA by 2 neuroradiologists independently and were compared against DSA as the reference standard. Statistical analysis was performed using the κ statistic and the χ2 test. RESULTS Sixty-eight treated intracranial aneurysms were included. The intermodality agreement was κ = 0.82 (95% CI, 0.67-0.97) between DISCO and DSA and 0.44 (95% CI, 0.28-0.61) between TOF and DSA. Modified Raymond-Roy Classification scores matched DSA scores in 60/68 cases (88%; χ2 = 144.4, P < .001 for DISCO and 46/68 cases (68%; χ2 = 65.0, P < .001) for TOF. The diagnostic accuracy for the detection of aneurysm remnants was higher for DISCO (0.96; 95% CI, 0.88-0.99) than for TOF (0.79; 95% CI, 0.68-0.88). CONCLUSIONS In patients with endovascularly treated intracranial aneurysms, DISCO-MRA provides superior diagnostic performance in comparison with TOF-MRA in delineating residual aneurysms in a fraction of the time.
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Affiliation(s)
- P Shahrouki
- From the Department of Radiological Sciences (P.S., A.C., K.N.), University of California Los Angeles, Los Angeles, California
| | - R Gupta
- Department of Radiology (R.G., P.B., A.D., K.N.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - P Belani
- Department of Radiology (R.G., P.B., A.D., K.N.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - A Chien
- From the Department of Radiological Sciences (P.S., A.C., K.N.), University of California Los Angeles, Los Angeles, California
| | - A H Doshi
- Department of Radiology (R.G., P.B., A.D., K.N.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - R De Leacy
- Department of Neurosurgery (R.D.L., J,F., J.M.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - J T Fifi
- Department of Neurosurgery (R.D.L., J,F., J.M.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - J Mocco
- Department of Neurosurgery (R.D.L., J,F., J.M.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - K Nael
- From the Department of Radiological Sciences (P.S., A.C., K.N.), University of California Los Angeles, Los Angeles, California .,Department of Radiology (R.G., P.B., A.D., K.N.), Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
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Thamburaj K, Zammar S, Tsay A, Tun K, Simon S, Kalapos P, Fiorelli M, Cockroft K. Magnetic Resonance Angiography after Flow Diversion: The use of complementary MRA techniques to monitor aneurysm occlusion as well as device and arterial branch patency after flow diverter placement. World Neurosurg 2022; 162:e147-e155. [PMID: 35248768 DOI: 10.1016/j.wneu.2022.02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies have been performed to evaluate flow diversion with MRA. They have shown better success for MRA to assess the aneurysm response but limited success for the stent patency. Further, the patency of arterial branches on MRA remains to be explored. METHODS 31 consecutive cases of carotid aneurysms treated with flow diversion were retrospectively evaluated with noncontrast time of flight (TOF), contrast enhanced TOF (CTOF) and cine MRA (TWIST) independently by two investigators for aneurysm occlusion, stent patency and arterial branch patency. DSA served as the gold standard technique. RESULTS There were 6 males and 25 females in the age range of years (mean ±SD). Stent patency, aneurysm occlusion and branch patency, mostly revealed substantial to perfect interobserver agreement (k >0.60). The sensitivity, specificity, positive and negative predictive values for the stent patency on source images of TOF were 0.99,0.84, 0.42 and 0.99 and on CTOF were 0.99, 0.89, 0.50 and 0.99 respectively.Sensitivity for the aneurysm response on the three MRAs ranged from 0.88 to 0.93,specificity from 0.64 to 0.75, positive predictive value from 0.69 to 0.79 and negative predictive value from 0.86 to 0.90. Sensitivity for the arterial branch patency among the three MRAs, ranged from 0.55 to 0.93, specificity from 0.61 to 0.68, positive predictive value from 0.79 to 0.93 and negative predictive value from 0.22 to 0.90. CONCLUSIONS Aneurysm occlusion, stent patency and arterial branch patency in flow diversion can be successfully evaluated with the combination of three MRA techniques.
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Affiliation(s)
| | - Samer Zammar
- Department of Neurosurgery PennState Health Milton S Hershey Medical Center and PennState College of Medicine PennState University, Hershey, PA 17033
| | - Annie Tsay
- Internal Medicine Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139
| | - Kyaw Tun
- Pennstate Health Department of Radiology, Community Practice Division
| | - Scott Simon
- Department of Neurosurgery PennState Health Milton S Hershey Medical Center and PennState College of Medicine PennState University, Hershey, PA 17033
| | | | - Marco Fiorelli
- Department of Human Neurosciences, Sapienza University of Rome, Viale del Universita, 30, 00185, Rome, Italy
| | - Kevin Cockroft
- Department of Neurosurgery PennState Health Milton S Hershey Medical Center and PennState College of Medicine PennState University, Hershey, PA 17033
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