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Wali AR, Pathuri S, Brandel MG, Sindewald RW, Hirshman BR, Bravo JA, Steinberg JA, Olson SE, Pannell JS, Khalessi A, Santiago-Dieppa D. Reducing frame rate and pulse rate for routine diagnostic cerebral angiography: ALARA principles in practice. J Cerebrovasc Endovasc Neurosurg 2024; 26:46-50. [PMID: 38092365 PMCID: PMC10995471 DOI: 10.7461/jcen.2023.e2023.01.007] [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: 01/20/2023] [Revised: 08/21/2023] [Accepted: 09/16/2023] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE Diagnostic cerebral angiograms (DCAs) are widely used in neurosurgery due to their high sensitivity and specificity to diagnose and characterize pathology using ionizing radiation. Eliminating unnecessary radiation is critical to reduce risk to patients, providers, and health care staff. We investigated if reducing pulse and frame rates during routine DCAs would decrease radiation burden without compromising image quality. METHODS We performed a retrospective review of prospectively acquired data after implementing a quality improvement protocol in which pulse rate and frame rate were reduced from 15 p/s to 7.5 p/s and 7.5 f/s to 4.0 f/s respectively. Radiation doses and exposures were calculated. Two endovascular neurosurgeons reviewed randomly selected angiograms of both doses and blindly assessed their quality. RESULTS A total of 40 consecutive angiograms were retrospectively analyzed, 20 prior to the protocol change and 20 after. After the intervention, radiation dose, radiation per run, total exposure, and exposure per run were all significantly decreased even after adjustment for BMI (all p<0.05). On multivariable analysis, we identified a 46% decrease in total radiation dose and 39% decrease in exposure without compromising image quality or procedure time. CONCLUSIONS We demonstrated that for routine DCAs, pulse rate of 7.5 with a frame rate of 4.0 is sufficient to obtain diagnostic information without compromising image quality or elongating procedure time. In the interest of patient, provider, and health care staff safety, we strongly encourage all interventionalists to be cognizant of radiation usage to avoid unnecessary radiation exposure and consequential health risks.
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Affiliation(s)
- Arvin R. Wali
- Department of Neurosurgery, University of California San Diego, CA, USA
| | - Sarath Pathuri
- Long School of Medicine, University of Texas Health Sciences Center at San Antonio, TX, USA
| | | | - Ryan W. Sindewald
- Department of Neurosurgery, University of California San Diego, CA, USA
| | - Brian R. Hirshman
- Department of Neurosurgery, University of California San Diego, CA, USA
| | - Javier A. Bravo
- Department of General Surgery, University of California San Diego, CA, USA
| | | | - Scott E. Olson
- Department of Neurosurgery, University of California San Diego, CA, USA
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Baek J, Jeong HW, Heo YJ, Yun S, Kang M, Kim B, Kim EJ, Lim SM, Lee B. Comparison of Safety and Diagnostic Efficacy of Iohexol 240 mgI/mL, Iopamidol 250 mgI/mL, and Iodixanol 270 mgI/mL in Cerebral Angiography: A Prospective, Multicenter Study. Neurointervention 2023; 19:82-91. [PMID: 38834304 DOI: 10.5469/neuroint.2024.00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024] Open
Abstract
PURPOSE This multicenter prospective study aimed to evaluate the quality and diagnostic effectiveness of cerebral angiography images obtained using low-concentration iodinated contrast agents (iohexol 240 mgI/mL, iopamidol 250 mgI/mL, and iodixanol 270 mgI/mL) and to assess the safety thereof. The study addresses the need for safer contrast agent alternatives without compromising the diagnostic quality of identifying cerebrovascular disease. MATERIALS AND METHODS Conducted in 5 medical centers in South Korea, we enrolled patients aged 19 years or older who were referred for diagnostic cerebral angiography under non-emergency conditions, excluding those with specific health conditions and sensitivities. The study design included a prospective, observational approach with a 1-way analysis of variance (ANOVA) for sample size calculation, aiming for a total sample of 231 participants for adequate power. Image quality was evaluated using a 4-level scale by 2 independent, blinded radiologists, and adverse reactions were monitored both immediately and up to 7 days post-procedure. Statistical analysis involved 1-way ANOVA and Kruskal-Wallis tests to assess the image quality and safety profiles of the contrast agents. RESULTS Among 266 patients screened, 243 were included in the final analysis. The evaluation revealed no statistically significant differences in image quality among the 3 types of low-concentration contrast agents. Adverse events were observed in 28.8% of patients, with 27.2% experiencing acute reactions, primarily mild reactions, and 3.3% experiencing delayed reactions. The overall safety profile showed no significant changes in vital signs or electrocardiogram readings before and after contrast agent injection. CONCLUSION Using low-concentration iodinated contrast agents for cerebral angiography provides image quality comparable to that of conventional high-concentration agents, with no significant increase in adverse events, suggesting a safer alternative for patients.
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Affiliation(s)
- Jinwook Baek
- Department of Radiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Hae Woong Jeong
- Department of Radiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Young Jin Heo
- Department of Radiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Suyoung Yun
- Department of Radiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Myongjin Kang
- Department of Radiology, Dong-A University Hospital, Busan, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Eui Jong Kim
- Department of Radiology, Kyung Hee University Hospital, Seoul, Korea
| | - Soo Mee Lim
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Boeun Lee
- Department of Radiology, Ewha Womans University Seoul Hospital, Seoul, Korea
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Ki HJ, Kim BS, Kim JK, Choi JH, Shin YS, Choi Y, Shin NY, Jang J, Ahn KJ. Low-Dose Three-Dimensional Rotational Angiography for Evaluating Intracranial Aneurysms: Analysis of Image Quality and Radiation Dose. Korean J Radiol 2022; 23:256-263. [PMID: 35029071 PMCID: PMC8814704 DOI: 10.3348/kjr.2021.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to evaluate the image quality and dose reduction of low-dose three-dimensional (3D) rotational angiography (RA) for evaluating intracranial aneurysms. Materials and Methods We retrospectively evaluated the clinical data and 3D RA datasets obtained from 146 prospectively registered patients (male:female, 46:100; median age, 58 years; range, 19–81 years). The subjective image quality of 79 examinations obtained from a conventional method and 67 examinations obtained from a low-dose (5-seconds and 0.10-µGy/frame) method was assessed by two neurointerventionists using a 3-point scale for four evaluation criteria. The total image quality score was then obtained as the average of the four scores. The image quality scores were compared between the two methods using a noninferiority statistical testing, with a margin of -0.2 (i.e., score of low-dose group – score of conventional group). For the evaluation of dose reduction, dose-area product (DAP) and air kerma (AK) were analyzed and compared between the two groups. Results The mean total image quality score ± standard deviation of the 3D RA was 2.97 ± 0.17 by reader 1 and 2.95 ± 0.20 by reader 2 for conventional group and 2.92 ± 0.30 and 2.95 ± 0.22, respectively, for low-dose group. The image quality of the 3D RA in the low-dose group was not inferior to that of the conventional group according to the total image quality score as well as individual scores for the four criteria in both readers. The mean DAP and AK per rotation were 5.87 Gy-cm2 and 0.56 Gy, respectively, in the conventional group, and 1.32 Gy-cm2 (p < 0.001) and 0.17 Gy (p < 0.001), respectively, in the low-dose group. Conclusion Low-dose 3D RA was not inferior in image quality and reduced the radiation dose by 70%–77% compared to the conventional 3D RA in evaluating intracranial aneurysms.
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Affiliation(s)
- Hee Jong Ki
- Department of Neurosurgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Bum-Soo Kim
- Department of Radiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.
| | - Jun-Ki Kim
- Department of Neurosurgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jai Ho Choi
- Department of Neurosurgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yangsean Choi
- Department of Radiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Na-Young Shin
- Department of Radiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jinhee Jang
- Department of Radiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Kook-Jin Ahn
- Department of Radiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Nocum DJ, Robinson J, Halaki M, Båth M, Mekiš N, Liang E, Thompson N, Moscova M, Reed W. UTERINE ARTERY EMBOLISATION: CONTINUOUS QUALITY IMPROVEMENT REDUCES RADIATION DOSE WHILE MAINTAINING IMAGE QUALITY. RADIATION PROTECTION DOSIMETRY 2021; 196:159-166. [PMID: 34595527 DOI: 10.1093/rpd/ncab145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/01/2021] [Accepted: 09/09/2021] [Indexed: 06/13/2023]
Abstract
The purpose of this study was to introduce a continuous quality improvement (CQI) program for radiation dose optimisation during uterine artery embolisation (UAE) and assess its impact on dose reduction and image quality. The CQI program investigated the effects of optimising radiation dose parameters on the kerma-area product (KAP) and image quality when comparing a 'CQI intervention' group (n = 50) and 'Control' group (n = 50). Visual grading characteristics (VGC) analysis was used to assess image quality, using the 'Control' group as a reference. A significant reduction in KAP by 17% (P = 0.041, d = 0.2) and reference air kerma (Ka, r) by 20% (P = 0.027, d = 0.2) was shown between the two groups. The VGC analysis resulted in an area under the VGC curve (AUCVGC) of 0.54, indicating no significant difference in image quality between the two groups (P = 0.670). The implementation of the CQI program and optimisation of radiation dose parameters improved the UAE radiation dose practices at our centre. The dose reduction demonstrated no detrimental effects on image quality.
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Affiliation(s)
- Don J Nocum
- San Radiology & Nuclear Medicine, Sydney Adventist Hospital, Wahroonga, NSW, Australia
- Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - John Robinson
- Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Mark Halaki
- Discipline of Exercise and Sports Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Magnus Båth
- Department of Radiation Physics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Nejc Mekiš
- Medical Imaging and Radiotherapy Department, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Eisen Liang
- San Radiology & Nuclear Medicine, Sydney Adventist Hospital, Wahroonga, NSW, Australia
- Sydney Adventist Hospital Clinical School, Faculty of Medicine and Health, University of Sydney, Wahroonga, NSW, Australia
| | - Nadine Thompson
- San Radiology & Nuclear Medicine, Sydney Adventist Hospital, Wahroonga, NSW, Australia
- Sydney Adventist Hospital Clinical School, Faculty of Medicine and Health, University of Sydney, Wahroonga, NSW, Australia
| | - Michelle Moscova
- School of Medical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Warren Reed
- Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Medical Imaging Optimisation and Perception Group (MIOPeG), Discipline of Medical Imaging Science, Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Feasibility of low-dose digital subtraction angiography protocols for the endovascular treatment of intracranial dural arteriovenous fistulas. Neuroradiology 2020; 63:267-273. [PMID: 32857215 DOI: 10.1007/s00234-020-02537-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Among neurointerventional procedures, the embolization of complex shunt lesions usually requires more radiation dose. We aimed to evaluate the procedural outcome and safety in using low-dose DSA protocols for intracranial dural arteriovenous fistula (AVF) embolization treatment. METHODS Between January 2014 and July 2018, 55 patients with dural AVFs who underwent endovascular treatment were included in the study. The low-dose group (n = 27) included from January 2016 used various low-dose DSA protocols made by modifying the thickness of the copper filter or the detector entrance dose. We compared radiation dose metrics, such as air-kerma, kerma-air product (KAP), and fluoroscopy time, as well as clinical and imaging outcomes with the conventional-dose group (n = 28) included before January 2016. RESULTS The total KAP was 40.1% lower in the low-dose group (87.9 vs. 146.7 Gy cm2, p = 0.002). The average number of DSA runs (25.1 vs. 25.5, p = 0.86) and fluoroscopy times (77.4 vs. 69.7 min, p = 0.48) were similar between the groups. An immediate favorable occlusion rate (total or near total occlusion) was achieved in 41 (74.5%) patients. Ten patients (18.2%) underwent additional procedures due to residual (n = 6) and/or recurrent (n = 5) lesions. At a median of 10 months follow-up, 45 patients (86.5%) had achieved favorable occlusion. Treatment outcomes showed no significant between-group differences. There was one case (1.8%) of procedure-related complications in the low-dose group. All but one patient showed favorable clinical outcomes (modified Rankin score ≤ 2). CONCLUSION The low-dose protocols were feasible by showing significant radiation dose reduction and acceptable procedural outcome.
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Song Y, Han S, Kim BJ, Oh SH, Kim JS, Kim TI, Lee DH. Low-Dose Fluoroscopy Protocol for Diagnostic Cerebral Angiography. Neurointervention 2020; 15:67-73. [PMID: 32450675 PMCID: PMC7412660 DOI: 10.5469/neuroint.2020.00129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE We applied a low-dose fluoroscopic protocol in routine diagnostic cerebral angiography and evaluated the feasibility of the protocol. MATERIALS AND METHODS We retrospectively reviewed a total of 60 patients who underwent diagnostic cerebral angiography for various neurovascular diseases from September to November 2019. Routine protocols were used for patients in the first phase and low-dose protocols in the second phase. We compared radiation dose, fluoroscopy time, and complications between groups. RESULTS Age, diseases, and operators were not significantly different between the two groups. The mean fluoroscopy dose significantly decreased by 52% in the low-dose group (3.09 vs. 6.38 Gy·cm2 ); however, the total dose was not significantly different between the two groups (34.07 vs. 33.70 Gy·cm2 ). The total fluoroscopic time was slightly longer in the low-dose group, but the difference was not statistically significant (12.2. vs. 12.5 minutes). In all patients, angiography was successfully performed without complications. CONCLUSION The low-dose fluoroscopy protocol is feasible to apply for diagnostic cerebral angiography in that this protocol could significantly reduce the fluoroscopic dose.
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Affiliation(s)
- Yunsun Song
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seongsik Han
- Department of Radiologic Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Jun Kim
- Advanced Therapies, Siemens Healthineers Ltd., Seoul, Korea
| | - Seong Heum Oh
- Department of Radiologic Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Su Kim
- Department of Radiologic Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Radiologic Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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