Dual-Energy CT Angiography in the Evaluation of Intracranial Aneurysms: Image Quality, Radiation Dose, and Comparison With 3D Rotational Digital Subtraction Angiography

Current trends in the characterization and monitoring of vascular response to cancer therapy

Tumor vascular physiology is an important determinant of disease progression as well as the therapeutic outcome of cancer treatment. Angiogenesis or the lack of it provides crucial information about the tumor's blood supply and therefore can be used as an index for cancer growth and progression. While standalone anti-angiogenic therapy demonstrated limited therapeutic benefits, its combination with chemotherapeutic agents improved the overall survival of cancer patients. This could be attributed to the effect of vascular normalization, a dynamic process that temporarily reverts abnormal vasculature to the normal phenotype maximizing the delivery and intratumor distribution of chemotherapeutic agents. Longitudinal monitoring of vascular changes following antiangiogenic therapy can indicate an optimal window for drug administration and estimate the potential outcome of treatment. This review primarily focuses on the status of various imaging modalities used for the longitudinal characterization of vascular changes before and after anti-angiogenic therapies and their clinical prospects.

A retrospective observation study for the diagnostic effect of dual-source CT angiography on traumatic subarachnoid hemorrhage patients

Identification of potential cerebrovascular disorder in the patient with traumatic subarachnoid hemorrhage (tSAH) is a key element to decrease the complication occurrence and mortality rate. In this study, we aim to compare the diagnostic values between dual-source computed tomography angiography (DSCTA) and traditional tomography angiography (CTA) in identification of potential cerebrovascular disorder among tSAH patients. A total of 113 tSAH patients with the hemorrhage involving more than 2 cisterns were recruited. Among that, 42 patients received DSCTA scans, and another 71 patients received traditional CTA scans. Subsequently, all patients received digital subtraction angiography (DSA) tests to confirm the presence of the cerebrovascular disorder. In DSCTA scan group, 21.4 % (9/42) patients were reported to have cerebrovascular disorders: seven patients had intracranial aneurysms; a patient had pseudoaneurysm with carotid artery cavernous sinus fistula; and a patient had Moyamoya disease. DSA tests had the same results with that with DSCTA scans. In the cohort receiving CTA scans, 19.7 % (14/71) patients were reported to had intracranial aneurysms. However, the positive results of DSA tests for this cohort were 22.5 % (16/71). Two inconsistent results between the CTA scan and DSA test were found, including an arteriovenous malformation and an arteriovenous fistula. In summary, DSCTA and CTA had similar positive rates but differ in diagnostic accuracy for identification of cerebrovascular disorders in tSAH patients.

Diagnosis and management of subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.

Neuroradiology Applications of Dual and Multi-energy Computed Tomography

Computed tomography (CT) imaging has become an essential diagnostic tool for most emergent clinical conditions, owing to its speed, accuracy, cost, and few contraindications, compared with MR imaging cross-sectional imaging. Spectral CT, which includes dual, multienergy, and photon-counting CT, is superior to conventional single-energy CT (SECT) in many respects. Spectral information enables differentiation between materials with similar Hounsfield Unit attenuations on SECT; examples include but are not limited to "virtual noncontrast," "virtual noncalcium," and most notably for neuro applications, "hemorrhage versus iodine." This article expands on the many possible benefits of spectral CT in neuroimaging.

Imaging Modalities for Intracranial Aneurysm: More Than Meets the Eye

Intracranial aneurysms (IA) are often asymptomatic and have a prevalence of 3 to 5% in the adult population. The risk of IA rupture is low, however when it occurs half of the patients dies from subarachnoid hemorrhage (SAH). To avoid this fatal evolution, the main treatment is an invasive surgical procedure, which is considered to be at high risk of rupture. This risk score of IA rupture is evaluated mainly according to its size and location. Therefore, angiography and anatomic imaging of the intracranial aneurysm are crucial for its diagnosis. Moreover, it has become obvious in recent years that several other factors are implied in this complication, such as the blood flow complexity or inflammation. These recent findings lead to the development of new IA imaging tools such as vessel wall imaging, 4D-MRI, or molecular MRI to visualize inflammation at the site of IA in human and animal models. In this review, we will summarize IA imaging techniques used for the patients and those currently in development.

Radiological investigations in non-aneurysmal subarachnoid haemorrhage: A 5-year review

•

All patients with a Fisher grade 2 bleed and a negative CT angiogram had catheter angiography negative for any abnormality.

•

Neuroradiologists identified vascular abnormalities not reported by district general hospitals.

•

Follow-up MRI may be a useful adjunct in subarachnoid haemorrhage.

Principles and Applications of Dual Energy Computed Tomography in Neuroradiology

Dual-energy computed tomography (DE CT) is a promising tool with many current and evolving applications. Available DE CT scanners usually consist of one or two tubes, or use layered detectors for spectral separation. Most DE CT scanners can be used in single energy or dual-energy mode, except for the layered detector scanners that always acquire data in dual-energy mode. However, the layered detector scanners can retrospectively integrate the data from two layers to obtain conventional single energy images. DE CT mode enables generation of virtual monochromatic images, blended images, iodine quantification, improving conspicuity of iodinated contrast enhancement, and material decomposition maps or more sophisticated quantitative analysis not possible with conventional SE CT acquisition with an acceptable or even lower dose than the SE CT. This article reviews the basic principles of dual-energy CT and highlights many of its clinical applications in the evaluation of neurological conditions.

Use of dual-energy computed tomography post endovascular treatment of cerebral aneurysm

Background:

Along with surgical clipping, endovascular management is one of the mainstay treatment options for cerebral aneurysms. However, immediate post procedural imaging is often hard to interpret due to the presence of contrast material. Dual-energy computed tomography (CT) allows differentiation between contrast extravasation and intracranial hemorrhage and this case illustrates the importance of this following endovascular treatment of an unruptured cerebral aneurysm.

Case Description:

A patient presented with acute ophthalmoplegia secondary to mass effect from an intracavernous ICA fusiform aneurysm. The patient underwent an endovascular flow diverting stent to treat this aneurysm. Post procedure, the patient had a reduced level of consciousness and underwent a conventional CT showing diffuse subarachnoid hyperdensity of the left hemisphere. Dual-energy CT allowed accurate differentiation and illustrated diffuse contrast material extravasation, allowing patient to continue on dual antiplatelets and therapeutic anticoagulation to reduce the risk of ischemic injury post endovascular stent.

Conclusion:

Use of dual-energy CT in the setting of endovascular management of intracranial aneurysms allows accurate diagnosis of any postoperative complications. Specifically, differentiating between subarachnoid hemorrhage and contrast extravasation is vital in these patients due to the significant consequences to their ongoing management in regard to continuation or cessation of antiplatelets or anticoagulation. With increasing access to this technology, its use should become standard practice in the post-operative investigation of these patients undergoing endovascular treatment.

Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage

Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.

Carotid and cerebrovascular dual-energy computed tomography angiography: Optimization of window settings for virtual monoenergetic imaging reconstruction

PURPOSE

Dedicated post-processing of dual-energy computed tomography angiography (DE-CTA) datasets has been shown to allow for increased vascular contrast. The goal of our study was to define optimal window settings for displaying virtual monoenergetic images (VMI) reconstructed from dual-energy carotid and cerebrovascular DE-CTA.

METHODS

Fifty-seven patients who underwent clinically-indicated carotid and cerebrovascular third-generation dual-source DE-CTA were retrospectively evaluated. Standard linearly-blended (M_0.6), 70-keV traditional VMI (M70), and 40-keV noise-optimized VMI (M40+) reconstructions were analyzed. For M70 and M40+ datasets, the subjectively best window setting (width and level, B-W/L) was independently determined by two observers and subsequently related with aortic arch attenuation to calculate optimized values (O-W/L) using linear regression. Subjective evaluation of image quality (IQ) between W/L settings were assessed by two additional readers. Repeated measures analysis of variance were performed to compare W/L settings and IQ indices between M_0.6, M70, and M40 + .

RESULTS

B-W/L and O-W/L for M70 were 580/210 and 560/200, and for M40+ were 1630/570 and 1560/550, respectively, higher than standard DE-CTA W/L settings (450/100). Highest subjective scores were observed for M40+ regarding overall IQ (all p < 0.001).

CONCLUSION

Application of O-W/L settings is mandatory to optimize subjective IQ of VMI reconstructions of DE-CTA.

K-edge subtraction imaging for iodine and calcium separation at a compact synchrotron x-ray source

Purpose: About one third of all deaths worldwide can be traced to some form of cardiovascular disease. The gold standard for the diagnosis and interventional treatment of blood vessels is digital subtraction angiography (DSA). An alternative to DSA is K-edge subtraction (KES) imaging, which has been shown to be advantageous for moving organs and for eliminating image artifacts caused by patient movement. As highly brilliant, monochromatic x-rays are required for this method, it has been limited to synchrotron facilities so far, restraining the applicability in the clinical routine. Over the past decades, compact synchrotron x-ray sources based on inverse Compton scattering have been evolving; these provide x-rays with sufficient brilliance and meet spatial and financial requirements for laboratory settings or university hospitals. Approach: We demonstrate a proof-of-principle KES imaging experiment using the Munich Compact Light Source (MuCLS), the first user-dedicated installation of a compact synchrotron x-ray source worldwide. A series of experiments were performed both on a phantom and an excised human carotid to demonstrate the ability of the proposed KES technique to separate the iodine contrast agent and calcifications. Results: It is shown that the proposed filter-based KES method allows for the iodine-contrast agent and calcium to be clearly separated, thereby providing x-ray images only showing one of the two materials. Conclusions: The results show that the quasimonochromatic spectrum of the MuCLS enables filter-based KES imaging and can become an important tool in preclinical research and possible future clinical diagnostics.

A Review of the Applications of Dual-Energy CT in Acute Neuroimaging

Dual-energy computed tomography (CT) is a promising tool with increasing availability and multiple emerging and established clinical applications in neuroradiology. With its ability to allow characterization of materials based on their differential attenuation when imaged at two different energy levels, dual-energy CT can help identify the composition of brain, neck, and spinal components. Virtual monoenergetic imaging allows a range of simulated single energy-level reconstructions to be created with postprocessing. Low-energy reconstructions can aid identification of edema, ischemia, and subtle lesions due to increased soft tissue contrast as well as increasing contrast-to-noise ratios on angiographic imaging. Higher energy reconstructions can reduce image artifact from dental amalgam, aneurysm clips and coils, spinal hardware, dense contrast, and dense bones. Differentiating iodine from hemorrhage may help guide management of patients after thrombectomy and aid diagnosis of enhancing tumors within parenchymal hemorrhages. Iodine quantification may predict hematoma expansion in aneurysmal bleeds and outcomes in traumatic brain injury. Calcium and bone subtraction can be used to distinguish hemorrhage from brain parenchymal mineralization as well as improving visualization of extra-axial lesions and vessels adjacent to dense plaque or skull. This article reviews the basics of dual-energy CT and highlights many of its clinical applications in the evaluation of acute neurological presentations.

Three-dimensional visualization of aneurysm wall calcification by cerebral angiography: Technical case report

BACKGROUND

We describe on a 57-year-old man with an incidental middle cerebral artery (MCA) aneurysm in whom a preoperative standard three-dimensional rotational angiogram (3D-RA) was used to depict luminal morphology along with 3D density rendering to precisely locate aneurysm wall calcification.

METHODS

To detect aneurysm calcification, a native 3D rotational angiogram was acquired for calcium density visualization, followed by an intraarterial contrast-enhanced 3D rotational angiogram in the same location. Both data sets were postprocessed obtaining a 3D calcium volume rendering on a 3D-RA.

RESULTS

Depiction of both the MCA luminal aneurysm morphology as well as calcium-rich components in the aneurysm wall was valuable to determine treatment strategy towards surgery.

CONCLUSION

Imaging of luminal morphology and calcification within the same angiographic procedure allows for a plain and simple estimation of the degree and distribution of brain aneurysm wall calcification with limited amount of additional radiation dosage.

Application of computed tomography angiography for evaluating clinical morphology in intracranial aneurysms - monocentric study

Objective

To examine the clinical effect of computed tomography angiography (CTA) on parameters of intracranial aneurysms in different locations and with different sizes using digital subtraction angiography (DSA) as the standard.

Methods

Patients with intracranial aneurysms who underwent CTA examinations at the same center and received DSA examinations within 3 days were analyzed retrospectively. The morphological parameters of the aneurysms and parent arteries were measured with these two methods.

Results

Mean aneurysm size and parent artery diameter were not different between CTA and DSA. The size of microaneurysms was significantly smaller with DSA than with CTA. The aneurysmal neck width was not different between CTA and DSA. DSA could clearly evaluate the relationship between the aneurysmal neck and the parent artery in all cases. However, CTA had a 90% accuracy rate of visualizing this relationship.

Conclusion

The accuracy rates of evaluating aneurysm size and the aneurysmal neck width and parent artery diameter are similar between CTA and DSA. A DSA examination is essential for evaluating the relationship among microaneurysms, the aneurysmal neck, and the parent artery. CTA is widely applied and more safe in clinical practice, while DSA has a better guiding effect than CTA for some complicated aneurysms.

Current Perspectives in Imaging Modalities for the Assessment of Unruptured Intracranial Aneurysms: A Comparative Analysis and Review

BACKGROUND

Intracranial aneurysms (IAs) are pathologic dilatations of cerebral arteries. This systematic review summarizes and compares imaging techniques for assessing unruptured IAs (UIAs). This review also addresses their uses in different scopes of practice. Pathophysiologic mechanisms are reviewed to better understand the clinical usefulness of each imaging modality.

METHODS

A literature review was performed using PubMed with these search terms: "intracranial aneurysm," "cerebral aneurysm," "magnetic resonance angiography (MRA)," computed tomography angiography (CTA)," "catheter angiography," "digital subtraction angiography," "molecular imaging," "ferumoxytol," and "myeloperoxidase". Only studies in English were cited.

RESULTS

Since the development and improvement of noninvasive diagnostic imaging (computed tomography angiography and magnetic resonance angiography), many prospective studies and meta-analyses have compared these tests with gold standard digital subtraction angiography (DSA). Although computed tomography angiography and magnetic resonance angiography have lower detection rates for UIAs, they are vital in the treatment and follow-up of UIAs. The reduction in ionizing radiation and lack of endovascular instrumentation with these modalities provide benefits compared with DSA. Novel molecular imaging techniques to detect inflammation within the aneurysmal wall with the goal of stratifying risk based on level of inflammation are under investigation.

CONCLUSIONS

DSA remains the gold standard for preoperative planning and follow-up for patients with IA. Newer imaging modalities such as ferumoxytol-enhanced magnetic resonance imaging are emerging techniques that provide critical in vivo information about the inflammatory milieu within aneurysm walls. With further study, these techniques may provide aneurysm rupture risk and prediction models for individualized patient care.

Advances in the Study of the Middle Cranial Fossa through Cutting Edge Neuroimaging Techniques

The objective of this paper is to present a morphometric study of the middle cranial fossa from the study of 87 patients using cutting edge multislice computed tomography scans (32 detectors) and Magnetic Resonance Imaging. The study presents a detailed anatomical-radiological and morphometric analysis of the middle cranial fossa as well as its neurovascular elements in normal conditions. The implications of this investigation in training and clinical contexts are discussed.

Dual-Energy CT in Emergency Neuroimaging: Added Value and Novel Applications

Dual-energy computed tomography (CT) is a powerful diagnostic tool that is becoming more widely clinically available. Dual-energy CT has the potential to aid in the detection or add diagnostic confidence in the evaluation of a variety of emergent neurologic conditions with use of postprocessing techniques that allow one to take advantage of the different x-ray energy-dependent absorption behaviors of different materials. Differentiating iodine from hemorrhage may help in delineating CT angiographic spot signs, which are small foci of intracranial hemorrhage seen on CT angiograms in cases of acute hemorrhage. Bone subtraction can be used to effectively exclude osseous structures surrounding enhancing vessels at imaging for improved vessel visualization and to create images that are similar in appearance to three-dimensional magnetic resonance imaging vessel reconstructions. Bone subtraction may also be helpful for improving the conspicuity of small extra-axial fluid collections and extra-axial masses. Material characterization can be helpful for clarifying whether small foci of intermediate attenuation represent hemorrhage, calcification, or a foreign material, and it may also be useful for quantifying the amount of hemorrhage or iodine in preexisting or incidentally detected lesions. Virtual monochromatic imaging also can be used to problem solve in challenging cases. ^©RSNA, 2016.

Small Intracranial Aneurysms: Diagnostic Accuracy of CT Angiography

Purpose To assess the accuracy of computed tomographic (CT) angiography for diagnosis of cerebral aneurysms 5 mm or smaller, with digital subtraction angiography (DSA) as the reference standard, in a large patient cohort Materials and Methods This retrospective study was approved by the local institutional review board with a waiver of written informed consent. A total of 1366 patients who underwent cerebral CT angiography followed by DSA were included. The performance of CT angiography for depiction of aneurysms was evaluated by two readers on a per-patient and per-aneurysm basis and based on size of aneurysm, location, and status of rupture. The performance of CT angiography for diagnosis of aneurysms of different size, location, and rupture status was compared by using χ² test. κ statistic was used to assess interreader agreement for diagnosis of aneurysms. Results Of 1366 patients, 579 patients had 711 small aneurysms at DSA. By using DSA as the reference standard, the respective sensitivity, specificity, and accuracy of CT angiography for readers 1 and 2 for detection of small aneurysms on a per-patient basis were 97.1% (562 of 579) and 97.4% (564 of 579), 98.5% (451 of 458) and 99.1% (454 of 458), and 97.7% (1013 of 1037) and 98.2% (1018 of 1037) and those on a per-aneurysm basis were 95.2% (677 of 711) and 95.4% (678 of 711), 96.6% (451 of 467) and 97.0% (454 of 468), and 95.8% (1128 of 1178) and 96.0% (1132 of 1179). The sensitivities of CT angiography were lower for detection of aneurysms smaller than 3 mm and unruptured compared with aneurysms that were 3-5 mm and ruptured (P < .001). No difference existed for the sensitivities of CT angiography for diagnosis of aneurysms in the anterior versus posterior circulation (P > .0167). Excellent or good interreader agreement was found for detection of intracranial aneurysms on a per-patient (κ = 0.982) and per-aneurysm (κ = 0.748) basis. Conclusion This large cohort study demonstrated that CT angiography had high accuracy for detection of small cerebral aneurysms, including those smaller than 3 mm. ^© RSNA, 2017 Online supplemental material is available for this article.

Dual- versus Single-Energy CT-Angiography Imaging for Patients Undergoing Intracranial Aneurysm Repair

BACKGROUND

The invasiveness and risk of thromboembolic complications of catheter angiography underline the need for alternative imaging modalities in patients following intracranial aneurysm (IA) repair. However, the overall image quality of existing noninvasive imaging modalities, such as single-energy CT angiography (SE-CTA), compromises its value in this respect.

OBJECTIVE

We prospectively investigated the value of a novel dual-energy CTA (DE-CTA) scanner and algorithm for assessing the degree of occlusion and parent vessel patency in patients following IA repair.

METHODS

A prospective cohort of 17 patients underwent DE-CTA imaging following surgical or endovascular IA repair. This dataset was matched with an identical historical cohort of 17 patients, who underwent IA repair and SE-CTA imaging. Beam-hardening artifacts, as a measure for objective imaging quality were analyzed based on the volume of a prolate ellipsoid, whereas subjective imaging quality at the IA site and corresponding parent vessels was rated by 2 independent neuroradiologists on a scale from 4 (excellent, no artifacts) to 1 (poor, severe artifacts).

RESULTS

Objective DE-CTA image quality was markedly higher, compared to SE-CTA in patients undergoing surgical (0.77 ± 0.23 vs. 10.91 ± 1.88 mL, respectively; p < 0.001) or endovascular (32.36 ± 10.62 vs. 107.63 ± 24.51 mL, respectively; p = 0.026) IA repair. Subjective image quality for DE-CTA was significantly improved compared to SE-CTA in the surgical group but not in the endovascular group. The calculated dose values for DE-CTA in our study remain markedly below the legally required radiation dose limits.

CONCLUSION

The imaging quality of DE-CTA, especially for patients undergoing surgical IA repair, is distinctly superior, compared to SE-CTA imaging. Therefore, DE-CTA may serve as a noninvasive alternative for assessing the IA occlusion rate and parent vessel patency.

Microscopic dual-energy CT (microDECT): a flexible tool for multichannel ex vivo 3D imaging of biological specimens

Dual-energy computed tomography (DECT) uses two different x-ray energy spectra in order to differentiate between tissues, materials or elements in a single sample or patient. DECT is becoming increasingly popular in clinical imaging and preclinical in vivo imaging of small animal models, but there have been only very few reports on ex vivo DECT of biological samples at microscopic resolutions. The present study has three main aims. First, we explore the potential of microscopic DECT (microDECT) for delivering isotropic multichannel 3D images of fixed biological samples with standard commercial laboratory-based microCT setups at spatial resolutions reaching below 10 μm. Second, we aim for retaining the maximum image resolution and quality during the material decomposition. Third, we want to test the suitability for microDECT imaging of different contrast agents currently used for ex vivo staining of biological samples. To address these aims, we used microCT scans of four different samples stained with x-ray dense contrast agents. MicroDECT scans were acquired with five different commercial microCT scanners from four companies. We present a detailed description of the microDECT workflow, including sample preparation, image acquisition, image processing and postreconstruction material decomposition, which may serve as practical guide for applying microDECT. The MATLAB script (The Mathworks Inc., Natick, MA, USA) used for material decomposition (including a graphical user interface) is provided as a supplement to this paper (https://github.com/microDECT/DECTDec). In general, the presented microDECT workflow yielded satisfactory results for all tested specimens. Original scan resolutions have been mostly retained in the separate material fractions after basis material decomposition. In addition to decomposition of mineralized tissues (inherent sample contrast) and stained soft tissues, we present a case of double labelling of different soft tissues with subsequent material decomposition. We conclude that, in contrast to in vivo DECT examinations, small ex vivo specimens offer some clear advantages regarding technical parameters of the microCT setup and the use of contrast agents. These include a higher flexibility in source peak voltages and x-ray filters, a lower degree of beam hardening due to small sample size, the lack of restriction to nontoxic contrast agents and the lack of a limit in exposure time and radiation dose. We argue that microDECT, because of its flexibility combined with already established contrast agents and the vast number of currently unexploited stains, will in future represent an important technique for various applications in biological research.

Single Phase Dual-energy CT Angiography: One-stop-shop Tool for Evaluating Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhages have extremely high case fatality in clinic. Early and rapid identifications of ruptured intracranial aneurysms seem to be especially important. Here we evaluate clinical value of single phase contrast-enhanced dual-energy CT angiograph (DE-CTA) as a one-stop-shop tool in detecting aneurysmal subarachnoid hemorrhage. One hundred and five patients who underwent true non-enhanced CT (TNCT), contrast-enhanced DE-CTA and digital subtraction angiography (DSA) were included. Image quality and detectability of intracranial hemorrhage were evaluated and compared between virtual non-enhanced CT (VNCT) images reconstructed from DE-CTA and TNCT. There was no statistical difference in image quality (P > 0.05) between VNCT and TNCT. The agreement of VNCT and TNCT in detecting intracranial hemorrhage reached 98.1% on a per-patient basis. With DSA as reference standard, sensitivity and specificity on a per-patient were 98.3% and 97.9% for DE-CTA in intracranial aneurysm detection. Effective dose of DE-CTA was reduced by 75.0% compared to conventional digital subtraction CTA. Thus, single phase contrast-enhanced DE-CTA is optimal reliable one-stop-shop tool for detecting intracranial hemorrhage with VNCT and intracranial aneurysms with DE-CTA with substantial radiation dose reduction compared with conventional digital subtraction CTA.

Subtraction CT angiography for the detection of intracranial aneurysms: A meta-analysis

The aim of this meta-analysis was to investigate the accuracy of subtraction computed tomography angiography (CTA) for diagnosing intracranial aneurysms. A systematic literature search up to January 1, 2013 was performed in PubMed. Two independent reviewers selected 8 studies that compared subtraction CTA with digital subtraction angiography. Data from the studies were used to construct a 2×2 contingency table on a per-patient basis in ≥5 diseased and 5 non-diseased patients, with additional data on a per-aneurysm basis. Overall, subtraction CTA had a pooled sensitivity of 99% [95% confidence interval (CI), 95-100%] and specificity of 94% (95% CI, 86-97%) for detecting and ruling out cerebral aneurysms, respectively, on a per-patient basis. On a per-aneurysm basis, the pooled sensitivity was 96% (95% CI, 90-99%), and the specificity was 91% (95% CI, 85-95%). In conclusion, subtraction CTA is a highly sensitive, specific and non-invasive method for the diagnosis and evaluation of intracranial aneurysms.

Diagnostic Impact of Bone-Subtraction CT Angiography for Patients with Acute Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Detection and evaluation of ruptured aneurysms is critical for choosing an appropriate endovascular or neurosurgical intervention. Our aim was to assess whether bone-subtraction CTA is capable of guiding treatment for cerebral aneurysms in patients with acute SAH and could replace DSA.

MATERIALS AND METHODS

We prospectively studied 116 consecutive patients with SAH with 16-detector row bone-subtraction CTA and DSA before intracranial aneurysm treatment. Two independent neuroradiologists reviewed the bone-subtraction CTA blinded to DSA (reference standard). We determined the accuracy of bone-subtraction CTA for aneurysm detection and the measurement of aneurysm dimensions and compared the radiation doses of the 2 imaging modalities.

RESULTS

Seventy-one patients (61%) had 74 aneurysms on DSA. Bone-subtraction CTA detected 73 of these aneurysms, but it detected 1 additional aneurysm. On a per-aneurysm basis, sensitivity, specificity, and positive and negative predictive values for bone-subtraction CTA were 99%, 98%, and 99% and 98%, respectively. For aneurysms of ≤3 mm, sensitivity was 94% (95% CI, 73%-99%). Bone-subtraction CTA slightly overestimated neck and dome diameters by <0.2 mm and overestimated the dome-to-neck ratios by 2% on average. Dose-length product was 565 ± 201 mGy × cm for bone-subtraction CTA and 1609 ± 1300 mGy × cm for DSA.

CONCLUSIONS

Bone-subtraction CTA is as accurate as DSA in detecting cerebral aneurysms after SAH, provides similar information about aneurysm configuration and measures, and reduces the average effective radiation dose for vascular diagnostics by 65%. Diagnostic equivalence in association with dose reduction suggests replacing DSA with bone-subtraction CTA in the diagnostic work-up of spontaneous SAH.

Noise Suppression for Dual-Energy CT Through Entropy Minimization

In dual energy CT (DECT), noise amplification during signal decomposition significantly limits the utility of basis material images. Since clinically relevant objects typically contain a limited number of different materials, we propose an Image-domain Decomposition method through Entropy Minimization (IDEM) for noise suppression in DECT. Pixels of decomposed images are first linearly transformed into 2D clusters of data points, which are highly asymmetric due to strong signal correlation. An optimal axis is identified in the 2D space via numerical search such that the projection of data clusters onto the axis has minimum entropy. Noise suppression is performed on each image pixel by estimating the center-of-mass value of each data cluster along the direction perpendicular to the projection axis. The IDEM method is distinct from other noise suppression techniques in that it does not suppress pixel noise by reducing spatial variation between neighboring pixels. As supported by studies on Catphan©600 and anthropomorphic head phantoms, this feature endows our algorithm with a unique capability of reducing noise standard deviation on DECT decomposed images by approximately one order of magnitude while preserving spatial resolution and image noise power spectra (NPS). Compared with a filtering method and recently developed iterative method at the same level of noise suppression, the IDEM algorithm obtains high-resolution images with less artifacts. It also maintains accuracy of electron density measurements with less than 2% bias error. The IDEM method effectively suppresses noise of DECT for quantitative use, with appealing features on preservation of image spatial resolution and NPS.

Spontaneous subarachnoid hemorrhage and negative initial vascular imaging--should further investigation depend upon the pattern of hemorrhage on the presenting CT?

BACKGROUND

Multiple investigations are usually performed in patients with spontaneous SAH who have negative initial angiography. This study aimed to evaluate the most appropriate use of additional imaging studies and how this may be influenced by the findings of the initial CT.

METHODS

A retrospective analysis was performed on a prospectively collected cohort of patients referred with spontaneous SAH and negative initial angiography. The patients were divided into four categories based upon the distribution of blood on the initial CT: perimesencephalic (pSAH), diffuse (dSAH), sulcal (sSAH) and CT negative (CSF positive for xanthochromia) (nCT-pLP). The number and nature of the subsequent imaging investigations were reviewed, and the results were correlated with the findings of the presenting CT.

RESULTS

One hundred fourteen patients were included in the study. Repeat imaging found five relevant abnormalities. Three cases of vasculitis were diagnosed on the first DSA following a negative CTA. A case of dissecting aneurysm was revealed on the third neurovascular study. A hemorrhagic spinal tumor presented with xanthochromia. No subsequent abnormality was found on the third DSA or MRI head. No case of pSAH had a subsequent positive finding if the initial CTA was negative.

CONCLUSIONS

Certain patterns of SAH are associated with a low yield of abnormalities on repeat imaging if the initial angiography is normal. The authors believe that the pattern of hemorrhage on the presenting CT should be used to guide the most appropriate use of further imaging modalities and present a diagnostic algorithm for this purpose.

Neuroimaging of headaches associated with vascular disorders

Headaches from vascular causes need to be differentiated from primary headaches because a misdiagnosis may lead to dire consequences for the patient. Neuroimaging is critical in identifying patients with vascular headaches and identifying the nature of the pathologic disorder causing these headaches. In addition, the imaging findings guide the physician regarding the optimal treatment modality for these lesions. This review summarizes the nuances of differentiating patients with secondary headaches related to vascular disease and discusses pertinent neuroimaging studies.

Prevalence and clinical significance of extravascular incidental findings in patients undergoing CT cervico-cerebral angiography

INTRODUCTION

CT cervico-cerebral angiography (CTCCA) is now the first line diagnostic imaging modality for the majority of vascular pathologies of the head and neck with diagnostic value comparable to or better than traditional angiographic techniques. The aim of this study was to assess the prevalence, clinical significance and management of extravascular incidental findings detected on CTCCA.

MATERIALS AND METHODS

A retrospective review of the CTCCA reports of 302 consecutive patients from 2009 to 2013 was undertaken. Extravascular incidental findings were classified, according to an adaptation of the CT colonography data and reporting system (CRADS), as EV1-EV4. EV1=no incidental findings, EV2=clinically insignificant incidental finding, EV3=incidental finding of intermediate clinical significance, EV4=highly clinically significant finding. Follow up of the electronic medical records of patients with EV3 or EV4 findings was undertaken to determine subsequent management.

RESULTS

Potentially clinically significant findings were demonstrated in 14.2% of patients with 8.6% of patients having a highly clinically significant finding. 4 incidental findings were confirmed to be malignant lesions and 5 required acute intervention. In addition 19% of patients with highly clinically significant incidental findings did not receive appropriate follow up.

DISCUSSION

This study has demonstrated the presence of clinically important incidental findings in a significant proportion of patients undergoing CTCCA with a significant minority of these patients not receiving follow up. A standardised method of reporting incidental findings, such as that used in this paper, would aid radiologists and referring physicians in recording and communicating these findings.

Dual-Energy CT: What the Neuroradiologist Should Know

Because of the different attenuations of tissues at different energy levels, dual-energy CT offers tissue differentiation and characterization, reduction of artifacts, and remodeling of contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR), hereby creating new opportunities and insights in CT imaging. The applications for dual-energy imaging in neuroradiology are various and still expanding. Automated bone removal is used in CT angiography and CT venography of the intracranial vessels. Monoenergetic reconstructions can be used in patients with or without metal implants in the brain and spine to reduce artifacts, improve CNR and SNR, or to improve iodine conspicuity. Differentiation of iodine and hemorrhage is used in high-density lesions, after intra-arterial recanalization in stroke patients or after administration of contrast media. Detection of underlying (vascular and non-vascular) pathology and spot sign can be used in patients presenting with (acute) intracranial hemorrhage.

The value of cerebral CT angiography with low tube voltage in detection of intracranial aneurysms

Objective. The aim of this study is to investigate the value of cerebral CT angiography (CTA) with low tube voltage in detection of intracranial aneurysms. Materials and Methods. A total of 294 consecutive patients with spontaneous subarachnoid hemorrhage (SAH) were enrolled in this study and randomly assigned into conventional voltage CTA (C-CTA) group and low voltage CTA (L-CTA) group. The objective and subjective image qualities were analyzed and compared between C-CTA and L-CTA groups. With the results of 3D-DSA as “gold standard,” the sensitivity, specificity, and accuracy of C-CTA and L-CTA in diagnosis of aneurysms were calculated and compared with each other. Results. Compared with group C-CTA, the CT dose index volume (CTDIvol) of group L-CTA reduced by 35.65%. There were no significant differences between C-CTA and L-CTA groups regarding objective and subjective image qualities. The sensitivity, specificity, and accuracy of L-CTA in diagnosis of aneurysms were 95.16%, 99.72%, and 99.42%, respectively. There were no significant differences in sensitivity, specificity, and accuracy between the C-CTA and L-CTA groups. Conclusion. The value of cerebral CTA with 100 kV low tube voltage in detection of intracranial aneurysms is significant, and it should be recommended as a routine scan method.

Radiation dose and image quality of 70 kVp cerebral CT angiography with optimized sinogram-affirmed iterative reconstruction: comparison with 120 kVp cerebral CT angiography

OBJECTIVES

To evaluate radiation dose, image quality, and optimal level of sinogram-affirmed iterative reconstruction (SAFIRE) of cerebral CT angiography (CTA) at 70 kVp.

METHODS

One hundred patients were prospectively classified into two groups: Group A (n = 50), 70 kVp cerebral CTA with 5 levels of SAFIRE reconstruction (S1-S5); and Group B (n = 50), 120 kVp with filtered back projection (FBP) reconstruction. CT attenuation values, noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the internal carotid artery (ICA) and middle cerebral artery (MCA) were measured. Subjective image quality was evaluated. Effective dose (ED) was estimated.

RESULTS

CT attenuation and noise of the ICA and MCA in Group A were higher than those of Group B (all P < 0.001) while the SNRICA, SNRMCA, CNRICA, and CNRMCA of Group A at S4-5 were comparable to (P > 0.05) or higher than in Group B (P < 0.05). There was no difference in overall image quality between Group A S3-5 and Group B (P > 0.05). ED was 0.2 ± 0.0 mSv for Group A with 85 % ED reduction in comparison to Group B (1.3 ± 0.2 mSv).

CONCLUSION

Cerebral CTA at 70 kVp is feasible, allowing for substantial radiation dose reduction. SAFIRE S4 level is recommended for obtaining optimal image quality.

KEY POINTS

• 70 kVp cerebral CTA is feasible and provides diagnostic image quality. • 70 kVp cerebral CTA resulted in 85% effective dose reduction. • S4 level of SAFIRE is recommended for 70 kVp cerebral CTA.

Iterative image-domain decomposition for dual-energy CT

PURPOSE

Dual energy CT (DECT) imaging plays an important role in advanced imaging applications due to its capability of material decomposition. Direct decomposition via matrix inversion suffers from significant degradation of image signal-to-noise ratios, which reduces clinical values of DECT. Existing denoising algorithms achieve suboptimal performance since they suppress image noise either before or after the decomposition and do not fully explore the noise statistical properties of the decomposition process. In this work, the authors propose an iterative image-domain decomposition method for noise suppression in DECT, using the full variance-covariance matrix of the decomposed images.

METHODS

The proposed algorithm is formulated in the form of least-square estimation with smoothness regularization. Based on the design principles of a best linear unbiased estimator, the authors include the inverse of the estimated variance-covariance matrix of the decomposed images as the penalty weight in the least-square term. The regularization term enforces the image smoothness by calculating the square sum of neighboring pixel value differences. To retain the boundary sharpness of the decomposed images, the authors detect the edges in the CT images before decomposition. These edge pixels have small weights in the calculation of the regularization term. Distinct from the existing denoising algorithms applied on the images before or after decomposition, the method has an iterative process for noise suppression, with decomposition performed in each iteration. The authors implement the proposed algorithm using a standard conjugate gradient algorithm. The method performance is evaluated using an evaluation phantom (Catphan©600) and an anthropomorphic head phantom. The results are compared with those generated using direct matrix inversion with no noise suppression, a denoising method applied on the decomposed images, and an existing algorithm with similar formulation as the proposed method but with an edge-preserving regularization term.

RESULTS

On the Catphan phantom, the method maintains the same spatial resolution on the decomposed images as that of the CT images before decomposition (8 pairs/cm) while significantly reducing their noise standard deviation. Compared to that obtained by the direct matrix inversion, the noise standard deviation in the images decomposed by the proposed algorithm is reduced by over 98%. Without considering the noise correlation properties in the formulation, the denoising scheme degrades the spatial resolution to 6 pairs/cm for the same level of noise suppression. Compared to the edge-preserving algorithm, the method achieves better low-contrast detectability. A quantitative study is performed on the contrast-rod slice of Catphan phantom. The proposed method achieves lower electron density measurement error as compared to that by the direct matrix inversion, and significantly reduces the error variation by over 97%. On the head phantom, the method reduces the noise standard deviation of decomposed images by over 97% without blurring the sinus structures.

CONCLUSIONS

The authors propose an iterative image-domain decomposition method for DECT. The method combines noise suppression and material decomposition into an iterative process and achieves both goals simultaneously. By exploring the full variance-covariance properties of the decomposed images and utilizing the edge predetection, the proposed algorithm shows superior performance on noise suppression with high image spatial resolution and low-contrast detectability.

Usefulness of monochromatic imaging with metal artifact reduction software for computed tomography angiography after intracranial aneurysm coil embolization

BACKGROUND

Recently, a newly developed fast-kV switching dual energy CT scanner with a gemstone detector generates virtual high keV images as monochromatic imaging (MI). Each MI can be reconstructed by metal artifact reduction software (MARS) to reduce metal artifact.

PURPOSE

To evaluate the degree of metal artifacts reduction and vessel visualization around the platinum coils using dual energy CT with MARS.

MATERIAL AND METHODS

Dual energy CT was performed using a Discovery CT750 HD scanner (GE Healthcare, Milwaukee, WI, USA). In a phantom study, we measured the mean standard deviation within regions of interest around a 10-mm-diameter platinum coil mass on MI with and without MARS. Thirteen patients who underwent CTA after endovascular embolization for cerebral aneurysm with platinum coils were included in a clinical study. We visually assessed the arteries around the platinum coil mass on MI with and without MARS.

RESULTS

Each standard deviation near the coil mass on MI with MARS was significantly lower than that without MARS in a phantom study. On CTA of a clinical study, better visibility of neighboring arteries was obtained in 11 of 13 patients on MI with MARS compared to without MARS due to metal artifact reduction.

CONCLUSION

Dual energy CT with MARS reduces metal artifact of platinum coils, resulting in favorable vessel visualization around the coil mass on CTA after embolization.

Comparison of lower extremity atherosclerosis in diabetic and non-diabetic patients using multidetector computed tomography

Background

Lower extremity atherosclerosis (LEA) is among the most serious diabetic complications and leads to non-traumatic amputations. The recently developed dual-source CT (DSCT) and 320- multidetector computed tomography (MDCT) may help to detect plaques more precisely. The aim of our study was to evaluate the differences in LEA between diabetic and non-diabetic patients using MDCT angiography.

Methods

DSCT and 320-MDCT angiographies of the lower extremities were performed in 161 patients (60 diabetic and 101 non-diabetic). The plaque type, distribution, shape and obstructive natures were compared.

Results

Compared with non-diabetic patients, diabetic patients had higher peripheral neuropathy, history of cerebrovasuclar infarction and hypertension rates. A total of 2898 vascular segments were included in the analysis. Plaque and stenosis were detected in 681 segments in 60 diabetic patients (63.1%) and 854 segments in 101 non-diabetic patients (46.9%; p <0.05). Regarding these plaques, diabetic patients had a higher incidence of mixed plaques (34.2% vs. 27.1% for non-diabetic patients). An increased moderate stenosis rate and decreased occlusion rate were observed in diabetic patients relative to non-diabetic patients (35.8% vs. 28.3%; and 6.6% vs. 11.4%; respectively). In diabetic patients, 362 (53.2%) plaques were detected in the distal lower leg segments, whereas in non-diabetic patients, 551 (64.5%) plaques were found in the proximal upper leg segments. The type IV plaque shape, in which the full lumen was involved, was detected more frequently in diabetic patients than in non-diabetic patients (13.1% vs. 8.2%).

Conclusion

Diabetes is associated with a higher incidence of plaque, increased incidence of mixed plaques, moderate stenosis and localisation primarily in the distal lower leg segments. The advanced and non-invasive MDCT could be used for routine preoperative evaluations of LEA.

Clinical practice guideline for the management of intracranial aneurysms

Purpose

An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture.

Materials and Methods

We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN).

Results

We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method.

Conclusion

This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.

Low tube voltage and low contrast material volume cerebral CT angiography

OBJECTIVES

To evaluate the image quality, radiation dose and diagnostic accuracy of low kVp and low contrast material volume cerebral CT angiography (CTA) in intracranial aneurysm detection.

METHODS

One hundred twenty patients were randomly divided into three groups (n = 40 for each): Group A, 70 ml iodinated contrast agent/120 kVp; group B, 30 ml/100 kVp; group C, 30 ml/80 kVp. The CT numbers, noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured in the internal carotid artery (ICA) and middle cerebral artery (MCA). Subjective image quality was evaluated. For patients undergoing DSA, diagnostic accuracy of CTA was calculated with DSA as reference standard and compared.

RESULTS

CT numbers of ICA and MCA were higher in groups B and C than in group A (P < 0.01). SNR and CNR in groups A and B were higher than in group C (both P < 0.05). There was no difference in subjective image quality among the three groups (P = 0.939). Diagnostic accuracy for aneurysm detection among these groups had no statistical difference (P = 1.00). Compared with group A, the radiation dose of groups B and C was decreased by 45% and 74%.

CONCLUSION

Cerebral CTA at 100 or 80 kVp using 30 ml contrast agent can obtain diagnostic image quality with a low radiation dose while maintaining the same diagnostic accuracy for aneurysm detection.

KEY POINTS

• Cerebral CTA is feasible using 100/80 kVp and 30 ml contrast agent. • This approach obtains diagnostic image quality with 45-74% radiation dose reduction. • Diagnostic accuracy for intracranial aneurysm detection seems not to be compromised.