Skip to main content
SpringerLink
Log in

Visualization of flow diverter stent wall apposition during intracranial aneurysm treatment using a virtually diluted cone beam CT technique (Vessel ASSIST)

  • Interventional Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

Flow diverters (FD) have poor radiopacity, challenging visualization of deployment and vessel wall apposition with conventional neuroimaging modalities. We evaluated a novel cone beam computed tomography (CT) imaging technique that allows virtual dilution (VD) of contrast media to facilitate workflow and ensure accurate assessment of FD wall apposition.

Methods

We retrospectively evaluated all patients treated for intracranial aneurysms with FD at our institution between November 2018 and November 2019. Undiluted injected dual cone beam CT acquisitions performed post-stenting were displayed with VD software (GE Healthcare). The resulting images were compared with conventional two-dimensional (2D) digital subtraction angiography (DSA) images. Two neurointerventionalists (Reader 1 and Reader 2, (R1, R2)) independently assessed FD deployment and wall apposition. Confidence in the diagnosis, inter-reader agreement, and X-ray exposure were assessed.

Results

A total of 27 cases were reviewed. FD deployment and wall apposition scores were 4.2 ± 1.0 (R1) and 4.0 ± 1.1 (R2) for DSA and 3.7 ± 1.2 (R1) and 4.1 ± 1.0 (R2) for VD. Confidence in the diagnosis was improved with VD, with scores of 3.7 ± 0.7 (R1) and 4.0 ± 0.7 (R2) using DSA and 4.9 ± 0.2 (R1) and 4.9 ± 0.2 (R2) using VD (P < 0.001). Inter-reader agreement using 2D DSA was improved from moderate (0.49324) to good (0.7272) (P < 0.0001). There were no significant differences in inter-reader agreement in the deployment assessment (P = 0.68) or dose-area product (P = 0.54) between techniques.

Conclusion

VD imaging with dual cone beam CT enables accurate assessment of FD wall apposition after deployment with greater confidence and improved inter-reader agreement versus conventional 2D DSA alone, with comparable X-ray exposure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafe A, Cekirge S, Fiorella D, Jabbour P, Levy E, McDougall C, Siddiqui A, Szikora I, Woo H, Albuquerque F, Bozorgchami H, Dashti SR, Delgado Almandoz JE, Kelly ME, Turner R, Woodward BK, Brinjikji W, Lanzino G, Lylyk P (2015) International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 36(1):108–115. https://doi.org/10.3174/ajnr.A4111

    Article  CAS  PubMed  Google Scholar 

  2. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF (2013) Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 44(2):442–447. https://doi.org/10.1161/STROKEAHA.112.678151

    Article  PubMed  Google Scholar 

  3. Kizilkilic O, Kocer N, Metaxas GE, Babic D, Homan R, Islak C (2012) Utility of VasoCT in the treatment of intracranial aneurysm with flow-diverter stents. J Neurosurg 117(1):45–49. https://doi.org/10.3171/2012.4.JNS111660

    Article  PubMed  Google Scholar 

  4. Ding D, Starke RM, Durst CR, Gaughen JR Jr, Evans AJ, Jensen ME, Liu KC (2014) DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms. J Clin Neurosci 21(11):1981–1983. https://doi.org/10.1016/j.jocn.2014.04.003

    Article  PubMed  Google Scholar 

  5. Heller R, Calnan DR, Lanfranchi M, Madan N, Malek AM (2013) Incomplete stent apposition in Enterprise stent-mediated coiling of aneurysms: persistence over time and risk of delayed ischemic events. J Neurosurg 118(5):1014–1022. https://doi.org/10.3171/2013.2.JNS121427

    Article  PubMed  Google Scholar 

  6. Rouchaud A, Ramana C, Brinjikji W, Ding YH, Dai D, Gunderson T, Cebral J, Kallmes DF, Kadirvel R (2016) Wall apposition is a key factor for aneurysm occlusion after flow diversion: a histologic evaluation in 41 rabbits. AJNR Am J Neuroradiol 37(11):2087–2091. https://doi.org/10.3174/ajnr.A4848

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Ahmed SU, Mocco J, Zhang X, Kelly M, Doshi A, Nael K, De Leacy R (2019) MRA versus DSA for the follow-up imaging of intracranial aneurysms treated using endovascular techniques: a meta-analysis. J Neurointerv Surg 11(10):1009–1014. https://doi.org/10.1136/neurintsurg-2019-014936

    Article  PubMed  Google Scholar 

  8. Yuki I, Kambayashi Y, Ikemura A, Abe Y, Kan I, Mohamed A, Dahmani C, Suzuki T, Ishibashi T, Takao H, Urashima M, Murayama Y (2016) High-resolution C-arm CT and metal artifact reduction software: a novel imaging modality for analyzing aneurysms treated with stent-assisted coil embolization. AJNR Am J Neuroradiol 37(2):317–323. https://doi.org/10.3174/ajnr.A4509

    Article  CAS  PubMed  Google Scholar 

  9. Reyes D, Becerra V, Alcala I, Linfante I, Dabus G (2018) Usefulness of cone beam intra-arterial CTA for evaluation of flow diverters: a practical approach for daily use. Interv Neurol 7(6):457–463. https://doi.org/10.1159/000490577

    Article  PubMed  PubMed Central  Google Scholar 

  10. Kuriyama T, Sakai N, Beppu M, Sakai C, Imamura H, Masago K, Katakami N, Isoda H (2018) Quantitative analysis of cone beam CT for delineating stents in stent-assisted coil embolization. AJNR Am J Neuroradiol 39(3):488–493. https://doi.org/10.3174/ajnr.A5533

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Clarencon F, Di Maria F, Gabrieli J, Shotar E, Degos V, Nouet A, Biondi A, Sourour NA (2017) Clinical impact of flat panel volume CT angiography in evaluating the accurate intraoperative deployment of flow-diverter stents. AJNR Am J Neuroradiol 38(10):1966–1972. https://doi.org/10.3174/ajnr.A5343

    Article  CAS  PubMed  Google Scholar 

  12. Srinivasan VM, Chintalapani G, Camstra KM, Effendi ST, Cherian J, Johnson JN, Chen SR, Kan P (2018) Fast acquisition cone-beam computed tomography: initial experience with a 10 s protocol. J Neurointerv Surg. 10(9):916–920. https://doi.org/10.1136/neurintsurg-2017-013475

    Article  PubMed  Google Scholar 

  13. Kellermann R, Serowy S, Beuing O, Skalej M (2019) Deployment of flow diverter devices: prediction of foreshortening and validation of the simulation in 18 clinical cases. Neuroradiology. 61:1319–1326. https://doi.org/10.1007/s00234-019-02287-w

    Article  PubMed  Google Scholar 

  14. Kato N, Yuki I, Ishibashi T, Ikemura A, Kan I, Nishimura K, Kodama T, Kaku S, Abe Y, Otani K, Murayama Y (2019) Visualization of stent apposition after stent-assisted coiling of intracranial aneurysms using high resolution 3D fusion images acquired by C-arm CT. J Neurointerv Surg 12:192–196. https://doi.org/10.1136/neurintsurg-2019-014966

    Article  PubMed  PubMed Central  Google Scholar 

  15. Ionita CN, Natarajan SK, Wang W, Hopkins LN, Levy EI, Siddiqui AH, Bednarek DR, Rudin S (2011) Evaluation of a second-generation self-expanding variable-porosity flow diverter in a rabbit elastase aneurysm model. AJNR Am J Neuroradiol 32(8):1399–1407. https://doi.org/10.3174/ajnr.A2548

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Makoyeva A, Bing F, Darsaut TE, Salazkin I, Raymond J (2013) The varying porosity of braided self-expanding stents and flow diverters: an experimental study. AJNR Am J Neuroradiol 34(3):596–602. https://doi.org/10.3174/ajnr.A3234

    Article  CAS  PubMed  Google Scholar 

  17. Chintalapani G, Chinnadurai P, Maier A, Xia Y, Bauer S, Shaltoni H, Morsi H, Mawad ME (2016) The added value of volume-of-interest C-arm CT imaging during endovascular treatment of intracranial aneurysms. AJNR Am J Neuroradiol 37(4):660–666. https://doi.org/10.3174/ajnr.A4605

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The authors acknowledge Superior Medical Experts for research and drafting assistance.

Contributors

Material preparation, data collection, and analysis were performed by Dr. Ameer Hassan, Dr. Tekle Wondwossen, and Mr. Jim Wise. Ms. Elizabeth Burke drafted the article, and all authors provided critical interpretation and revisions and approved the final manuscript.

Funding

This study was supported by a research grant from GE Healthcare.

Author information

Authors and Affiliations

  1. Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA

    Ameer E. Hassan & Wondwossen G. Tekle

  2. Valley Baptist Neuroscience Institute, Valley Baptist Medical Center, 2121 Pease St., Suite 1D, Harlingen, TX, 78550, USA

    Ameer E. Hassan & Wondwossen G. Tekle

  3. GE Healthcare, Chicago, IL, USA

    Jim Wise

  4. The Ohio State University, Columbus, OH, USA

    Elizabeth M. Burke

Authors
  1. Ameer E. Hassan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jim Wise
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elizabeth M. Burke
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wondwossen G. Tekle
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ameer E. Hassan.

Ethics declarations

Conflict of interest

AEH serves as a consultant and speaker for GE Healthcare, Medtronic, Stryker, Microvention, Penumbra, Balt USA, and Genentech. JW is employed by GE Healthcare. EMB contracts with Superior Medical Experts. WGT has no conflicts of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Patient informed consent was waived because of the retrospective nature of the study design.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hassan, A.E., Wise, J., Burke, E.M. et al. Visualization of flow diverter stent wall apposition during intracranial aneurysm treatment using a virtually diluted cone beam CT technique (Vessel ASSIST). Neuroradiology 63, 125–131 (2021). https://doi.org/10.1007/s00234-020-02507-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-020-02507-8

Keywords

Search

Navigation