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Evaluation of sporadic intracranial cavernous malformations for detecting associated developmental venous anomalies: added diagnostic value of C-arm contrast-enhanced cone-beam CT to routine contrast-enhanced MRI

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Abstract

Objective

Our purpose was to investigate the added diagnostic value of C-arm contrast-enhanced cone-beam CT (CE-CBCT) to routine contrast-enhanced MRI (CE-MRI) in detecting associated developmental venous anomalies (DVAs) in patients with sporadic intracranial cavernous malformations (ICMs).

Methods

Fifty-six patients (53 with single and three with double ICMs) met the inclusion criteria. All patients had routine CE-MRI scans performed at 1.5 Tesla. The imaging studies (CE-MRI and CE-CBCT) were retrospectively and independently reviewed by two observers, with consensus by a third. Group difference, intra- and interobserver agreement, and diagnostic performance of the modalities in detecting associated DVAs were calculated. Reference standard was CE-MRI.

Results

On CE-MRI and CE-CBCT, 37 (66%; of 56) and 47 patients (84%; of 56) had associated DVAs, respectively. In 10 patients (52.6%; of CE-MRI negatives [n=19]), CE-CBCT improved the diagnosis. Nine patients (16%; of 56) had no DVA on both imaging techniques. Difference in proportions of associated DVAs on CE-MRI and CE-CBCT was statistically significant, p < 0.05. Sensitivity, specificity, positive likelihood ratio, and area under the curve of CE-CBCT were 100% (95% confidence interval [CI]: 90.5-100%), 47.3% (95% CI: 24.4-71.1%), 1.9 (95%CI: 1.240-2.911), 0.737 (95%CI: 0.602-0.845), respectively. Intraobserver agreement was excellent for CE-MRI, kappa (κ) coefficient = 0.960, and CE-CBCT, κ=0.931. Interobserver agreement was substantial for CE-MRI, κ=0.803, and excellent for CE-CBCT, κ=0.810.

Conclusions

CE-CBCT is a useful imaging technique especially in patients with negative routine CE-MRI in terms of detecting associated DVAs. In nearly half of these particular patients, it reveals an associated DVA as a new diagnosis.

Key Points

• Although it is known to be the gold standard, some of the DVAs associated with ICMs are underdiagnosed with CE-MRI.

• In nearly half of the patients with negative routine CE-MRI, CE-CBCT reveals an associated DVA as a new diagnosis.

• Intra- and interobserver agreement on CE-CBCT is excellent in terms of detecting associated DVAs.

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Abbreviations

CBCT:

C-arm cone-beam computed tomography

CE-CBCT:

C-arm contrast-enhanced cone-beam computed tomography

CE-MRI :

Contrast-enhanced magnetic resonance imaging

DSA:

Digital subtraction angiography

DVA:

Developmental venous anomaly

FOV:

Field of view

GRE:

Gradient -echo

ICM:

Intracranial cavernous malformation

MRI :

Magnetic resonance imaging

NLR:

Negative likelihood ratio

SWI :

Susceptibility-weighted imaging

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Acknowledgements

A partial abstract of this study (maximum 250 words) has been submitted to ECR (European Congress of Radiology) 2018, accepted and presented as oral presentation (control number: 1976; presentation number: B-0687).

Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Radiology, Istanbul Training and Research Hospital, Istanbul, Turkey

    Burak Kocak

  2. Department of Radiology, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey

    Osman Kizilkilic, Amalya Zeynalova, Naci Kocer & Civan Islak

  3. Department of Radiology, Canakkale Mehmet Akif Ersoy State Hospital, Canakkale, Turkey

    Bora Korkmazer

Authors
  1. Burak Kocak
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  2. Osman Kizilkilic
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  3. Amalya Zeynalova
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  4. Bora Korkmazer
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  5. Naci Kocer
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  6. Civan Islak
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Corresponding author

Correspondence to Civan Islak.

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Guarantor

The scientific guarantor of this publication is Civan Islak.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors (Burak Kocak) has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Some study subjects or cohorts have been previously reported in authors’ previous publication Kocak B, Kizilkilic O, Oz B, Bakkaloglu DV, Isler C, Kocer N, Islak C. Ultra-high-resolution C-arm flat-detector CT angiography evaluation reveals 3-fold higher association rate for sporadic intracranial cavernous malformations and developmental venous anomalies: a retrospective study in consecutive 58 patients with 60 cavernous malformations. Eur Radiol. 2017 Jun;27(6):2629-2639. doi: 10.1007/s00330-016-4595-9. Epub 2016 Sep 21.

Methodology

• retrospective

• diagnostic study

• performed at one institution

Electronic supplementary material

Video 1

: CE-CBCT reconstruction of the patient presented in Fig. 2. Movie was made from anterior-posterior, cranial-caudal and lateral-lateral views, respectively. Please focus on the red circle which shows the associated DVA in detail. (MP4 13476 kb)

Video 2

: CE-CBCT reconstruction of the patient presented in Fig. 3. Movie was made from various viewpoints. Please focus on the red circle, which shows the associated DVA and its angioarchitecture in detail. ICM was also evident next to the DVA. (MP4 11221 kb)

Video 3

: CE-CBCT reconstruction of the patient presented in Fig. 4. Movie was made from various viewpoints. Please focus on the red ovoid shape, which shows the associated DVA and its angioarchitecture in detail. (MP4 24198 kb)

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Kocak, B., Kizilkilic, O., Zeynalova, A. et al. Evaluation of sporadic intracranial cavernous malformations for detecting associated developmental venous anomalies: added diagnostic value of C-arm contrast-enhanced cone-beam CT to routine contrast-enhanced MRI. Eur Radiol 29, 783–791 (2019). https://doi.org/10.1007/s00330-018-5652-3

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  • DOI: https://doi.org/10.1007/s00330-018-5652-3

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