High-resolution 3D volumetric contrast-enhanced MR angiography with a blood pool agent (ferumoxytol) for diagnostic evaluation of pediatric brain arteriovenous malformations

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OBJECTIVE

Patients with brain arteriovenous malformations (AVMs) often require repeat imaging with MRI or MR angiography (MRA), CT angiography (CTA), and digital subtraction angiography (DSA). The ideal imaging modality provides excellent vascular visualization without incurring added risks, such as radiation exposure. The purpose of this study is to evaluate the performance of ferumoxytol-enhanced MRA using a high-resolution 3D volumetric sequence (fe-SPGR) for visualizing and grading pediatric brain AVMs in comparison with CTA and DSA, which is the current imaging gold standard.

METHODS

In this retrospective cohort study, 21 patients with AVMs evaluated by fe-SPGR, CTA, and DSA between April 2014 and August 2017 were included. Two experienced raters graded AVMs using Spetzler-Martin criteria on all imaging studies. Lesion conspicuity (LC) and diagnostic confidence (DC) were assessed using a 5-point Likert scale, and interrater agreement was determined. The Kruskal-Wallis test was performed to assess the raters’ grades and scores of LC and DC, with subsequent post hoc pairwise comparisons to assess for statistically significant differences between pairs of groups at p < 0.05.

RESULTS

Assigned Spetzler-Martin grades for AVMs on DSA, fe-SPGR, and CTA were not significantly different (p = 0.991). LC and DC scores were higher with fe-SPGR than with CTA (p < 0.05). A significant difference in LC scores was found between CTA and fe-SPGR (p < 0.001) and CTA and DSA (p < 0.001) but not between fe-SPGR and DSA (p = 0.146). A significant difference in DC scores was found among DSA, fe-SPGR, and CTA (p < 0.001) and between all pairs of the groups (p < 0.05). Interrater agreement was good to very good for all image groups (κ = 0.77–1.0, p < 0.001).

CONCLUSIONS

Fe-SPGR performed robustly in the diagnostic evaluation of brain AVMs, with improved visual depiction of AVMs compared with CTA and comparable Spetzler-Martin grading relative to CTA and DSA.

ABBREVIATIONS ASL = arterial spin labeling; AVM = arteriovenous malformation; CE-MRA = contrast-enhanced MRA; CTA = CT angiography; DAP = dose area product; DC = diagnostic confidence; DLP = dose length product; DSA = digital subtraction angiography; fe-SPGR = ferumoxytol-enhanced spoiled gradient recalled acquisition echo; fMRI = functional MRI; LC = lesion conspicuity; MRA = MR angiography; TOF = time of flight.
Article Information

Contributor Notes

Correspondence Michael Iv: Stanford University Medical Center, Stanford, CA. miv@stanford.edu.INCLUDE WHEN CITING Published online June 8, 2018; DOI: 10.3171/2018.3.PEDS17723.

S.C. and K.W.Y. contributed equally to this article and share senior authorship.

Disclosures Dr. Alley: clinical or research support for this study from GE Medical, and direct stock ownership in Arterys.

© AANS, except where prohibited by US copyright law.

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