Ferumoxytol-enhanced MRI for surveillance of pediatric cerebral arteriovenous malformations

Restricted access

OBJECTIVE

Children with intracranial arteriovenous malformations (AVMs) undergo digital DSA for lesion surveillance following their initial diagnosis. However, DSA carries risks of radiation exposure, particularly for the growing pediatric brain and over lifetime. The authors evaluated whether MRI enhanced with a blood pool ferumoxytol (Fe) contrast agent (Fe-MRI) can be used for surveillance of residual or recurrent AVMs.

METHODS

A retrospective cohort was assembled of children with an established AVM diagnosis who underwent surveillance by both DSA and 3-T Fe-MRI from 2014 to 2016. Two neuroradiologists blinded to the DSA results independently assessed Fe-enhanced T1-weighted spoiled gradient recalled acquisition in steady state (Fe-SPGR) scans and, if available, arterial spin labeling (ASL) perfusion scans for residual or recurrent AVMs. Diagnostic confidence was examined using a Likert scale. Sensitivity, specificity, and intermodality reliability were determined using DSA studies as the gold standard. Radiation exposure related to DSA was calculated as total dose area product (TDAP) and effective dose.

RESULTS

Fifteen patients were included in this study (mean age 10 years, range 3–15 years). The mean time between the first surveillance DSA and Fe-MRI studies was 17 days (SD 47). Intermodality agreement was excellent between Fe-SPGR and DSA (κ = 1.00) but poor between ASL and DSA (κ = 0.53; 95% CI 0.18–0.89). The sensitivity and specificity for detecting residual AVMs using Fe-SPGR were 100% and 100%, and using ASL they were 72% and 100%, respectively. Radiologists reported overall high diagnostic confidence using Fe-SPGR. On average, patients received two surveillance DSA studies over the study period, which on average equated to a TDAP of 117.2 Gy×cm2 (95% CI 77.2–157.4 Gy×cm2) and an effective dose of 7.8 mSv (95% CI 4.4–8.8 mSv).

CONCLUSIONS

Fe-MRI performed similarly to DSA for the surveillance of residual AVMs. Future multicenter studies could further investigate the efficacy of Fe-MRI as a noninvasive alternative to DSA for monitoring AVMs in children.

ABBREVIATIONS ASL = arterial spin labeling; AVM = arteriovenous malformation; Fe-MRI = ferumoxytol-enhanced MRI; Fe-SPGR = ferumoxytol-enhanced T1-weighted spoiled gradient recalled acquisition in steady state; SNR = signal-to-noise ratio; TDAP = total dose area product.
Article Information

Contributor Notes

Correspondence Kristen W. Yeom: Lucile Packard Children’s Hospital, Stanford University, Palo Alto, CA. kyeom@stanford.edu.INCLUDE WHEN CITING Published online July 19, 2019; DOI: 10.3171/2019.5.PEDS1957.

Y.H. and T.G.S. share first authorship of this work. S.H.C. and K.W.Y. share senior authorship of this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Burger IMMurphy KJJordan LCTamargo RJGailloud P: Safety of cerebral digital subtraction angiography in children: complication rate analysis in 241 consecutive diagnostic angiograms. Stroke 37:253525392006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Ding DStarke RMKano HMathieu DHuang PPFeliciano C: International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation. J Neurosurg Pediatr 19:1271352017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Dósa ETuladhar SMuldoon LLHamilton BERooney WDNeuwelt EA: MRI using ferumoxytol improves the visualization of central nervous system vascular malformations. Stroke 42:158115882011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Fullerton HJAchrol ASJohnston SCMcCulloch CEHigashida RTLawton MT: Long-term hemorrhage risk in children versus adults with brain arteriovenous malformations. Stroke 36:209921042005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Gulani VCalamante FShellock FGKanal EReeder SB: Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol 16:5645702017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Haridass AMaclean JChakraborty SSinclair JSzanto JIancu D: Dynamic CT angiography for Cyberknife radiosurgery planning of intracranial arteriovenous malformations: a technical/feasibility report. Radiol Oncol 49:1921992015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Hoffman CESantillan ARotman LGobin YPSouweidane MM: Complications of cerebral angiography in children younger than 3 years of age. J Neurosurg Pediatr 13:4144192014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Hope MDHope TAZhu CFaraji FHaraldsson HOrdovas KG: Vascular imaging with ferumoxytol as a contrast agent. AJR Am J Roentgenol 205:W366W3732015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Iv MChoudhri ODodd RLVasanawala SSAlley MTMoseley M: High-resolution 3D volumetric contrast-enhanced MR angiography with a blood pool agent (ferumoxytol) for diagnostic evaluation of pediatric brain arteriovenous malformations. J Neurosurg Pediatr 22:2512602018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Karhunen PJPenttilä AErkinjuntti T: Arteriovenous malformation of the brain: imaging by postmortem angiography. Forensic Sci Int 48:9191990

  • 11

    Lee CCReardon MABall BZChen CJYen CPXu Z: The predictive value of magnetic resonance imaging in evaluating intracranial arteriovenous malformation obliteration after stereotactic radiosurgery. J Neurosurg 123:1361442015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Manninen ALIsokangas JMKarttunen ASiniluoto TNieminen MT: A comparison of radiation exposure between diagnostic CTA and DSA examinations of cerebral and cervicocerebral vessels. AJNR Am J Neuroradiol 33:203820422012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Miller DLBalter SSchueler BAWagner LKStrauss KJVañó E: Clinical radiation management for fluoroscopically guided interventional procedures. Radiology 257:3213322010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Mohr JPKejda-Scharler JPile-Spellman J: Diagnosis and treatment of arteriovenous malformations. Curr Neurol Neurosci Rep 13:3242013

  • 15

    Morgenstern PFHoffman CEKocharian GSingh RStieg PESouweidane MM: Postoperative imaging for detection of recurrent arteriovenous malformations in children. J Neurosurg Pediatr 17:1341402016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    National Council on Radiation Protection and Measurements: Limitation of exposure to ionizing radiation: recommendations of the National Council on Radiation Protection and Measurements. Bethesda, MD: National Council on Radiation Protection and Measurements1993

    • Export Citation
  • 17

    Nguyen KLYoshida THan FAyad IReemtsen BLSalusky IB: MRI with ferumoxytol: a single center experience of safety across the age spectrum. J Magn Reson Imaging 45:8048122017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Pearce MSSalotti JALittle MPMcHugh KLee CKim KP: Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 380:4995052012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Vasanawala SSNguyen KLHope MDBridges MDHope TAReeder SB: Safety and technique of ferumoxytol administration for MRI. Magn Reson Med 75:210721112016

  • 20

    Yu SLWang RWang RWang SYao YQZhang D: Accuracy of vessel-encoded pseudocontinuous arterial spin-labeling in identification of feeding arteries in patients with intracranial arteriovenous malformations. AJNR Am J Neuroradiol 35:65712014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Zhang BDong YLiang LLian ZLiu JLuo X: The incidence, classification, and management of acute adverse reactions to the low-osmolar iodinated contrast media Isovue and Ultravist in contrast-enhanced computed tomography scanning. Medicine (Baltimore) 95:e31702016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 40 40 40
Full Text Views 9 9 9
PDF Downloads 16 16 16
EPUB Downloads 0 0 0
PubMed
Google Scholar