Ferumoxytol-enhanced MRI for surveillance of pediatric cerebral arteriovenous malformations

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  • 1 Division of Pediatric Neurosurgery and
  • | 2 Department of Radiology, Lucile Packard Children’s Hospital, Stanford University School of Medicine;
  • | 3 Environmental Health and Safety, Stanford University, Stanford, California;
  • | 4 Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
  • | 5 Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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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.

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  • 1

    Burger IM, Murphy KJ, Jordan LC, Tamargo RJ, Gailloud P: Safety of cerebral digital subtraction angiography in children: complication rate analysis in 241 consecutive diagnostic angiograms. Stroke 37:25352539, 2006

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

    Ding D, Starke RM, Kano H, Mathieu D, Huang PP, Feliciano C, et al.: International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation. J Neurosurg Pediatr 19:127135, 2017

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

    Dósa E, Tuladhar S, Muldoon LL, Hamilton BE, Rooney WD, Neuwelt EA: MRI using ferumoxytol improves the visualization of central nervous system vascular malformations. Stroke 42:15811588, 2011

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

    Fullerton HJ, Achrol AS, Johnston SC, McCulloch CE, Higashida RT, Lawton MT, et al.: Long-term hemorrhage risk in children versus adults with brain arteriovenous malformations. Stroke 36:20992104, 2005

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

    Gulani V, Calamante F, Shellock FG, Kanal E, Reeder SB: Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol 16:564570, 2017

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

    Haridass A, Maclean J, Chakraborty S, Sinclair J, Szanto J, Iancu D, et al.: Dynamic CT angiography for Cyberknife radiosurgery planning of intracranial arteriovenous malformations: a technical/feasibility report. Radiol Oncol 49:192199, 2015

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

    Hoffman CE, Santillan A, Rotman L, Gobin YP, Souweidane MM: Complications of cerebral angiography in children younger than 3 years of age. J Neurosurg Pediatr 13:414419, 2014

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

    Hope MD, Hope TA, Zhu C, Faraji F, Haraldsson H, Ordovas KG, et al.: Vascular imaging with ferumoxytol as a contrast agent. AJR Am J Roentgenol 205:W366W373, 2015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Iv M, Choudhri O, Dodd RL, Vasanawala SS, Alley MT, Moseley M, et al.: 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 22:251260, 2018

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

    Karhunen PJ, Penttilä A, Erkinjuntti T: Arteriovenous malformation of the brain: imaging by postmortem angiography. Forensic Sci Int 48:919, 1990

  • 11

    Lee CC, Reardon MA, Ball BZ, Chen CJ, Yen CP, Xu Z, et al.: The predictive value of magnetic resonance imaging in evaluating intracranial arteriovenous malformation obliteration after stereotactic radiosurgery. J Neurosurg 123:136144, 2015

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

    Manninen AL, Isokangas JM, Karttunen A, Siniluoto T, Nieminen MT: A comparison of radiation exposure between diagnostic CTA and DSA examinations of cerebral and cervicocerebral vessels. AJNR Am J Neuroradiol 33:20382042, 2012

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

    Miller DL, Balter S, Schueler BA, Wagner LK, Strauss KJ, Vañó E: Clinical radiation management for fluoroscopically guided interventional procedures. Radiology 257:321332, 2010

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

    Mohr JP, Kejda-Scharler J, Pile-Spellman J: Diagnosis and treatment of arteriovenous malformations. Curr Neurol Neurosci Rep 13:324, 2013

  • 15

    Morgenstern PF, Hoffman CE, Kocharian G, Singh R, Stieg PE, Souweidane MM: Postoperative imaging for detection of recurrent arteriovenous malformations in children. J Neurosurg Pediatr 17:134140, 2016

    • 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 Measurements, 1993

    • Search Google Scholar
    • Export Citation
  • 17

    Nguyen KL, Yoshida T, Han F, Ayad I, Reemtsen BL, Salusky IB, et al.: MRI with ferumoxytol: a single center experience of safety across the age spectrum. J Magn Reson Imaging 45:804812, 2017

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

    Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al.: Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 380:499505, 2012

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

    Vasanawala SS, Nguyen KL, Hope MD, Bridges MD, Hope TA, Reeder SB, et al.: Safety and technique of ferumoxytol administration for MRI. Magn Reson Med 75:21072111, 2016

  • 20

    Yu SL, Wang R, Wang R, Wang S, Yao YQ, Zhang D, et al.: Accuracy of vessel-encoded pseudocontinuous arterial spin-labeling in identification of feeding arteries in patients with intracranial arteriovenous malformations. AJNR Am J Neuroradiol 35:6571, 2014

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

    Zhang B, Dong Y, Liang L, Lian Z, Liu J, Luo X, et al.: 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:e3170, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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