Superior performance of cone-beam CT angiography in characterization of intracranial atherosclerosis

Clinical article

Mina G. Safain M.D., Jason P. Rahal M.D., Samir Patel B.S., Alexandra Lauric Ph.D., Edward Feldmann M.D., and Adel M. Malek M.D., Ph.D.
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  • Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center, and Tufts University School of Medicine, Boston, Massachusetts
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Object

Intracranial atherosclerotic disease (ICAD) carries a high risk of stroke. Evaluation of ICAD has focused on assessing the absolute degree of stenosis, although plaque morphology has recently demonstrated increasing relevance. The authors provide the first report of the use of ultra-high-resolution C-arm cone-beam CT angiography (CBCT-A) in the evaluation of vessel stenosis as well as plaque morphology.

Methods

Between August 2009 and July 2012, CBCT-A was used in all patients with ICAD who underwent catheter-based angiography at the authors' institution (n = 18). Lesions were evaluated for maximum degree of stenosis as well as plaque morphological characteristics (ulcerated, calcified, dissected, or spiculated) via digital subtraction angiography (DSA), 3D-rotational angiography (3DRA), and CBCT-A. The different imaging modalities were compared in their assessment of absolute stenosis as well as their ability to resolve different plaque morphologies.

Results

Lesions were found to have similar degrees of stenosis when utilizing CBCT-A compared with 3DRA, but both 3DRA and CBCT-A differed from DSA in their assessment of the absolute degree of stenosis. CBCT-A provided the most detailed resolution of plaque morphology, identifying a new plaque characteristic in 61% of patients (n = 11) when compared with DSA and 50% (n = 9) when compared with 3DRA. CBCT-A identified all lesion characteristics visualized on DSA and 3DRA.

Conclusions

CBCT-A provides detailed spatial resolution of plaque morphology and may add to DSA and 3DRA in the evaluation of ICAD. Further prospective study is warranted to determine any benefit CBCTA-A may provide in clinical decision making and risk stratification over existing conventional imaging modalities.

Abbreviations used in this paper:

CBCT = cone-beam CT; CBCT-A = CBCT angiography; CBCT-A-N = CBCT-A–normal; CBCT-A-S = CBCT-A–sharp kernel; CTA = CT angiography; DSA = digital subtraction angiography; HU = Hounsfield unit; ICA = internal carotid artery; ICAD = intracranial atherosclerotic disease; MIP-MPR = maximum intensity projection multiplanar reconstruction; MRA = MR angiography; TCD = transcranial Doppler ultrasonography; TIA = transient ischemic attack; 3DRA = 3D-rotational angiography.

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