Stasis index from hemodynamic analysis using quantitative DSA correlates with hemorrhage of supratentorial arteriovenous malformation: a cross-sectional study

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OBJECTIVE

Assessments of hemorrhage risk based on angioarchitecture have yielded inconsistent results, and quantitative hemodynamic studies have been limited to small numbers of patients. The authors examined whether cerebral hemodynamic analysis using quantitative digital subtraction angiography (QDSA) can outperform conventional DSA angioarchitecture analysis in evaluating the risk of hemorrhage associated with supratentorial arteriovenous malformations (AVMs).

METHODS

A cross-sectional study was performed by retrospectively reviewing adult supratentorial AVM patients who had undergone both DSA and MRI studies between 2011 and 2017. Angioarchitecture characteristics, DSA parameters, age, sex, and nidus volume were analyzed using univariate and multivariate logistic regression, and QDSA software analysis was performed on DSA images. Based on the QDSA analysis, a stasis index, defined as the inflow gradient divided by the absolute value of the outflow gradient, was determined. The receiver operating characteristic (ROC) curve was used to compare diagnostic performances of conventional DSA angioarchitecture analysis and analysis using hemodynamic parameters based on QDSA.

RESULTS

A total of 119 supratentorial AVM patients were included. After adjustment for age at diagnosis, sex, and nidus volume, the exclusive deep venous drainage (p < 0.01), observed through conventional angioarchitecture examination using DSA, and the stasis index of the most dominant drainage vein (p = 0.02), measured with QDSA hemodynamic analysis, were independent risk factors for hemorrhage. The areas under the ROC curves for the conventional DSA method (0.75) and QDSA hemodynamics analysis (0.73) were similar. A venous stasis index greater than 2.18 discriminated the hemorrhage group with a sensitivity of 52.6% and a specificity of 81.5%.

CONCLUSIONS

In QDSA, a higher stasis index of the most dominant drainage vein is an objective warning sign associated with supratentorial AVM rupture. Risk assessments of AVMs using QDSA and conventional DSA angioarchitecture were equivalent. Because QDSA is a complementary noninvasive approach without extra radiation or contrast media, comprehensive hemorrhagic risk assessment of cerebral AVMs should include both DSA angioarchitecture and QDSA analyses.

ABBREVIATIONS AU = arbitrary units; AUC = area under the curve; AVM = arteriovenous malformation; BAT = bolus arrival time; DSA = digital subtraction angiography; FWHM = full width at half maximum; ICA = internal carotid artery; QDSA = quantitative digital subtraction angiography; ROC = receiver operating characteristic; ROI = region of interest.

Article Information

Correspondence Chung Jung Lin: Taipei Veterans General Hospital, Taipei City, Taiwan. bcjlin@gmail.com.

INCLUDE WHEN CITING Published online April 26, 2019; DOI: 10.3171/2019.1.JNS183386.

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

Figures

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    Color-coded QDSA and the time-attenuation curve. Left: Lateral view of parametric color-coded QDSA. Selected ROIs are the cavernous segment of the ICA (white circle) and the proximal segment of the most prominent drainage vein (red circle). The color spectrum represents the time-to-peak (TTP) values in seconds. Right: Parameters from the time-attenuation curve used for QDSA. TTP was defined as the time required for the bolus to reach the peak density over the course of the whole angiographic series. Other parameters were defined based on the peak density and TTP. Bolus arrival time (BAT) was defined as the first time point at which the density exceeded 20 AU.32 The flow gradients were derived from fitting 4 consecutive temporal data points in the gamma variant function sequentially using the linear least-squares method. The largest and smallest slopes among all fitted linear functions were defined as the inflow and outflow gradients, respectively. The stasis index was defined as the inflow gradient divided by the absolute value of the outflow gradient. The FWHM was the duration required for the bolus to achieve and then to decline to 50% of the peak density.

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    Patient selection flowchart.

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    Comparison of angioarchitecture and hemodynamic parameters for hemorrhagic estimation. ROC curves comparing the stasis index of the drainage vein (solid line) and exclusive deep venous drainage character (dashed line) for cerebral AVM hemorrhagic presentation after adjustment for age, sex, and nidus volume. The AUCs of the stasis index measured from QDSA and exclusive deep venous drainage character identified according to angioarchitecture were 0.73 and 0.75, respectively.

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