Korean J Radiol.  2009 Aug;10(4):333-339. 10.3348/kjr.2009.10.4.333.

Detection of Residual Brain Arteriovenous Malformations after Radiosurgery: Diagnostic Accuracy of Contrast-Enhanced Three-Dimensional Time of Flight MR Angiography at 3.0 Tesla

• Lee KE
• Choi CG
• Choi JW
• Choi BS
• Lee DH
• Kim SJ
• Kwon DH

• KMID: 1777260
• DOI: http://doi.org/10.3348/kjr.2009.10.4.333

Abstract

OBJECTIVE
Although three-dimensional time-of-flight magnetic resonance angiography (3D TOF-MRA) is used frequently as a follow-up tool to assess the response of arteriovenous malformations (AVMs) after radiosurgery, the diagnostic accuracy of 3D TOF-MRA is not well known. We evaluated the diagnostic accuracy of contrast-enhanced 3D TOF-MRA at 3.0 Tesla for the detection of residual AVMs.
MATERIALS AND METHODS
This study included 32 AVMs from 32 patients who had been treated with radiosurgery (males/females: 21/11; average patient age, 33.1 years). The time interval between radiosurgery and MRA was an average of 35.3 months (range, 12-88 months). Three-dimensional TOF-MRA was obtained at a magnetic field strength of 3.0 Tesla after infusion of contrast media, with a measured voxel size of 0.40 x 0.80 x 1.4 (0.45) mm3 and a reconstructed voxel size of 0.27 x 0.27 x 0.70 (0.05) mm3 after zero-filling. X-ray angiography was performed as the reference of standard within six months after MRA (an average of two months). To determine the presence of a residual AVM, the source images of 3D TOF-MRA were independently reviewed, focusing on the presence of abnormally hyperintense fine tangled or tubular structures with continuity as seen on consecutive slices by two observers blinded to the X-ray angiography results.
RESULTS
A residual AVM was identified in 10 patients (10 of 32, 31%) on X-ray angiography. The inter-observer agreement for MRA was excellent (kappa= 0.813). For the detection of a residual AVM after radiosurgery as determined by observer 1 and observer 2, the source images of MRA had an overall sensitivity of 100%/90% (10 of 10, 9 of 10), specificity of 68%/68% (15 of 22, 15 of 22), positive predictive value of 59%/56% (10 of 17, 9 of 16), negative predictive value of 100%/94% (15 of 15, 15 of 16) and diagnostic accuracy of 78%/75% (25 of 32, 24 of 32), respectively.
CONCLUSION
The sensitivity of contrast-enhanced 3D TOF-MRA at 3.0 Tesla is high but the specificity is not sufficient for the detection of a residual AVM after radiosurgery.

Keyword

Brain; Arteriovenous malformation; Radiosurgery; Magnetic resonance (MR); Angiography

MeSH Terms

Adult
Contrast Media
Female
Humans
Intracranial Arteriovenous Malformations/*diagnosis/*surgery
Magnetic Resonance Angiography/methods/*standards
Male
*Radiosurgery
Sensitivity and Specificity

Figure

• 

  Fig. 1 Findings for typical true positive case. 45-year-old woman had ruptured arteriovenous malformation located at right medial temporo-occipital lobe and was treated with gamma-knife 46 months prior. A. Source image of 3D TOF-MRA shows entangled tubular enhancing lesions (arrows) in right medial temporooccipital lobe, which were interpreted as due to presence of residual arteriovenous malformation with draining vein by both observers. B. Lateral view of right internal carotid angiogram demonstrates presence of residual arteriovenous malformation (arrows) with early draining vein (arrowheads).

• 

  Fig. 2 Findings for typical true negative case. 21-year-old man had ruptured arteriovenous malformation located at left parietal lobe and was treated with gamma-knife 28 months prior. A. Source image of 3D TOF-MRA shows large encephalomalatic change and focal mild brain parenchymal enhancement without branching pattern (arrows) in left medial parietal lobe, which was interpreted as due to complete obliteration of arteriovenous malformation by both observers. B. On left internal carotid and vertebral angiogram (not shown here), no residual arteriovenous malformation or early draining vein is seen.

• 

  Fig. 3 Findings for false positive case. 51-year-old man had arteriovenous malformation located at left parietal lobe and was treated by gamma-knife 18 months prior. A. Source image of 3D TOF-MRA shows irregular parenchymal enhancement and tubular enhancing vessels located at left parietal lobe (arrows). Both observers interpreted this case as due to presence of residual arteriovenous malformation. B, C. On left internal carotid angiogram, no residual arteriovenous malformation is seen but still persistent ectasia of feeding artery and abnormal small vein (arrowheads) are seen.

• 

  Fig. 4 Findings for false negative case by observer 2. 18-year-old woman had arteriovenous malformation at right frontal lobe and was treated by gamma-knife 88 months prior. A. Source image of 3D TOF-MRA shows fine reticular enhancing lesion (arrows) located at posterior margin of encephalomalatic change. Observer 2 interpreted this case as due to complete obliteration of arteriovenous malformation with radiation change. B. Right internal carotid angiogram demonstrates presence of residual arteriovenous malformation (arrows) with early draining vein (arrowheads).

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