Evaluation of the occlusion status of coiled intracranial aneurysms with MR angiography at 3T: is contrast enhancement necessary?

Abstract

Background and purpose: MR angiography (MRA) is increasingly used as a noninvasive imaging technique for the follow-up of coiled intracranial aneurysms. However, the need for contrast enhancement has not yet been elucidated. We compared 3D time-of-flight MRA (TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3T with catheter angiography.

Materials and methods: Sixty-seven patients with 72 aneurysms underwent TOF-MRA, CE-MRA, and catheter-angiography 6 months after coiling. Occlusion status on MRA was classified as adequate (complete and neck remnant) or incomplete by 2 independent observers. For TOF-MRA and CE-MRA, interobserver agreement, intermodality agreement, and correlation with angiography were assessed by kappa statistics.

Results: Catheter-angiography revealed incomplete occlusion in 12 (17%) of the 69 aneurysms; 3 aneurysms were excluded due to MR imaging artifacts. Interobserver agreement was good for CE-MRA (kappa = 0.77; 95% confidence interval [CI], 0.55-0.98) and very good for TOF-MRA (kappa = 0.89; 95% CI, 0.75-1.00). Correlation of TOF-MRA and CE-MRA with angiography was good. The sensitivity of TOF-MRA and CE-MRA was 75% (95% CI, 43%-95%); the specificity of TOF-MRA was 98% (95% CI, 91%-100%) and of CE-MRA, 97% (95% CI, 88%-100%). All 5 incompletely occluded aneurysms, which were additionally treated, were correctly identified with both MRA techniques. Areas under the receiver operating characteristic curve for TOF-MRA and CE-MRA were 0.90 (95% CI, 0.79-1.00) and 0.91 (95% CI, 0.79-1.00). Intermodality agreement between TOF-MRA and CE-MRA was very good (kappa = 0.83; 95% CI, 0.65-1.00), with full agreement in 66 (96%) of the 69 aneurysms.

Conclusions: In this study, TOF-MRA and CE-MRA at 3T were equivalent in evaluating the occlusion status of intracranial aneurysms after coiling. Because TOF-MRA does not involve contrast administration, this method is preferred over CE-MRA.

Fig 1.

Flow chart of all coiled aneurysms at 6-month follow-up. *Three aneurysms were excluded due to coil artifacts and venous overprojection on CE-MRA. One of these aneurysms was also excluded due to coil artifacts on TOF-MRA.

Fig 2.

Disagreement between both TOF-MRA and CE-MRA with angiography on the occlusion of a carotid tip aneurysm. A, Angiogram obtained immediately after coiling shows adequate occlusion with a small neck remnant (arrow). B, Follow-up TOF-MRA at 6 months shows complete occlusion (arrow). C, Follow-up CE-MRA at 6 months shows a small neck remnant (arrow). D, Follow-up angiogram at 6 months shows incomplete occlusion (arrow). Because the geometry of the reopened aneurysm was unfavorable, this patient was not retreated but subjected to extended follow-up.

Fig 3.

Disagreement between both TOF-MRA and CE-MRA with angiography on the occlusion of a middle cerebral artery aneurysm. A, Angiogram obtained immediately after coiling shows a small neck remnant (arrow). B, Follow-up TOF-MRA at 6 months shows a small neck remnant (arrow). C, Follow-up CE-MRA at 6 months shows a small neck remnant (arrow). D, Follow-up angiogram shows incomplete occlusion (arrow). Because the geometry of the reopened aneurysm was unfavorable, this patient was not retreated but was subjected to extended follow-up.

Fig 4.

Disagreement between both TOF-MRA and CE-MRA with angiography on the occlusion of a carotid artery aneurysm. A, Angiogram obtained immediately after coiling shows a small neck remnant (arrow). B, Follow-up TOF-MRA at 6 months shows a small neck remnant (arrow). C, Follow-up CE-MRA at 6 months shows a small neck remnant (arrow). D, Follow-up angiogram at 6 months shows incomplete occlusion (arrow). Because the geometry of the reopened aneurysm was unfavorable, this patient was not retreated but was subjected to extended follow-up.

Fig 5.

Agreement between TOF-MRA, CE-MRA, and angiography on the occlusion of a partially thrombosed superior cerebellar artery aneurysm. A, Angiogram obtained immediately after coiling shows complete occlusion (arrow). B, Follow-up TOF-MRA at 6 months shows incomplete occlusion (arrow). C, Follow-up CE-MRA at 6 month shows incomplete occlusion (arrow). D, Follow-up angiogram at 6 month shows incomplete occlusion (arrow). The aneurysm was additionally coiled without complications, and complete occlusion was achieved.