DOI:10.2214/AJR.04.1595
AJR 2006; 186:75-84
© American Roentgen Ray Society
Three-Dimensional Rotational Angiography of Neurovascular Lesions in Pediatric Patients
John M. Racadio1,
Bradley L. Fricke,
Blaise V. Jones and
Lane F. Donnelly
1 Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333
Burnet Ave., Cincinnati, OH 45229-3039.
Received October 12, 2004;
accepted after revision January 31, 2005.
Address correspondence to J. M. Racadio
(john.racadio{at}cchmc.org).
Abstract
OBJECTIVE. In this pictorial essay, we review the 3D rotational
angiography (RA) studies of six pediatric patients; in these cases, the
information obtained with 3D RA was uniquely beneficial in diagnosis and
treatment planning.
CONCLUSION. Three-dimensional RA is an excellent tool for the
evaluation of a number of intracranial lesions in pediatric patients: There is
less total radiation exposure from a single rotational run than from CT or a
conventional angiography examination that involves more than one view and the
study is quick, with data acquisition requiring less than 8 sec and fully
rendered 3D reconstructions generated within 180 sec.
Keywords: head and neck imaging • interventional radiology • neuroimaging • pediatric imaging • pediatric radiology
Introduction
The accurate depiction of intracranial vascular lesions and related anatomy
with imaging is essential for appropriate clinical management. Historically,
these lesions have been evaluated with catheter angiography using 2D digital
subtraction techniques. However, overlapping vessels and large areas of
opacification can obscure vascular relationships, and complex vascular
structures often require multiple contrast injections for adequate evaluation,
increasing radiation dose and risk of nephrotoxicity and volume overload from
increased contrast load [1].
Minimizing the radiation dose is particularly important in children because of
the relatively increased lifetime cancer risk as compared with adults
[2].
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Fig. 1A —Vein of Galen aneurysmal malformation in 8-month-old female
infant. Anteroposterior angiogram with injection in left vertebral artery
shows vein of Galen aneurysmal malformation (arrows) with primary
supply from left posterior choroidal artery (arrowheads).
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Fig. 1B —Vein of Galen aneurysmal malformation in 8-month-old female
infant. Anteroposterior gradient-rendered view of 3D rotational angiography
(RA) shows precise location and orientation of feeding artery
(arrows) to malformation.
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Fig. 1C —Vein of Galen aneurysmal malformation in 8-month-old female
infant. Two views of shaded-surface cut-away 3D RA show flow into aneurysmal
malformation through feeding vessel (arrows) and precise diameter of
feeding vessel in preparation for coil embolization.
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Fig. 1D —Vein of Galen aneurysmal malformation in 8-month-old female
infant. Two views from volume-rendered 3D RA obtained 16 months after partial
embolization. Note previous area of embolization (arrows), as
determined with conventional angiography, and new vessel (arrowheads)
feeding aneurysmal malformation. Cut-away feature of 3D RA workstation used to
locate exact site of feeding vessel enters aneurysmal malformation from the
left.
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Fig. 1E —Vein of Galen aneurysmal malformation in 8-month-old female
infant. Oblique view of shaded-surface reconstruction from left vertebral
artery injection after second embolization. Previously placed embolization
coils (arrows) are gray with residual right-sided posterior choroidal
arterial feeder (arrowheads) inferior and lateral to coil mass.
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The use of RA in the evaluation of intracranial aneurysms was first
described in 1972 [3] and was
advanced into clinical practice in 1975
[4]. The benefits of 3D digital
reconstruction of rotational data were reported in animal and in vitro studies
in 1997 [5] and clinically in
1998 [6]. The reports also
described the usefulness of 3D RA in the evaluation of intracranial
arteriovenous malformations and cerebral aneurysms in adults
[7]. However, there has been no
published literature describing the evaluation of neurovascular lesions in
pediatric patients with 3D RA to our knowledge. In this pictorial essay, we
review 3D RA studies in six children in which the information obtained with 3D
RA was uniquely beneficial in diagnosis and treatment planning.
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Fig. 2A —2-month-old female infant with arteriovenous fistula from
middle cerebral artery to vein of Labbé. Axial T2-weighted MR image
shows enlarged transverse sinus (arrows) secondary to arteriovenous
fistula.
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Fig. 2C —2-month-old female infant with arteriovenous fistula from
middle cerebral artery to vein of Labbé. Anteroposterior
gradient-rendered view of 3D rotational angiography (RA) shows arteriovenous
fistula from middle cerebral artery (arrows) to vein of Labbé
(arrowheads). Three-dimensional RA was performed immediately before
coil embolization.
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Fig. 2D —2-month-old female infant with arteriovenous fistula from
middle cerebral artery to vein of Labbé. Medial gradient-rendered view
of 3D RA shows arteriovenous fistula from middle cerebral artery
(arrows) to vein of Labbé (arrowheads).
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Fig. 2E —2-month-old female infant with arteriovenous fistula from
middle cerebral artery to vein of Labbé. Posterior craniocaudal oblique
volume-rendered view of 3D RA shows arteriovenous fistula from middle cerebral
artery (arrows) to vein of Labbé (arrowheads). On the
basis of 3D RA images, chronology of coil embolization was planned; patient
underwent two scheduled rounds of embolization with obliteration of
arteriovenous fistula.
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Fig. 3A —Arteriovenous malformation (AVM) of mandible in 10-year-old
girl who presented with massive hemorrhage after attempted extraction of
impacted molar tooth. Coronal contrast-enhanced T1-weighted MR image shows
enhancement within left mandible (arrows) and enlarged draining vein
(arrowheads), indicating high-flow AVM.
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Fig. 3B —Arteriovenous malformation (AVM) of mandible in 10-year-old
girl who presented with massive hemorrhage after attempted extraction of
impacted molar tooth. Lateral oblique projection of volume-rendered MR
angiography shows dilated vein draining from AVM (arrows) in
mandible, with arterial supply from internal maxillary artery (M) and lingual
and facial arteries (arrowheads).
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Fig. 3C —Arteriovenous malformation (AVM) of mandible in 10-year-old
girl who presented with massive hemorrhage after attempted extraction of
impacted molar tooth. Medial view of volume color-rendered 3D rotational
angiography from injection of left external carotid artery shows supply to AVM
from lingual and facial arteries (arrows) and from palatal branches
of internal maxillary artery (arrowheads).
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Fig. 3D —Arteriovenous malformation (AVM) of mandible in 10-year-old
girl who presented with massive hemorrhage after attempted extraction of
impacted molar tooth. Lateral view of same reconstruction as C shows
AVM (arrows) and markedly dilated draining vein
(arrowheads).
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Three-Dimensional RA Technique
All patients underwent 3D RA on an Integris Allura Biplane unit (Philips
Medical Systems). Three-dimensional images were reconstructed from data
collected using a 180° rotational arc. During the rotational examination,
contrast material was hand-injected into the vascular territory of
interest.
A total of 120 images were obtained in this arc. Radiation exposure, as
measured with a pelvic phantom, was found to be 4.4 Gy/cm2 when 120
images were obtained. This compares to a total dose of 9.6 Gy/cm2
resulting from two angiographic series obtained in the anteroposterior and
lateral planes. Three-dimensional reconstructions are performed in 180 sec and
are available for analysis and manipulation on a dedicated 3D RA
workstation.
Clinical Utility
Vascular Malformations
Three-dimensional imaging is useful in defining both intracranial and
extracranial vascular malformations. The configuration of their feeding
vessels, transition points, and draining veins is shown
[7]. In children, these
malformations are typically high-flow, with complex anatomy of both arterial
feeders and venous drainage. The 3D RA data set enables highly detailed
anatomic analysis of arterial supply to malformations so that decisions
regarding microcatheter choice, angle of approach, and chronology of
embolization can be made with a single arteriographic run (Figs.
1A,
1B,
1C,
1D, and
1E). This information aids in
determining the type of coils or embolic material appropriate for endovascular
therapy and for assessment of potential open surgical treatment (Figs.
2A,
2B,
2C,
2D, and
2E). In patients with complex
malformations, 3D RA volume color rendering can be used to show the transition
from arterial to venous components (Figs.
3A,
3B,
3C, and
3D).
Aneurysms
In the evaluation of intracranial aneurysms, 3D RA allows detailed
information concerning the aneurysmal neck, including diameter, morphology,
and orientation of the feeding arteries and surrounding vessels
[7]. These characteristics are
essential to determine the appropriate type and size of endovascular coils for
embolization. The 3D RA workstation offers a virtual 3D "cut-away"
option, which enables the radiologist to visualize the exact location,
orientation, and size of the feeding vessels, even in a highly complex
vascular web. Three-dimensional reconstruction of rotational data generates
images that can be visualized in any plane, which is beneficial for treatment
planning. A single rotation replaces multiple static views that would be
necessary to otherwise define aneurysms and, as previously mentioned, can
decrease total radiation dose. The detailed real-time analysis afforded by 3D
RA has established its usefulness in adults, and this experience can be
directly applied to the less frequently encountered pediatric patient with
intracranial aneurysm.
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Fig. 4A —Meningioma in 7-year-old boy. Axial contrast-enhanced
T1-weighted MR image shows meningioma (arrows) in left parietal lobe
is impinging on branches of middle cerebral artery in sylvian fissure.
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Fig. 4B —Meningioma in 7-year-old boy. Lateral oblique volume-rendered
view of 3D rotational angiography (RA) from left common carotid arterial
injection shows external carotid artery (arrowheads), internal
carotid artery (I), and vessel paucity (arrows) in area of
meningioma.
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Tumors
Three-dimensional RA also has been shown to be useful in evaluating the
vascular anatomy of intracranial neoplasms for surgical planning or
preoperative embolization. The 3D RA data set enables delineation of the exact
vascular supply to the tumor, providing the neurosurgical team with an ideal
surgical approach and decreasing the risk of encountering unexpected vascular
anatomy in the operating suite (Figs.
4A,
4B,
4C,
4D, and
4E).
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Fig. 4C —Meningioma in 7-year-old boy. Anteroposterior shaded-surface
views of 3D RA without (left image) and with (right image)
spherical volume measurement of tumor (green) show location and mass
effect of meningioma. Internal carotid artery (arrows) and
superficial temporal branch of external carotid artery (arrowheads)
are shown.
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Fig. 4D —Meningioma in 7-year-old boy. Lateral oblique shaded-surface
view of 3D RA depicts spherical volume measurement of tumor (green).
Internal carotid artery (arrows) and superficial temporal branch of
external carotid artery (arrowheads) are shown.
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Fig. 4E —Meningioma in 7-year-old boy. Lateral shaded-surface view of
3D RA with spherical volume measurement (green). Internal carotid
artery (arrows) and superficial temporal branch of external carotid
artery (arrowheads) are shown. Three-dimensional RA enables
neurosurgical team to delineate ideal surgical approach that would identify
middle cerebral artery branches at risk before encountering them in operating
suite.
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Trauma
MDCT is a quick and readily available imaging technique to evaluate trauma
patients. However, certain lesions can produce a great amount of artifact on
CT images, and when in close proximity to vessels or vital tissues, it may be
difficult to assess these structures for injury. Both conventional angiography
and 3D RA can be used as an adjunct for evaluation of these patients. The
rotational angiogram itself takes seconds to acquire, with only a 180-sec lag
time for reconstruction of the 3D image. Dynamic information can also be
obtained from the 2D rotational raw data. Whereas the 3D reconstruction can be
subject to the same metallic artifact that compromises CT, the 2D data are
unencumbered and give the clinician excellent 180° diagnostic images to
make a well-informed and confident decision (Figs.
5A,
5B,
5C, and
5D). Three-dimensional RA is
also useful in delineating incidental findings detected on posttraumatic
imaging evaluation (Figs. 6A,
6B,
6C, and
6D).
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Fig. 5C —10-year-old boy with gunshot injury to neck. Medial posterior
oblique shaded-surface view of 3D rotational angiography (RA) shows bullet
near common carotid artery. Note artifactual defect suggesting spasm or
stenosis of common carotid artery adjacent to bullet.
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Fig. 5D —10-year-old boy with gunshot injury to neck. Medial anterior
oblique view from 2D RA shows bullet does not contact common carotid artery,
which is intact. Surgical exploration and anticoagulation therapy were
withheld, and patient recovered.
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Fig. 6A —Calcified lesion near vertebral artery in 15-year-old boy who
underwent CT for evaluation of football injury. Axial CT image shows
incidental calcified lesion (arrows) near left vertebral artery
(arrowheads).
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Fig. 6B —Calcified lesion near vertebral artery in 15-year-old boy who
underwent CT for evaluation of football injury. MR angiography image shows
left vertebral artery (arrows) but does not exclude vessel injury
secondary to artifact and irregular appearance of vessel wall.
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Fig. 6C —Calcified lesion near vertebral artery in 15-year-old boy who
underwent CT for evaluation of football injury. Anteroposterior shaded-surface
view of 3D rotational angiography (RA) shows vertebral artery
(arrows) without evidence of vascular lesion.
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Fig. 6D —Calcified lesion near vertebral artery in 15-year-old boy who
underwent CT for evaluation of football injury. Medial shaded-surface view of
3D RA shows intact vertebral artery (arrows). Three-dimensional RA
was performed and showed no evidence for dissection or pseudoaneurysm. Lesion
has remained stable and is presumed unrelated to trauma at presentation.
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Conclusion
Three-dimensional RA is an excellent tool for the evaluation of a number of
intracranial lesions in children: There is less total radiation exposure from
a single rotational run than from CT or a conventional angiography examination
that involves more than one view and the study is quick, with data acquisition
requiring less than 8 sec and fully rendered 3D reconstructions generated
within 180 sec. By eliminating multiple oblique angiographic injections, the
overall contrast load is decreased when compared with conventional angiography
or CT. Multiple 3D reconstruction renderings and options available at the 3D
RA workstation allow the radiologist to better understand complex intracranial
lesions in real time. Three-dimensional RA will continue to benefit pediatric
patients with complex intracranial lesions in the diagnosis, evaluation, and
determination of the most effective treatment strategies.
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Abstract
Introduction
