1. Bologna XIX Symposium Neuroradiologicum

2. Follow Up of Coiled Intracranial Aneurysms: MRA vs. DSA XIX Symposium Neuroradiologicum Bologna Dr. Stefan Celedin Klagenfurt / Austria

3. Bologna XIX Symposium Neuroradiologicum How to Check if the Mine is Still Defused

4. Bologna XIX Symposium Neuroradiologicum Follow Up in Austria F/U in Austria

5. Bologna XIX Symposium Neuroradiologicum DSA vs. MRA F/U in Austria Gold Standard

6. Bologna XIX Symposium Neuroradiologicum DSA vs. MRA Flat – Panel – Detector Matrix 5 Standard Projections 3D – Rotational - Angio 2 Standard Projections Matrix / TE Coil-Type / Stent 3 Tesla 1,5 Tesla K-Space 2D Time of Flight +/- contrast Ce-MRA First Pass Steady State with Blood Pool 3D Time of Flight +/- contrast MOTSA Multiple Overlapping Thin Slab Acquisition F/U in Austria Gold Standard Literature

7. Bologna XIX Symposium Neuroradiologicum F/U in Austria Gold Standard Literature

8. Bologna XIX Symposium Neuroradiologicum Smaller Methodologically Heterogeneous Single-Center-Studies Buhk et al: No Advantage of time-of-flight magnetic resonance angiography at 3 Tesla coompared to 1,5 Tesla in follow-up after endovascular treatment of cerebral aneurysms: Neuroradiology 2008;50(10):855-861 Deutschmann et al: Diagnostic accuracy of 3D time-of-flight MR angiography compared with digital subtraction angiography for follow-up of coiled intracranial aneurysms: influence of aneurysm size. AJNR 2007;28(4):628-634 Ferré et al: Time-of-Flight MR angiography at 3T versus digital subraction angiography in the imaging follow-up of 51 intracranial aneurysms treated with coils. EurJRadiol 2009;72(3):365-369 Gauvrit et al: Intracranial Aneurysms treated with Guglielmi detachable coils: long-term imaging follow up with contrast enhanced magnetic resonsnce angiography. J Neurosurg 2008;108(3):443-449 Kwee et al: MR angiography in the follow up of intracraniel aneurysms treated with gulielmi detachable coils: systematic review and meta-analysis. Neuroradiology 2007;49(9):703-713 Urbach et al: Three-dimensional time-of-flight MR angiography at 3T compared to digital substraction angiography in the follow-up of ruptured and coiled intracraniel aneurysms: a prospective study. Neuroradiology 2008;50(5)383-389 Wong et al: Assessment of brain aneurysms by using high-resolution magnetic resonsnce angiography after endovascular coil delivery. J Neurosurg 2007;107(2):283-289 F/U in Austria Gold Standard Literature

9. Bologna XIX Symposium Neuroradiologicum Meta – Analysis I Kwee T: MR angiography in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils: systematic review and meta-analysis. Neuroradiology. 2007;49(9):703-13 Included 16 Studies Detection of Residual Flow TOF: Sensitivity: 83,3% (95% CI 70.3 – 91,3%) Specificity: 90,6% (95% CI 80.4 – 95.8%) Detection of Residual Flow ceMRA: Sensitivity: 86,8% (95% CI 71,4 – 94,5%) Specificity: 91,9% (95% CI 79.8 - 97.0%) F/U in Austria Gold Standard Literatur Meta-Analysis

10. Bologna XIX Symposium Neuroradiologicum Conclusion Kwee: Both TOF-MRA and ce-MRA achieve a moderate to high diagnostic performance. Studies of moderate methodological quality Pooled estimates subject to heterogeneity. F/U in Austria Gold Standard Literature Meta-Analysis

11. Bologna XIX Symposium Neuroradiologicum Meta – Analysis II Weng HH: Meta-analysis on diagnostic accuracy of MR Angiography in follow-up of residual intracranial aneurysms treated with Gulielmi detachable coils. Interv Neuroradiol. 2008;14 Suppl2:53-63 Included 16 Studies Detection of Residual Flow TOF: Sensitivity: 90% (95% CI 79 – 95%) Specificity: 95% (95% CI 88 – 98%) Detection of Residual Flow ceMRA: Sensitivity: 92% (95% CI 79 – 97%) Specificity: 96 (95% CI 91 - 98%) F/U in Austria Gold Standard Literature Meta-Analysis

12. Bologna XIX Symposium Neuroradiologicum Conclusion Weng: The diagnostic accuracy of TOF-MRA and ce-MRA tests offer comparable and equal results and may obviate the invasive DS angiography F/U in Austria Gold Standard Literature Meta-Analysis

13. Bologna XIX Symposium Neuroradiologicum Intracranial Aneurysms Treated with Coil Placement: Test Characteristics of Follow-up MR Angiography-Multicenter Study Schaafsma Joanna et al Radiology July 2010 F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma

14. Bologna XIX Symposium Neuroradiologicum M & M 4 University Hospitals 311 pat, 343 aneurysms DSA: 3 Projections (AP, LV, OPT) MRA: 3D-TOF, ceMRA (1 st pass) 2 Neuroradiologists (1 Intervent.) Occlusion Class I-III (Roy) Occlusion Class: I&II vs. III F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM Complete Subtotal Incomplete

15. Bologna XIX Symposium Neuroradiologicum Image Evaluation: MRA: 1 Aneur. (platinum-iridium coils) excluded 2 Aneur. not interpretable in TOF (thombus/orientation) ceMRA only 6 Aneur. not interpretable in ceMRA (orientation/timing/contras t) TOF only DSA: 3 Aneur. not interpretable excluded F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge

16. Bologna XIX Symposium Neuroradiologicum Image Evaluation: Incomplete Occlusion: DSA: 25% patients (76; 95%CI 20-29%) 23% examinations (88; 95%CI 19-27%) Interobserver Agreement: DSA: κ 0,62 (95%CI 0,56-0,69) MRA: κ 0,64 (95%CI 0,57-0,70) INR: κ 0,61 (95%CI 0,54-0,68) INR/NINR: κ 0,65 (95%CI 0,60-0,71) F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge

17. Bologna XIX Symposium Neuroradiologicum Discrepancies 16 (88) incomplete Occlusion (III°) in DSA: 1 total Occlusion in MRA (coil artifacts) 15 subtotal (II°) Occlusions in MR 32 incomplete Occlusions in MRA: 20 subtotal in DSA 12 totally occluded in DSA F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge disc rep.

18. Bologna XIX Symposium Neuroradiologicum Discrepancies Accuracy: 0,89 Accuracy for 1,5T and 3T were comparable. F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge disc rep.

19. Bologna XIX Symposium Neuroradiologicum ceMRA Change of Classification in 6% (n=21) 9 Change = DSA 1 overstimated Degree of Occlusion 11 underestimated Degree of Occlusion Accuracy: TOF (0,86) and ceMRA (0,85) similar F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. ce MRA

20. Bologna XIX Symposium Neuroradiologicum Coil Artifacts Platinum-Iridium coils with nitinol Core Excluded. Artifacts impeded interpretation in 29 Aneurysms (8%) 22 @ TOF 1 @ ceMRA 6 @ both 1 MRA I°, DSA III° 8 MRA II°, DSA I° 20 MRA = DSA F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. Ce MRA coil s

21. Bologna XIX Symposium Neuroradiologicum Associated with Discrepancy Small Residual Lumen Suboptimal projection in DSA F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. Ce MRA coil s

22. Bologna XIX Symposium Neuroradiologicum Discussion TOF & ceMRA @ 1,5 and 3,0T high NPV for Aneurysm Recurrence. MRA showed all III° Occlusions that required treatment. No additional value of ceMRA over TOF Is Incomplete Occlusion in MRA but not in DSA false poitive? Imperfect reference test? F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. Ce MRA Coil d disc uss

23. Bologna XIX Symposium Neuroradiologicum Discussion Results favor the use of MRA at 1,5T or 3,0T instead of DSA. When MRA shows I or II° occlusion, DSA is likely not required. F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. Ce MRA Coil d disc uss

24. Bologna XIX Symposium Neuroradiologicum Conclusion Schaafsma et al The diagnostic performance of MR angiography in patients treated with coil placement is likely to be sufficient for it to replace routine follow-up intraarterial digital subtraction angiography, even though evaluation of costs and health benefits for both modalities is still needed. F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. Ce MRA Coil d Dis cuss con clude

25. Bologna XIX Symposium Neuroradiologicum The End F /U in Austria Gold Standard Literature Meta-Analysis Schaafsma MM ima ge Dis crep. Ce MRA Coil d Dis cuss Co nclude END