ACR Appropriateness Criteria® Cerebrovascular Diseases-Aneurysm, Vascular Malformation, and Subarachnoid Hemorrhage

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APPROPRIATE USE CRITERIA

ACR Appropriateness Criteria


Cerebrovascular Diseases-Aneurysm, Vascular
Malformation, and Subarachnoid Hemorrhage
Expert Panel on Neurological Imaging: Luke N. Ledbetter, MDa, Judah Burns, MD b,
Robert Y. Shih, MDc, Amna A. Ajam, MD, MBBS d, Michael D. Brown, MD, MSc e,
Santanu Chakraborty, MBBS, MSc f, Melissa A. Davis, MD, MBA g, Andrew F. Ducruet, MD h,
Christopher H. Hunt, MDi, Mary E. Lacy, MD j, Ryan K. Lee, MD, MBAk, Jeffrey S. Pannell, MD l,
Jeffrey M. Pollock, MD m, William J. Powers, MD n, Gavin Setzen, MDo, Matthew D. Shaines, MDp,
Pallavi S. Utukuri, MD q, Lily L. Wang, MBBS, MPH r, Amanda S. Corey, MD s

Abstract

Cerebrovascular disease is a broad topic. This document focuses on the imaging recommendations for the varied clinical scenarios
involving intracranial aneurysms, vascular malformations, and vasculitis, which all carry high risk of morbidity and mortality. Additional
imaging recommendations regarding complications of these conditions, including subarachnoid hemorrhage and vasospasm, are also

a o
Director, Head and Neck Imaging, University of California Los Angeles, Albany ENT & Allergy Services, PC, Albany, New York; American
Los Angeles, California. Academy of Otolaryngology-Head and Neck Surgery; President, Albany
b
Panel Chair and Program Director, Diagnostic Radiology Residency ENT & Allergy Services, PC.
p
Program, Montefiore Medical Center, Bronx, New York. Associate Chief, Hospital Medicine, Albert Einstein College of Medicine
c
Panel Vice-Chair, Uniformed Services University, Bethesda, Maryland. Montefiore Medical Center, Bronx, New York; Internal medicine physician.
d q
Ohio State University, Columbus, Ohio; Chief of Neuroradiology & MRI Clinical Site Director, Department of Radiology, Allen Hospital, New
at WRNMMC; and Associate Chief of Neuroradiology for AIRP. York Presbyterian, New York, New York; and Columbia University
e
Michigan State University, East Lansing, Michigan, American College of Medical Center, New York, New York.
r
Emergency Physicians. University of Cincinnati Medical Center, Cincinnati, Ohio.
f s
Ottawa Hospital Research Institute and the Department of Radiology, The Specialty Chair, Atlanta VA Health Care System and Emory University,
University of Ottawa, Ottawa, Ontario, Canada, Canadian Association of Atlanta, Georgia.
Radiologists. Corresponding author: Luke Ledbetter MD, Department of Radiology,
g
Director of Quality, Radiology, Emory University, Atlanta, Georgia; ACR David Geffen School of Medicine at UCLA, Ronald Reagan Medical
YPS Communications Liaison. Center, 757 Westwood Plaza, Suite 1621D, Los Angeles, CA, 90095-7532;
h
Barrow Neurological Institute, Phoenix, Arizona, Neurosurgery expert. e-mail: [email protected].
i
Mayo Clinic, Rochester, Minnesota. The American College of Radiology seeks and encourages collaboration
j
University of New Mexico, Albuquerque, New Mexico, American College with other organizations on the development of the ACR Appropriateness
of Physicians. Criteria through society representation on expert panels. Participation by
k
Chair, Department of Radiology, Einstein Healthcare Network, Phila- representatives from collaborating societies on the expert panel does not
delphia, Pennsylvania. necessarily imply individual or society endorsement of the final document.
l
University of California San Diego Medical Center, San Diego, California. Reprint requests to: [email protected].
m
Oregon Health & Science University, Portland, Oregon. The authors state that they have no conflict of interest related to the material
n
University of North Carolina School of Medicine, Chapel Hill, North discussed in this article. Drs Chakraborty, Ducruet, and Setzen are partners;
Carolina; American Academy of Neurology; Chair, Writing Group, and all other authors are non-partner/non-partnership track/employees.
American Heart Association/American Stroke Association Guidelines for The ACR Appropriateness Criteria documents are updated regularly. Please
the Early Management of Patients with Acute Ischemic Stroke, 2016- go to the ACR website at www.acr.org/ac to confirm that you are accessing
2019. the most current content.

Disclaimer: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment.
Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for
evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this
document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA
have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any
specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

Copyright ª 2021 American College of Radiology


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covered. While each variant presentation has unique imaging recommendations, the major focus of this document is neurovascular
imaging techniques.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are
reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current
medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness
Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of
imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion
may supplement the available evidence to recommend imaging or treatment.
Key Words: Aneurysm, Appropriateness Criteria, Appropriate Use Criteria, Arteriovenous malformation, AUC, Cerebral vasculitis,
Dural arteriovenous fistula, Subarachnoid hemorrhage, Vasospasm

J Am Coll Radiol 2021;18:S283-S304. Copyright ª 2021 American College of Radiology

ACR Appropriateness Criteria Cerebrovascular Diseases-Aneurysm, Vascular Malformation, and Subarachnoid


Hemorrhage. Variants 1 to 7 and Tables 1 and 2.

Variant 1. Known acute subarachnoid hemorrhage (SAH) on CT. Next imaging study.

Procedure Appropriateness Category Relative Radiation Level

Arteriography cervicocerebral Usually Appropriate ☢☢☢


CTA head with IV contrast Usually Appropriate ☢☢☢
MRA head without IV contrast May Be Appropriate O
US duplex Doppler carotid Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA head with IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

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Variant 2. Suspected cerebral vasospasm. Initial imaging.

Procedure Appropriateness Category Relative Radiation Level

Arteriography cervicocerebral Usually Appropriate ☢☢☢


CTA head with IV contrast Usually Appropriate ☢☢☢
US duplex Doppler transcranial May Be Appropriate O
MRI head perfusion with IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
CT head perfusion with IV contrast May Be Appropriate ☢☢☢
CT head without IV contrast May Be Appropriate ☢☢☢
US duplex Doppler carotid Usually Not Appropriate O
MRA head with IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

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Variant 3. Known cerebral aneurysm; untreated. Surveillance monitoring.

Procedure Appropriateness Category Relative Radiation Level

MRA head without IV contrast Usually Appropriate O


CTA head with IV contrast Usually Appropriate ☢☢☢
Arteriography cervicocerebral May Be Appropriate ☢☢☢
MRA head with IV contrast May Be Appropriate (Disagreement) O
MRA head without and with IV contrast May Be Appropriate O
US duplex Doppler carotid Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

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Variant 4. Known cerebral aneurysm; previously treated. Surveillance monitoring.

Procedure Appropriateness Category Relative Radiation Level

Arteriography cervicocerebral Usually Appropriate ☢☢☢


MRA head without and with IV contrast Usually Appropriate O
MRA head without IV contrast Usually Appropriate O
CTA head with IV contrast Usually Appropriate ☢☢☢
MRA head with IV contrast May Be Appropriate (Disagreement) O
US duplex Doppler carotid Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

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Variant 5. High-risk cerebral aneurysm screening.

Procedure Appropriateness Category Relative Radiation Level

MRA head without IV contrast Usually Appropriate O


CTA head with IV contrast Usually Appropriate ☢☢☢
US duplex Doppler carotid Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head with IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

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Variant 6. Known high-flow vascular malformation (AVM/AVF). Surveillance monitoring.

Procedure Appropriateness Category Relative Radiation Level

Arteriography cervicocerebral Usually Appropriate ☢☢☢


MRA head with IV contrast Usually Appropriate O
MRA head without and with IV contrast Usually Appropriate O
MRA head without IV contrast Usually Appropriate O
CTA head with IV contrast Usually Appropriate ☢☢☢
MRI head without and with IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
US duplex Doppler carotid Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Journal of the American College of Radiology S289


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Variant 7. Suspected central nervous system (CNS) vasculitis. Initial imaging.

Procedure Appropriateness Category Relative Radiation Level

MRA head without IV contrast Usually Appropriate O


MRI head without and with IV contrast Usually Appropriate O
MRI head without IV contrast Usually Appropriate O
Arteriography cervicocerebral May Be Appropriate ☢☢☢
CTA head with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler carotid Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA head with IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head with IV contrast Usually Not Appropriate O
MRV head with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Table 1. Appropriateness category names and definitions

Appropriateness Appropriateness
Category Name Rating Appropriateness Category Definition

Usually Appropriate 7, 8, or 9 The imaging procedure or treatment is indicated in the specified clinical scenarios
at a favorable risk-benefit ratio for patients.
May Be Appropriate 4, 5, or 6 The imaging procedure or treatment may be indicated in the specified clinical
scenarios as an alternative to imaging procedures or treatments with a more
favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate 5 The individual ratings are too dispersed from the panel median. The different
(Disagreement) label provides transparency regarding the panel’s recommendation. “May be
appropriate” is the rating category and a rating of 5 is assigned.
Usually Not 1, 2, or 3 The imaging procedure or treatment is unlikely to be indicated in the specified
Appropriate clinical scenarios, or the risk-benefit ratio for patients is likely to be
unfavorable.

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Table 2. Relative radiation level designations

RRL Adult Effective Dose Estimate Range (mSv) Pediatric Effective Dose Estimate Range (mSv)

O 0 0

☢ <0.1 <0.03

☢☢ 0.1-1 0.03-0.3

☢☢☢ 1-10 0.3-3

☢☢☢☢ 10-30 3-10

☢☢☢☢☢ 30-100 10-30

Note: Relative radiation level (RRL) assignments for some of the examinations cannot be made, because the actual patient doses in these
procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is
used). The RRLs for these examinations are designated as “varies.”

SUMMARY OF LITERATURE REVIEW All elements are essential: 1) timing, 2) reconstructions/


Introduction/Background reformats, and 3) 3-D renderings. Standard CTs with
Cerebrovascular diseases encompass broad and varied clin- contrast also include timing issues and reconstructions/
ical presentations and disease processes. This topic will focus reformats. Only in CTA, however, is 3-D rendering a
on clinical presentations based on aneurysms, vascular required element. This corresponds to the definitions that
malformations, subarachnoid hemorrhage (SAH), and the CMS has applied to the Current Procedural Terminol-
related cerebrovascular abnormalities, such as vasospasm and ogy codes.
central nervous system (CNS) vasculitis. For discussion
regarding the presentation of SAH and appropriate imaging, Initial Imaging Definition
please see the ACR Appropriateness Criteria topic on Initial imaging is defined as imaging at the beginning of the
“Headache” [1]. For potential SAH in the setting of head care episode for the medical condition defined by the
trauma, please see the ACR Appropriateness Criteria variant. More than one procedure can be considered usually
topic on “Head Trauma” [2]. The subset of cerebrovascular appropriate in the initial imaging evaluation when:
diseases and presentations are also broad and varied;
n There are procedures that are equivalent alternatives (ie,
therefore, the introduction and background of each variant
only one procedure will be ordered to provide the clinical
will be discussed individually.
information to effectively manage the patient’s care)
For discussion of cerebrovascular diseases related to
stroke, stroke-related conditions, or intraparenchymal OR
hemorrhage, please see the ACR Appropriateness Criteria n There are complementary procedures (ie, more than one
topic on “Cerebrovascular Disease-Stroke and Stroke-
procedure is ordered as a set or simultaneously where each
Related Conditions” that will be made available on the
procedure provides unique clinical information to effec-
ACR website when completed.
tively manage the patient’s care).

Special Imaging Considerations DISCUSSION OF PROCEDURES BY VARIANT


For the purposes of distinguishing between CT and CT
Variant 1: Known acute subarachnoid
angiography (CTA), ACR Appropriateness Criteria topics
hemorrhage (SAH) on CT. Next imaging study
use the definition in the ACR–NASCI–SIR–SPR Practice
Recommendations for imaging in the setting of suspected
Parameter for the Performance and Interpretation of Body
SAH with the clinical presentation of sudden, severe head-
Computed Tomography Angiography (CTA) [3]:
ache, or “worst headache of life” are guided by the ACR
CTA uses a thin-section CT acquisition that is timed to Appropriateness Criteria topic on “Headache” [1].
coincide with peak arterial or venous enhancement. The This variant will focus on imaging examinations used to
resultant volumetric dataset is interpreted using primary determine the source of SAH after initial detection. SAH,
transverse reconstructions as well as multiplanar refor- involving the basal cisterns, requires rapid triage and workup
mations and 3-D renderings. because a ruptured cerebral aneurysm is responsible for 70%

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of all nontraumatic SAHs [4,5]. The overall incidence of SAHs. However, CTA head sensitivity for detecting
aneurysmal SAH in the United States is between 9.7 and aneurysm decreases for aneurysms <3 mm in size
14.5 cases per 100,000 population and may be [4,10,13,15,17,19], in the setting of diffuse SAH [20],
underestimated due to the high risk of death prior to and for aneurysms occurring adjacent to an osseous
hospital admission [6-9]. Aneurysmal SAH results in structure [19]. CTA head may be sufficient to rule out a
significant morbidity and mortality with a quarter of vascular cause of SAH when the location of hemorrhage is
aneurysmal subarachnoid patients dying after presentation; isolated to the perimesencephalic region with follow-up
therefore, early diagnosis and repair is crucial to prevent catheter-directed angiography indicated in CTA negative
rebleeding [6]. Less common causes of SAH, often diffuse or peripheral SAHs [20].
presenting as isolated convexity SAH, such as tumors,
CTA Neck. There is no relevant literature to support the
stroke transformation, cerebral amyloid angiopathy, or
use of CTA neck in the initial imaging evaluation of known
reversible cerebral vasoconstriction syndrome, are not
acute SAH. CTA neck may be useful for potential treatment
considered here as their imaging and diagnosis often
planning, but preference will be individual or site specific.
follows the initial, commonly emergent, imaging
revaluation for common vascular lesions. Follow-up imag- CTV Head. There is no relevant literature to support the
ing for delayed complications of SAH, such as hydroceph- use of CT venography (CTV) head in the evaluation of
alus, should be directed by local protocols and clinical known acute SAH.
symptoms. The delayed complication of vasospasm after
MRA Head. MR angiography (MRA) head for the evalu-
SAH is discussed in Variant 2 of this topic.
ation of intracranial aneurysm demonstrated a pooled
Arteriography Cervicocerebral. Catheter-directed angi- sensitivity of 95% and specificity of 89% in one meta-
ography of the cerebral vasculature demonstrates high spatial analysis [21]. Diagnostic accuracy is increased, including
resolution, large field of view, and dynamic acquisition that for aneurysms >5 mm in size and at 3T scanner strength
leads to high diagnostic value in the evaluation of cerebro- [21,22]. The decrease in specificity, when compared with
vascular diseases resulting in SAH. Sensitivity and specificity CTA, is reported to have false-positive cases related to
are both >98% for catheter cerebral angiography when normal vascular variants of infundibular origin of vessels and
compared with surgical findings, including small aneurysms vessel loops [23]. Limitations of MRA head include required
<3 mm [10]. Catheter cerebral angiography also identified safety screening and relatively long acquisition time in
vascular abnormalities in up to 13% of patients with SAH urgent clinical scenarios.
and negative CTA imaging [11]. Although catheter
MRA Neck. There is no relevant literature to support the
cerebral angiography has been reported to be negative in
use of MRA neck in the evaluation of known acute SAH.
2% to 24% of patients with aneurysmal SAH, 3-D rota-
MRA neck may be useful for potential treatment planning,
tional angiography has been shown to identify an aneurysm
but preference will be individual or site specific.
on 25% of previously angiogram, both 2-D and 3-D,
negative patients [12]. Angiography is an invasive procedure MRI Head Perfusion. There is no relevant literature to
with a small complication risk related to intravascular support the use of MRI head perfusion in the evaluation of
instrumentation. known acute SAH.
CT Head Perfusion. There is no relevant literature to MRI Head. Although there is no relevant literature to
support the use of CT head perfusion in the evaluation of support the use of MRI head in the evaluation for a vascular
known acute SAH. source of known acute SAH, several studies evaluated the
use of MRI head in predicting clinical outcomes. Patients
CT Head. There is no relevant literature to support the use
with acute poor-grade SAH and diffusion-weighted imaging
of CT head in the evaluation of known (previously diag-
positive findings on MRI head had a less favorable long-
nosed by imaging or lumbar puncture) acute SAH. Rec-
term outcome when compared with patients without
ommendations for imaging in the setting of suspected SAH
diffusion-weighted imaging positive findings [24,25].
with the clinical presentation of sudden, severe headache or
“worst headache of life” are guided by the ACR Appropri- MRV Head. There is no relevant literature to support the
ateness Criteria topic on “Headache” [1]. use of MR venography (MRV) head in the evaluation of
known acute SAH.
CTA Head. CTA head is a fast, noninvasive study to
evaluate patients with acute SAH. CTA head has been US Duplex Doppler Carotid. There is no relevant
shown to have >90% sensitivity and specificity in the literature to support the use of carotid ultrasound (US)
evaluation for aneurysms [4,10,13-18] responsible for duplex Doppler in the evaluation of known acute SAH.

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US Duplex Doppler Transcranial. There is no relevant large- and medium-sized vessels. CT perfusion has been
literature to support the use of US transcranial with duplex studied in 3 separate clinical scenarios: early (0-3 days after
Doppler (TCD) in the evaluation of known acute SAH. SAH) prediction of future of delayed cerebral ischemia, late
detection of vasospasm, and late detection of ischemic
injury. Early use of CT head perfusion within the first 3
Variant 2: Suspected cerebral vasospasm.
days after SAH with qualitative perfusion abnormalities were
Initial imaging
associated with later development of vasospasm [26]. A
Vasospasm in the cerebral arteries occurs in approximately
more recent retrospective study of CT perfusion within 24
30% of patients with SAH and frequently occurs 7 to 10
hours of aneurysmal SAH and demonstrating perfusion
days after hemorrhage with spontaneous resolution by day
abnormalities did not correlate with the development of
21 [6]. Vasospasm is associated with delayed cerebral
delayed cerebral ischemia [32]. For the later use of CT
ischemia defined by delayed development of neurologic
perfusion after SAH, a meta-analysis demonstrated a sensi-
deficits after SAH not related to aneurysm treatment or
tivity of 74% and specificity of 93% in detecting vasospasm
other neurologic complications, such as hydrocephalus,
[33], and retrospective studies showed sensitivities of 84%
cerebral edema, or metabolic derangements [26].
to 93% and specificities of 57% to 73% in detected
Morbidity and mortality in SAH increases between 10%
delayed cerebral ischemia [29,34]. However, using CT
and 20% after onset of clinical symptoms of delayed
head perfusion to guide treatment decision in the setting
cerebral ischemia [27], and the symptoms are frequently
of neurologic symptoms of delayed cerebral ischemia did
nonreversible [28,29]. Imaging findings of vasospasm and
not improve outcomes when compared with treating all
guidance of treatment does not appear to improve clinical
patients without imaging guidance [28].
outcome after the onset of clinical symptoms [28].
Despite the association of moderate to severe vasospasm CT Head. SAH on CT head can be graded by the Fisher
and poor clinical outcome [30], only 50% patients with or modified Fisher scale. The higher the Fisher grade of
large-vessel vasospasm develop clinical ischemic neurologic SAH, the higher the patient risk for vasospasm [35].
symptoms [6], and delayed ischemia can occur in the Although CT head may be useful to provide a Fisher
absence of imaging findings of vasospasm [26]. However, grade and risk for vasospasm, the examination does not
given the clinical implications of delayed cerebral directly give information regarding the presence or absence
ischemia, early screening and detection of vasospasm of vasospasm. Anatomic changes of completed infarct
remains recommended [6]. related to delayed cerebral ischemia can also be identified
on CT head.
Arteriography Cervicocerebral. Conventional catheter-
directed cerebrovascular arteriography is the reference stan- CTA Head. CTA head can provide a less invasive evalua-
dard for characterization of intracranial vasospasm. How- tion of the intracranial cerebral vasculature compared with
ever, only approximately 50% of radiographic large-vessel catheter-directed angiography. In a meta-analysis, CTA head
vasospasm develops delayed cerebral ischemia, and given the detected vasospasm with a sensitivity and specificity of 80%
invasive nature and potential rare neurologic complications, and 93%, respectively [33]. CTA head is highly correlated
other less invasive screening methods are often performed to conventional angiography for larger proximal intracranial
before catheter angiogram [28]. In a large, international vessels with decreasing correlation in the smaller more distal
multicenter randomized trial, the presence of angiographic arteries [36].
vasospasm was strongly associated (odds ratio of 9.3) with
CTA Neck. There is no relevant literature to support the
the development of cerebral infarction. In the same study,
use of CTA neck in the evaluation of suspected cerebral
a small number of patients (3%) developed infarction
vasospasm.
without evidence of vasospasm on angiogram [31]. An
additional consideration to the angiographic evaluation of CTV Head. There is no relevant literature to support the
vasospasm is the potential for intra-arterial treatment of use of CTV head in the evaluation of suspected cerebral
vessel narrowing. However, intra-arterial treatment of vasospasm.
vasospasm lacks high-quality evidence of improvement of
MRA Head. There is no relevant literature to support the
outcomes at this time [6].
use of MRA head in the evaluation of suspected cerebral
CT Head Perfusion. CT head perfusion is a useful tool in vasospasm.
the evaluation of vasospasm. CT perfusion data provide MRA head evaluation of the intracranial arteries in the
information regarding the intraparenchymal small-vessel setting of suspected vasospasm is limited by background of
perfusion as opposed to CTA and TCD evaluation of hemorrhage and hemodynamic flow alterations with poor

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correlation to digital subtraction angiography (DSA) find- cerebral aneurysms are lacking [42]. Between 4% and 18%
ings [37]. of aneurysms demonstrate growth on imaging follow-up
[43,44], with a 12-fold higher risk of rupture in growing
MRA Neck. There is no relevant literature to support the
aneurysms [44]. Although aneurysm growth is associated
use of MRA neck in the evaluation of suspected cerebral
with size >7 mm, smaller aneurysms can grow and
vasospasm.
rupture [44]. Given the evidence of potential for growth
MRI Head Perfusion. Given the continued difficulty in and rupture of untreated and unruptured aneurysms,
identifying patients at risk for and in preventing vasospasm vascular imaging surveillance is recommended.
and delayed cerebral ischemia, advanced MRI head perfu-
Arteriography Cervicocerebral. Cervicocerebral arteri-
sion studies are now being performed. MRI head perfusion
ography remains the reference standard imaging examina-
with decreased intravoxel incoherent motion microvascular
tion for the evaluation of cerebral aneurysms with high
perfusion has been associated with vasospasm [38], and
spatial resolution, high signal-to-noise ratio, and dynamic
elevated blood-brain barrier permeability (Ktrans) was
image acquisition. However, given the invasive nature and
associated with patients who went on to develop delayed
potential complications of cervicocerebral arteriography, it is
cerebral ischemia [39]. Despite these early positive studies,
not ideal for routine patient surveillance.
no large or prospective studies have been performed to
support the widespread use of MRI head perfusion in the CT Head Perfusion. There is no relevant literature to
evaluation of suspected vasospasm. support the use of CT head perfusion in the surveillance of a
known, untreated cerebral aneurysm.
MRI Head. MRI head offers evaluation of consequences of
delayed cerebral ischemia including completed infarction. CT Head. There is no relevant literature to support the use
However, there is no relevant literature to support the use of of CT head in the surveillance of a known, untreated ce-
MRI head in the evaluation of suspected cerebral vasospasm. rebral aneurysm.
MRV Head. There is no relevant literature to support the CTA Head. CTA head is a fast and noninvasive study to
use of MRV head in the evaluation of suspected cerebral evaluate the intracranial vasculature. CTA head has been
vasospasm. shown to be >90% sensitive and specific in the evaluation
for aneurysms [4,10,13-18]. However, CTA head sensitivity
US Duplex Doppler Carotid. There is no relevant
for detecting an aneurysm decreases for aneurysms <3 mm
literature to support the use of carotid US duplex Doppler
in size [4,10,13,15,17,19] and for aneurysms occurring
in the evaluation of suspected cerebral vasospasm.
adjacent to an osseous structure [19].
US Duplex Doppler Transcranial. TCD is a quick and
CTA Neck. There is no relevant literature to support the
noninvasive modality to evaluate for increased arterial ve-
use of CTA neck in the surveillance of a known, untreated
locities in the setting of vasospasm. Given the ability to
cerebral aneurysm.
perform the examination at the bedside, daily TCD is
frequently used in the screening for vasospasm in at-risk CTV Head. There is no relevant literature to support the
populations. Vasospasm identified on TCD predicts use of CTV head in the surveillance of a known, untreated
delayed cerebral ischemia with 90% sensitivity, 92% nega- cerebral aneurysm.
tive predictive value, 71% specificity, and 57% positive
MRA Head. MRA head is an ideal candidate for imaging
predictive value [40]. Although screening for vasospasm
surveillance of known, untreated aneurysms because of its
with TCD has high sensitivity and negative predictive
noninvasive nature and ability to obtain diagnostic infor-
value, prolonged TCD screening past day 10 post-SAH
mation without intravenous (IV) contrast. The evaluation of
does not appear to increase detection of delayed cerebral
intracranial aneurysm with MRA head demonstrated a
ischemia [41]. In addition, there is no current high-quality
pooled sensitivity of 95% and specificity of 89% in one
literature relating detection of vasospasm on TCD to
meta-analysis [21]. Diagnostic accuracy is increased,
improved patient outcomes [40].
including for aneurysms <5 mm in size, at 3T scanner
strength [21,22]. Vessel loops and infundibular origins of
Variant 3: Known cerebral aneurysm; vessels can lead to false-positives for aneurysm on MRA
untreated. Surveillance monitoring [23]. Contrast-enhanced MRA head may increase visualized
Cerebral aneurysms are often incidentally discovered on detail of large aneurysms with complex flow dynamics or
intracranial vascular imaging. Definitive algorithmic guide- thrombosis [45]. However, there is no significant difference
lines for management and follow-up of incidentally found in diagnostic performance between time-of-flight MRA and

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contrast-enhanced MRA on the aforementioned meta- Arteriography Cervicocerebral. Cervicocerebral arteri-
analysis of MRA examinations in the diagnosis of aneu- ography remains the reference standard imaging examina-
rysms [21]. tion for the evaluation of treated cerebral aneurysms with
high spatial resolution, high signal-to-noise ratio, and dy-
MRA Neck. There is no relevant literature to support the
namic image acquisition. Aneurysm and parent vessel
use of MRA neck in the surveillance of a known, untreated
appearance is better visualized, as indwelling occlusion de-
cerebral aneurysm.
vice artifacts are less apparent on cervicocerebral arteriog-
MRI Head Perfusion. There is no relevant literature to raphy than on MRI or CT. Drawbacks for surveillance
support the use of MRI head perfusion in the surveillance of include invasiveness and small risk of vascular complication.
a known, untreated cerebral aneurysm.
CT Head Perfusion. There is no relevant literature to
MRI Head. There is no relevant literature to support the support the use of CT head perfusion in the surveillance of
use of MRI head in the surveillance of a known, untreated known, treated cerebral aneurysm.
cerebral aneurysm.
CT Head. There is no relevant literature to support the use
MRV Head. There is no relevant literature to support the of CT head in the surveillance of known, treated cerebral
use of MRV head in the surveillance of a known, untreated aneurysm.
cerebral aneurysm.
CTA Head. CTA head is useful for surveillance imaging of
US Duplex Doppler Carotid. There is no relevant treated cerebral aneurysms because of its noninvasive nature.
literature to support the use of carotid US duplex Doppler However, CTA is limited by large metallic streak artifacts
in the surveillance of a known, untreated cerebral aneurysm. encountered with metallic coils, stents, and devices.
Although artifact from metal cannot be removed, several
US Duplex Doppler Transcranial. There is no relevant
metal artifact reduction techniques are available to improve
literature to support the use of TCD in the surveillance of a
evaluation of treated aneurysms and the parent vessels [53-
known, untreated cerebral aneurysm.
57].
CTA Neck. There is no relevant literature to support the
Variant 4: Known cerebral aneurysm; use of CTA neck in the surveillance of known, treated ce-
previously treated. Surveillance monitoring rebral aneurysm.
Treatment of cerebral aneurysms is common to reduce the
CTV Head. There is no relevant literature to support the
risk of aneurysm rupture or rebleeding. Endovascular
use of CTV head in the surveillance of known, treated ce-
treatment is now the first-line therapy in most cases, whereas
rebral aneurysm.
aneurysms not amenable to endovascular repair require
surgical clipping or observation. Follow-up imaging after MRA Head. MRA head is a noninvasive examination
treatment is often performed to assess for potential refilling commonly used for treated aneurysm surveillance. This
of aneurysms and detect formation of new aneurysms. examination can be obtained without IV contrast using
Aneurysm remnants after surgical clipping are identified in time-of-flight imaging, with IV contrast to improve flow-
up to 11% of patients [46] and more frequently after related artifacts occasionally encountered in aneurysms, or
endovascular repair [47,48]. Recurrence of treated aneurysm a combination of both. In the setting of coiled aneurysms, a
is most common within 6 months of treatment but can meta-analysis found similar performance of both non-
occur in a more delayed manner [49]. Development of de contrast and contrast-enhanced examinations with sensitiv-
novo aneurysm occurs in 1% to 8% of patients with ities of 86% for both time-of-flight and contrast-enhanced
treated aneurysms [50-52]. MRA, as well as specificities of 84% and 89%, respectively
Imaging evaluation is focused on not only the treated [58]. MRA head was also compared directly with catheter-
aneurysm but also the integrity of the parent vessel and directed angiography and found to result in substantial
formation of new aneurysms. Intracranial aneurysms are agreement (kappa 0.73) regarding treatment recommenda-
treated with several different devices, including surgical tions between the 2 examinations [59]. Treatment with
clips, detachable coils, stents, and flow diverters, and each stents or flow diverters results in challenges in MRA
device will result in unique appearances as well as challenges, intraluminal evaluation of the stent. Contrast-enhanced
depending on the imaging modality used. Specific knowl- MRA outperforms time-of-flight MRA in the evaluation
edge of the technique utilized in prior treatment is helpful in of a treated aneurysm and parent vessel patency with
choosing a particular follow-up modality for each patient. indwelling stent; however, intraluminal detail is limited with

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both techniques [60]. Newer endovascular devices aneurysm are moyamoya [69], aortic dissection [70],
demonstrate magnetic susceptibility and Faraday cage bicuspid aortic valve [71], aortic aneurysm [72], and
effects, which limits MRA head utility in assessing for coarctation of the aorta [73].
aneurysm thrombosis or parent vessel patency when
Arteriography Cervicocerebral. Although cerebral arte-
compared with conventional arteriography [61-63].
riography is the reference standard for known or suspected
MRA Neck. There is no relevant literature to support the aneurysm, the invasive nature and potential complications
use of MRA neck in the surveillance of known, treated ce- are not suited for screening in a high-risk population. There
rebral aneurysm. is no relevant literature to support the use of cerebral arte-
riography in this population.
MRI Head Perfusion. There is no relevant literature to
support the use of MRI head perfusion in the surveillance of CT Head Perfusion. There is no relevant literature to
known, treated cerebral aneurysm. support the use of CT head perfusion in the screening of
patients at high risk for cerebral aneurysm.
MRI Head. There is no relevant literature to support the
use of MRI head in the surveillance of known, treated ce- CT Head. There is no relevant literature to support the use
rebral aneurysm. of CT head in the screening of patients at high risk for
cerebral aneurysm.
MRV Head. There is no relevant literature to support the
use of MRV head in the surveillance of known, treated CTA Head. CTA head is a fast, noninvasive study to
cerebral aneurysm. evaluate the intracranial vasculature. CTA head has been
shown to be >90% sensitive and specific in the evaluation
US Duplex Doppler Carotid. There is no relevant
for aneurysms [4,10,13-18]. However, CTA head sensitivity
literature to support the use of carotid US duplex Doppler
for detecting an aneurysm decreases for both aneurysms <3
in the surveillance of known, treated cerebral aneurysm.
mm in size [4,10,13,15,17,19] and aneurysms occurring
US Duplex Doppler Transcranial. There is no relevant adjacent to an osseous structure [19].
literature to support the use of TCD in the surveillance of
CTA Neck. There is no relevant literature to support the
known, treated cerebral aneurysm.
use of CTA neck in the screening of patients at high risk for
cerebral aneurysm.
Variant 5: High-risk cerebral aneurysm CTV Head. There is no relevant literature to support the
screening use of CTV head in the screening of patients at high risk for
Certain populations are at high risk of developing a cerebral cerebral aneurysm.
aneurysm. Given the high morbidity and mortality associ-
MRA Head. MRA head is an ideal candidate for screening
ated with aneurysm rupture, screening high-risk patients
high-risk populations for cerebral aneurysm due to its
may be beneficial. The incidence of aneurysm in the general
noninvasive nature and ability to obtain diagnostic infor-
population is near 1.8% [64]. The most studied high-risk
mation without IV contrast. The evaluation of intracranial
population is patients with autosomal dominant polycystic
aneurysm with MRA head demonstrated a pooled sensitivity
kidney disease (ADPKD). Patients with ADPKD have an
of 95% and specificity of 89% in one meta-analysis, in
increased prevalence of aneurysms between 10% and 11.5%
which 45% of the 67 missed aneurysms were <3 mm in
[65], with up to 21% of patients with ADPKD and a first-
size, and another 45% were between 3 and 5 mm in size,
degree relative with history of aneurysm [66]. Aneurysmal
6% were between 5 and 10 mm in size, and 4% >10 mm in
SAH occurs at a younger age, and risk of de novo
size [21]. Diagnostic accuracy is increased, including for
aneurysm formation is higher in ADPKD patients when
aneurysms <5 mm in size, at 3T scanner strength
compared with the general population [67]. Given the
[21,22]. Vessel loops and infundibular origins of vessels
relationship of ADPKD and cerebral aneurysms, screening
can lead to false-positives for aneurysm on MRA [23].
has been shown to be cost effective in several studies
Contrast-enhanced MRA head has no relevant literature to
[65,68]. The American Heart Association guidelines also
support its use in the screening of patients at high risk for
recommend offering screening to patients with 2 family
cerebral aneurysm.
members with intracranial aneurysms or SAH. A higher
risk of aneurysm occurrence in such families is found in MRA Neck. There is no relevant literature to support the
those with a history of hypertension, smoking, and female use of MRA neck in the screening of patients at high risk for
sex [42]. Other conditions with increased risk of cerebral cerebral aneurysm.

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MRI Head Perfusion. There is no relevant literature to not establish the benefit of interventional treatment of
support the use of MRI head perfusion in the screening of unruptured AVMs, which remains a debated issue. The
patients at high risk for cerebral aneurysm. optimal methods for surveillance of untreated AVMs are
not well established in the literature. However, treated
MRI Head. There is no relevant literature to support the
lesions usually require long-term follow-up, specifically le-
use of MRI head in the screening of patients at high risk for
sions treated with radiosurgery or embolization.
cerebral aneurysm.
Intracranial dural AVF (dAVF) is an abnormal shunt
MRV Head. There is no relevant literature to support the between a dural artery and venous sinus or cortical vein.
use of MRV head in the screening of patients at high risk for dAVFs demonstrate similar high-flow vascular shunting but
cerebral aneurysm. lack the central nidus associated with AVM. Signs and
symptoms of dAVF depend on the location, with posterior
US Duplex Doppler Carotid. There is no relevant
dural venous sinus lesion frequently presenting with pulsa-
literature to support the use of carotid US duplex Doppler
tile tinnitus or cavernous sinus lesions presenting with
in the screening of patients at high risk for cerebral
pain, proptosis, chemosis, and ophthalmoplegia [80].
aneurysm.
Complications of high-grade dAVF include hemorrhage or
US Duplex Doppler Transcranial. There is no relevant nonhemorrhagic neurologic defects and are associated with
literature to support the use of TCD in the screening of retrograde cortical venous drainage [80-83]. Treatment via
patients at high risk for cerebral aneurysm. endovascular or microsurgical approach is usually indicated
in high-grade dAVF with cortical venous drainage or
symptomatic lesions. Observation can be utilized in lower-
Variant 6: Known high-flow vascular grade lesions with less risk of hemorrhagic or neurologic
malformation (AVM/AVF). Surveillance complications [80,83]. This variant covers the surveillance
monitoring of both treated and untreated high-flow vascular
Intracranial high-flow vascular malformations include arte- malformations.
riovenous malformations (AVMs) and arteriovenous fistulas
Arteriography Cervicocerebral. Cervicocerebral angiog-
(AVFs). Both lesions are defined by an abnormal connection
raphy remains the reference standard for imaging of cere-
between the relatively high-pressure arterial system and the
brovascular disease, including AVM and dAVF. Angiography
low-pressure venous system resulting in a high-flow shunt-
demonstrates high spatial and temporal resolution of critical
ing of blood.
importance in the characterization of the intranidal aneurysm
AVMs are direct connections of artery to vein via
in AVM as well as potentially small arterial feeding vessels and
abnormal dilated vascular channels without normal inter-
venous drainage characteristics in both AVM and dAVF.
mediary capillary bed. The abnormal dilated vascular
Arteriography is critical in planning treatment in all high-flow
channels are known as the nidus [74]. Although the true
intracranial vascular malformations. Specifically, an arterio-
incidence of brain AVM is unknown, asymptomatic
gram of an AVM provides high-resolution imaging of the
prevalence on MRI is estimated at 0.05% [74,75].
nidus; however, 2-D angiographic images may overestimate
Between 10% and 20% of patients with hereditary
lesion volumes when compared with MRA or CTA [84]. The
hemorrhagic telangiectasia will have at least one AVM
addition of 3-D rotational cerebral arteriography results in
during their lifetime [74,76]. Symptomatic brain AVMs
more precise AVM nidus volume measurement when
present most commonly with hemorrhage or epilepsy
compared with CT and MRI [85].
[74]. The annual rupture risk of a brain AVM is 1.3%
for previously unruptured AVM and up to 4.8% for CT Head Perfusion. There is no relevant literature to
previously ruptured lesions [74,77]. Imaging findings support the use of CT head perfusion in the surveillance of
associated with higher hemorrhage risk include intranidal high-flow intracranial vascular malformations.
aneurysm, deep venous drainage, deep location, or venous
CT Head. Although larger AVMs can be visualized on CT
outflow obstruction [74,78]. Treatment for AVMs include
head because of hyperattenuating prominent vascular struc-
surgical resection, endovascular embolization, stereotactic
tures [83] and the osseous landmarks can be useful in
radiosurgery, or medical management. The ARUBA (A
radiation therapy treatment planning [85], there is no
Randomised trial of Unruptured Brain Arteriovenous
relevant literature to support the use of CT head in the
Malformations) trial concluded medical management alone
surveillance of high-flow intracranial vascular malformations.
was superior to medical management with interventional
therapy for the prevention of death or stroke in patients CTA Head. Sensitivity of CTA head was shown to be 90%
with unruptured brain AVMs [79]. However, the trial did for the overall detection of AVMs, 100% for AVMs >3 cm,

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and 88% for associated flow-related aneurysms when MRI Head. High-flow intracranial vascular malformations
compared with DSA [86]. For high-flow AVFs, CTA head can be identified on MRI head because of dilated vessels. In
demonstrated a sensitivity of 86% and specificity of 100% in a study evaluating MRI and AVM, T2-weighted images
patients with pulsatile tinnitus [87]. Indirect signs of cortical demonstrated overall sensitivity of 89% and 100% for
venous drainage, indicating higher-risk lesion for future lesions >3 cm as well as low (29%) sensitivity for
complication, on CTA exhibited sensitivities between 96% AVM-associated aneurysms [86]. MRI can also provide
for cortical venous dilatation and 62% for identification of a important information regarding the associated brain
medullary or pial vein. Drawbacks to CTA for surveillance parenchyma including ischemia on diffusion-weighted
monitoring include the lack of temporal resolution to directly imaging or gliosis on T2 and fluid-attenuated inversion-
determine flow dynamics of complex vascular lesions. recovery imaging [83].
CTA Neck. There is no relevant literature to support the MRV Head. There is no relevant literature to support the
use of CTA neck in the surveillance of high-flow intracranial use of MRV head in the surveillance of high-flow intracra-
vascular malformations. CTA neck may be useful for po- nial vascular malformations.
tential treatment planning, but preference will be individual
US Duplex Doppler Carotid. There is no relevant
or site specific.
literature to support the use of carotid US duplex Doppler
CTV Head. There is no relevant literature to support the in the surveillance of high-flow intracranial vascular
use of CTV head in the surveillance of high-flow intracranial malformations.
vascular malformations.
US Duplex Doppler Transcranial. There is no relevant
MRA Head. MRA head is frequently used in surveillance literature to support the use of TCD in the surveillance of
of known high-flow vascular malformations. In the setting high-flow intracranial vascular malformations.
of AVM, time-of-flight and contrast-enhanced MRA offer
good diagnostic accuracy but lack temporal resolution
for hemodynamics and information regarding the small Variant 7: Suspected central nervous system
angioarchitecture [88]. Multiple 4-D MRA techniques are (CNS) vasculitis. Initial imaging
available to provide temporal resolution with trade-off in CNS vasculitis refers to inflammation and destruction of the
spatial resolution. Although 4-D MRA demonstrates good blood vessels of the brain, spinal cord, or meninges [99].
agreement with DSA [89-91], MRA has limited sensitivity This variant will focus on primary CNS vasculitis, defined
for small nidus (<1 cm) or complete resolution after by vasculitis only involving the CNS as well as intracranial
treatment [88,92]. findings systemic vasculitis secondarily involving the CNS.
For AVF, time-of-flight MRA demonstrates excellent For evaluation of systemic vasculitis outside of the CNS,
intermodality agreement with DSA regarding the location of please see the ACR Appropriateness Criteria topic on
the fistula site and good agreement regarding the arterial “Noncerebral Vasculitis” [100]. Processes that can result
feeding vessels and venous drainage [93]. Time-of-flight and in secondary vasculitis involvement of the CNS include,
contrast-enhanced MRA demonstrated slightly lower nega- but are not limited to, autoimmune and autoinflammatory
tive predictive values in the evaluation of signs of cortical etiologies, such as polyarteritis nodosa, microscopic
venous reflux when compared with CTA [94]. There is polyangiitis, granulomatosis with polyangiitis, rheumatoid
good to excellent correlation of 4-D MRA techniques to arthritis, or systemic lupus erythematosus, as well as
DSA demonstrated in multiple studies [95-97]. infectious causes, such as varicella zoster virus, hepatitis C
virus, human deficiency virus, cytomegalovirus, and
MRA Neck. There is no relevant literature to support the
cysticercosis [99]. Secondary CNS vasculitis is frequently a
use of MRA neck in the surveillance of high-flow intracra-
late manifestation of the disease and frequently the
nial vascular malformations. MRA neck may be useful for
systemic process is already known at the time of CNS
potential treatment planning, but preference will be indi-
involvement.
vidual or site specific.
Primary CNS vasculitis is a rare disorder with 2.4
MRI Head Perfusion. MRI head perfusion demonstrates cases per 1 million person-years [99,101]. Primary CNS
variable perfusion abnormalities in the evaluation of hemo- vasculitis typically presents with headache, followed by
dynamic physiology of AVM [83]. Perfusion examinations, encephalopathy and behavioral changes. Focal neurological
including arterial spin-labeled perfusion imaging, may have deficit occurs in 20% to 30% of patients. Seizures and
a role in the evaluation of improved perfusion from obliter- intracranial hemorrhage may also occur. The diagnosis of
ation of AVMs after radiation therapy [98]. primary CNS vasculitis is challenging because of its

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nonspecific and varied symptoms. Diagnostic criteria for MRA Head. MRA head offers a noninvasive and radiation
CNS vasculitis proposed by Calabrese and Mallek in 1988 free examination of the intracranial vessels. As stated above
required diagnosis via histopathology or characteristic in the arteriography and CTA head sections, specificity of
findings on DSA [102,103]. Although angiographic vascular luminal imaging is limited by considerable overlap
diagnosis continues to be accepted by some authors [104], with other cerebrovascular disease, such as atherosclerosis
other authors have proposed diagnostic criteria that do not and reversible cerebral vasoconstriction syndrome, and
accept diagnosis based on angiography and require histology sensitivity is limited to resolution as vasculitis can involve
from biopsy or autopsy [105]. With a strong clinical small distal arteries below native resolution of MRA [99]. In
suspicion, brain imaging is important for supporting the a recent retrospective comparison of time-of-flight MRA to
diagnostic process and directing biopsy [99,106]. Imaging DSA, time-of-flight MRA was abnormal in 81% of patients
examinations with CNS vasculitis demonstrate numerous with angiographic findings of vasculitis and normal in 100%
nonspecific findings, such as infarcts, white matter injury, of patients with a normal angiogram. Although postcontrast
mass lesions, meningeal enhancement, or hemorrhage. imaging is utilized in vessel wall imaging MRI brain pro-
Characteristic vessel imaging findings, though not always tocols and MRA is typically included in the imaging pro-
present on histologically proven cases, include multifocal tocol, no relevant literature supports the use of postcontrast
stenosis and dilatation of the intracranial vasculature as well MRA in the initial imaging for suspected CNS vasculitis.
as characteristic pattern of vessel wall inflammation [107].
Many of the imaging features overlap with other MRA Neck. There is no relevant literature to support the
cerebrovascular diseases, such as reversible cerebral use of MRA neck in the initial imaging for suspected CNS
vasoconstriction syndrome or atherosclerotic disease. vasculitis. For the evaluation of systemic vasculitis, please see
the ACR Appropriateness Criteria topic on “Noncerebral
Arteriography Cervicocerebral. Cerebral arteriography Vasculitis” [100].
has long been the standard in imaging diagnosis of CNS
vasculitis due to its submillimeter resolution. However, ce- MRI Head Perfusion. There is no relevant literature to
rebral angiography has low specificity for vasculitis given support the use of MRI head perfusion in the initial imaging
significant overlap of findings with other cerebrovascular for suspected CNS vasculitis.
diseases, such as atherosclerosis or reversible cerebral vaso- MRI Head. MRI head is a useful examination in the
constriction syndrome, and limited sensitivity as the degree evaluation of CNS vasculitis given its superior soft-tissue
of vascular involvement can be below angiography resolu- characteristics of the brain parenchyma and vessel walls.
tion [99,107]. Multiple infarcts of variable ages are identified on MRI in
CT Head Perfusion. There is no relevant literature to up to 50% of patients with CNS vasculitis [99,101]. Other
support the use of CT head perfusion in the initial imaging findings of primary CNS vasculitis include mass lesions,
for suspected CNS vasculitis. meningeal enhancement, and hemorrhage in 5%, 8%, and
9% of cases, respectively [99,101]. Progressive confluent
CT Head. There is no relevant literature to support the use white matter lesions, cortical and subcortical T2 lesions,
of CT head in the initial imaging for suspected CNS multiple microhemorrhages, large single or multiple
vasculitis. enhancing mass lesions, and enhancing small vessels/
CTA Head. CTA head can characterize intracranial vessel perivascular spaces are also seen [105]. Although
luminal characteristics with limited resolution and evaluation parenchymal abnormalities on MRI have considerable
of the distal small arteries. Findings of CNS vasculitis on overlap with other CNS diseases, sensitivity of a normal
CTA include multifocal vessel wall narrowing and dilatation MRI for CNS vasculitis approaches 100% [99,101].
with considerable overlap with other nonvasculitis cerebral Recent advances in MRI intracranial vessel wall imaging
vascular diseases and sensitivity is limited to resolution [99]. shows promise in helping to differentiate CNS vasculitis
from other cerebrovascular diseases as inflammatory changes
CTA Neck. There is no relevant literature to support the
of the vessel wall differ between conditions, whereas luminal
use of CTA neck in the initial imaging for suspected CNS
stenoses and dilations can overlap [99,107-109]. In a recent
vasculitis. For the evaluation of systemic vasculitis, please see
retrospective study, the addition of contrast-enhanced MRI
the ACR Appropriateness Criteria topic on “Noncerebral
vessel wall imaging to luminal imaging (DSA, CTA, or
Vasculitis” [100].
MRA) increased radiological diagnostic accuracy to 89%
CTV Head. There is no relevant literature to support the when compared with 36% in luminal imaging alone in
use of CTV head in the initial imaging for suspected CNS differentiating among nonocclusive cerebrovascular diseases.
vasculitis. In this study the reference standard was the clinical

Journal of the American College of Radiology S299


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diagnosis, so it remains to be determined whether these
patient’s care). The panel did not agree on
findings have any clinical value [107].
recommending MRA head with IV contrast for this
MRV Head. There is no relevant literature to support the clinical scenario. There is insufficient medical
use of MRV head in the initial imaging for suspected CNS literature to conclude whether or not these patients
vasculitis. would benefit from MRA head with IV contrast.
This procedure in this patient population is
US Duplex Doppler Carotid. There is no relevant
controversial but may be appropriate.
literature to support the use of carotid US duplex Doppler
n Variant 5: MRA head without IV contrast or CTA
in the initial imaging for suspected CNS vasculitis.
head with IV contrast is usually appropriate for
US Duplex Doppler Transcranial. There is no relevant screening patients with high risk of cerebral aneurysm.
literature to support the use of TCD in the initial imaging These procedures are equivalent alternatives (ie, only
for suspected CNS vasculitis. one initial procedure will be ordered to provide the
clinical information to effectively manage the patient’s
SUMMARY OF RECOMMENDATIONS care).
n Variant 6: Arteriography cervicocerebral or MRA head
n Variant 1: Arteriography cervicocerebral or CTA head
with IV contrast or MRA head without and with IV
with IV contrast is usually appropriate as a next
contrast or CTA head with IV contrast or MRA
imaging study for patients with known acute SAH on
head without IV contrast is usually appropriate for
CT. These procedures are equivalent alternatives (ie,
surveillance monitoring for patients with known
only one initial procedure will be ordered to provide
high-flow vascular malformation (AVM/AVF). Arteri-
the clinical information to effectively manage the
ography cervicocerebral can be complementary to
patient’s care).
MRA head with IV contrast or MRA head without and
n Variant 2: Arteriography cervicocerebral or CTA head with IV contrast or CTA head with IV contrast or
with IV contrast is usually appropriate for the initial MRA head without IV. MRA head with IV contrast or
imaging of patients with suspected cerebral vasospasm. MRA head without and with IV contrast or CTA head
These procedures are equivalent alternatives (ie, only with IV contrast or MRA head without IV are equiv-
one initial procedure will be ordered to provide the alent alternatives (ie, only one initial procedure will be
clinical information to effectively manage the patient’s ordered to provide the clinical information to effec-
care). tively manage the patient’s care).
n Variant 3: MRA head without IV contrast or CTA n Variant 7: MRA head without IV contrast or MRI
head with IV contrast is usually appropriate for the head without and with IV contrast or MRI head
surveillance monitoring of patients with a known, without IV contrast is usually appropriate for the
untreated cerebral aneurysm. These procedures are initial imaging of patients with suspected CNS
equivalent alternatives (ie, only one initial procedure vasculitis. These procedures can be complementary
will be ordered to provide the clinical information to (ie, both can be performed simultaneously).
effectively manage the patient’s care). The panel did
not agree on recommending MRA head with IV
contrast for this clinical scenario. There is insufficient
SUPPORTING DOCUMENTS
medical literature to conclude whether or not these
The evidence table, literature search, and appendix for this
patients would benefit from MRA head with IV
topic are available at https://acsearch.acr.org/list. The ap-
contrast. This procedure in this patient population is
pendix includes the strength of evidence assessment and the
controversial but may be appropriate.
final rating round tabulations for each recommendation.
n Variant 4: Arteriography cervicocerebral or MRA head For additional information on the Appropriateness
without and with IV contrast or MRA head without IV Criteria methodology and other supporting documents go to
contrast or CTA head with IV contrast is usually www.acr.org/ac.
appropriate for the surveillance monitoring of patients
with known, treated cerebral aneurysm. These
RELATIVE RADIATION LEVEL INFORMATION
procedures are equivalent alternatives (ie, only one
Potential adverse health effects associated with radiation
initial procedure will be ordered to provide the
exposure are an important factor to consider when selecting
clinical information to effectively manage the
the appropriate imaging procedure. Because there is a wide

S300 Journal of the American College of Radiology


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personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
range of radiation exposures associated with different diag- 13. Donmez H, Serifov E, Kahriman G, Mavili E, Durak AC, Menku A.
Comparison of 16-row multislice CT angiography with conventional
nostic procedures, a relative radiation level (RRL) indication
angiography for detection and evaluation of intracranial aneurysms.
has been included for each imaging examination. The RRLs Eur J Radiol 2011;80:455-61.
are based on effective dose, which is a radiation dose 14. Guo W, He XY, Li XF, et al. Meta-analysis of diagnostic signifi-
quantity that is used to estimate population total radiation cance of sixty-four-row multi-section computed tomography
angiography and three-dimensional digital subtraction angiography
risk associated with an imaging procedure. Patients in the in patients with cerebral artery aneurysm. J Neurol Sci 2014;346:
pediatric age group are at inherently higher risk from 197-203.
exposure, because of both organ sensitivity and longer life 15. McKinney AM, Palmer CS, Truwit CL, Karagulle A, Teksam M.
Detection of aneurysms by 64-section multidetector CT angiography
expectancy (relevant to the long latency that appears to in patients acutely suspected of having an intracranial aneurysm and
accompany radiation exposure). For these reasons, the RRL comparison with digital subtraction and 3D rotational angiography.
dose estimate ranges for pediatric examinations are lower as AJNR Am J Neuroradiol 2008;29:594-602.
16. Prestigiacomo CJ, Sabit A, He W, Jethwa P, Gandhi C, Russin J.
compared with those specified for adults (see Table 2).
Three dimensional CT angiography versus digital subtraction angi-
Additional information regarding radiation dose assessment ography in the detection of intracranial aneurysms in subarachnoid
for imaging examinations can be found in the ACR hemorrhage. J Neurointerv Surg 2010;2:385-9.
Appropriateness Criteria Radiation Dose Assessment 17. Xing W, Chen W, Sheng J, et al. Sixty-four-row multislice computed
tomographic angiography in the diagnosis and characterization of
Introduction document [110]. intracranial aneurysms: comparison with 3D rotational angiography.
World Neurosurg 2011;76:105-13.
18. Zhao B, Lin F, Wu J, et al. A multicenter analysis of computed to-
mography angiography alone versus digital subtraction angiography
REFERENCES for the surgical treatment of poor-grade aneurysmal subarachnoid
1. Whitehead MT, Cardenas AM, Corey AS, et al. ACR Appropriate- hemorrhage. World Neurosurg 2016;91:106-11.
ness Criteria Headache. J Am Coll Radiol 2019;16:S364-77. 19. Philipp LR, McCracken DJ, McCracken CE, et al. Comparison be-
2. American College of Radiology. ACR Appropriateness Criteria: tween CTA and digital subtraction angiography in the diagnosis of
Head Trauma Available at: https://acsearch.acr.org/docs/69481/ ruptured aneurysms. Neurosurgery 2017;80:769-77.
Narrative/. Accessed March 26, 2021. 20. Agid R, Andersson T, Almqvist H, et al. Negative CT angiography
3. American College of Radiology. ACR–NASCI–SIR–SPR practice findings in patients with spontaneous subarachnoid hemorrhage:
parameter for the performance and interpretation of body computed when is digital subtraction angiography still needed? AJNR Am J
tomography angiography (CTA). Available at: https://www.acr.org/-/ Neuroradiol 2010;31:696-705.
media/ACR/Files/Practice-Parameters/body-cta.pdf. Accessed March 21. Sailer AM, Wagemans BA, Nelemans PJ, de Graaf R, van
26, 2021. Zwam WH. Diagnosing intracranial aneurysms with MR angiog-
4. Westerlaan HE, van Dijk JM, Jansen-van der Weide MC, et al. raphy: systematic review and meta-analysis. Stroke 2014;45:119-
Intracranial aneurysms in patients with subarachnoid hemorrhage: CT 26.
angiography as a primary examination tool for diagnosis—systematic 22. Li MH, Li YD, Gu BX, et al. Accurate diagnosis of small cerebral
review and meta-analysis. Radiology 2011;258:134-45. aneurysms </¼5 mm in diameter with 3.0-T MR angiography.
5. Khurram A, Kleinig T, Leyden J. Clinical associations and causes of Radiology 2014;271:553-60.
convexity subarachnoid hemorrhage. Stroke 2014;45:1151-3. 23. Cho YD, Lee JY, Kwon BJ, Kang HS, Han MH. False-positive
6. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for diagnosis of cerebral aneurysms using MR angiography: location,
the management of aneurysmal subarachnoid hemorrhage: a guideline anatomic cause, and added value of source image data. Clin Radiol
for healthcare professionals from the American Heart Association/ 2011;66:726-31.
American Stroke Association. Stroke 2012;43:1711-37. 24. Sato K, Shimizu H, Fujimura M, Inoue T, Matsumoto Y,
7. Labovitz DL, Halim AX, Brent B, Boden-Albala B, Hauser WA, Tominaga T. Acute-stage diffusion-weighted magnetic resonance
Sacco RL. Subarachnoid hemorrhage incidence among Whites, Blacks imaging for predicting outcome of poor-grade aneurysmal subarach-
and Caribbean Hispanics: the Northern Manhattan Study. Neuro- noid hemorrhage. J Cereb Blood Flow Metab 2010;30:1110-20.
epidemiology 2006;26:147-50. 25. Wartenberg KE, Sheth SJ, Michael Schmidt J, et al. Acute ischemic
8. Schievink WI, Wijdicks EF, Parisi JE, Piepgras DG, Whisnant JP. injury on diffusion-weighted magnetic resonance imaging after
Sudden death from aneurysmal subarachnoid hemorrhage. Neurology poor grade subarachnoid hemorrhage. Neurocrit Care 2011;14:
1995;45:871-4. 407-15.
9. Shea AM, Reed SD, Curtis LH, Alexander MJ, Villani JJ, 26. Washington CW, Zipfel GJ. Participants in the International Multi-
Schulman KA. Characteristics of nontraumatic subarachnoid hem- disciplinary Consensus Conference on the Critical Care Management
orrhage in the United States in 2003. Neurosurgery 2007;61:1131-7; of Subarachnoid Hemorrhage. Detection and monitoring of vaso-
discussion 37-8. spasm and delayed cerebral ischemia: a review and assessment of the
10. Wang H, Li W, He H, Luo L, Chen C, Guo Y. 320-detector row CT literature. Neurocrit Care 2011;15:312-7.
angiography for detection and evaluation of intracranial aneurysms: 27. Marshall SA, Kathuria S, Nyquist P, Gandhi D. Noninvasive imaging
comparison with conventional digital subtraction angiography. Clin techniques in the diagnosis and management of aneurysmal sub-
Radiol 2013;68:e15-20. arachnoid hemorrhage. Neurosurg Clin N Am 2010;21:305-23.
11. Heit JJ, Pastena GT, Nogueira RG, et al. Cerebral angiography for 28. Rawal S, Barnett C, John-Baptiste A, Thein HH, Krings T,
evaluation of patients with CT angiogram-negative subarachnoid Rinkel GJ. Effectiveness of diagnostic strategies in suspected delayed
hemorrhage: an 11-year experience. AJNR Am J Neuroradiol cerebral ischemia: a decision analysis. Stroke 2015;46:77-83.
2016;37:297-304. 29. Westermaier T, Pham M, Stetter C, et al. Value of transcranial
12. Bechan RS, van Rooij WJ, Peluso JP, Sluzewski M. Yield of repeat 3D Doppler, perfusion-CT and neurological evaluation to forecast sec-
angiography in patients with aneurysmal-type subarachnoid hemor- ondary ischemia after aneurysmal SAH. Neurocrit Care 2014;20:406-
rhage. AJNR Am J Neuroradiol 2016;37:2299-303. 12.

Journal of the American College of Radiology S301


Ledbetter et al n CVD-Aneurysm, Vascular Malformation, and SAH
Descargado para Anonymous User (n/a) en Getafe University Hospital de ClinicalKey.es por Elsevier en octubre 25, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
30. Ibrahim GM, Morgan BR, Macdonald RL. Patient phenotypes 49. Mortimer AM, Marsh H, Klimczak K, et al. Is long-term follow-up of
associated with outcomes after aneurysmal subarachnoid hemorrhage: adequately coil-occluded ruptured cerebral aneurysms always neces-
a principal component analysis. Stroke 2014;45:670-6. sary? A single-center study of recurrences after endovascular treat-
31. Crowley RW, Medel R, Dumont AS, et al. Angiographic vasospasm is ment. J Neurointerv Surg 2015;7:373-9.
strongly correlated with cerebral infarction after subarachnoid hem- 50. Vourla E, Filis A, Cornelius JF, et al. Natural history of de novo
orrhage. Stroke 2011;42:919-23. aneurysm formation in patients with treated aneurysmatic subarach-
32. Takahashi Y, Sasahara A, Yamazaki K, Inazuka M, Kasuya H. noid hemorrhage: a ten-year follow-up. World Neurosurg 2019;122:
Disturbance of CT perfusion within 24 h after onset is associated with e291-5.
WFNS grade but not development of DCI in patients with aneu- 51. Wang JY, Smith R, Ye X, et al. Serial imaging surveillance for patients
rysmal SAH. Acta Neurochir (Wien) 2017;159:2319-24. with a history of intracranial aneurysm: risk of de novo aneurysm
33. Greenberg ED, Gold R, Reichman M, et al. Diagnostic accuracy of formation. Neurosurgery 2015;77:32-42; discussion 42-3.
CT angiography and CT perfusion for cerebral vasospasm: a meta- 52. Zali A, Khoshnood RJ, Zarghi A. De novo aneurysms in long-
analysis. AJNR Am J Neuroradiol 2010;31:1853-60. term follow-up computed tomographic angiography of patients
34. Killeen RP, Gupta A, Delaney H, et al. Appropriate use of CT with clipped intracranial aneurysms. World Neurosurg 2014;82:
perfusion following aneurysmal subarachnoid hemorrhage: a Bayesian 722-5.
analysis approach. AJNR Am J Neuroradiol 2014;35:459-65. 53. Bier G, Bongers MN, Hempel JM, et al. Follow-up CT and CT
35. Phan K, Moore JM, Griessenauer CJ, et al. Ultra-early angio- angiography after intracranial aneurysm clipping and coiling-
graphic vasospasm after aneurysmal subarachnoid hemorrhage: a improved image quality by iterative metal artifact reduction. Neuro-
systematic review and meta-analysis. World Neurosurg 2017;102: radiology 2017;59:649-54.
632-638 e1. 54. Jia Y, Zhang J, Fan J, et al. Gemstone spectral imaging reduced
36. Ionita CC, Graffagnino C, Alexander MJ, Zaidat OO. The value of artefacts from metal coils or clips after treatment of cerebral an-
CT angiography and transcranial Doppler sonography in triaging eurysms: a retrospective study of 35 patients. Br J Radiol 2015;88:
suspected cerebral vasospasm in SAH prior to endovascular therapy. 20150222.
Neurocrit Care 2008;9:8-12. 55. Katsura M, Sato J, Akahane M, et al. Single-energy metal artifact
37. Hattingen E, Blasel S, Dumesnil R, Vatter H, Zanella FE, reduction technique for reducing metallic coil artifacts on post-
Weidauer S. MR angiography in patients with subarachnoid hemor- interventional cerebral CT and CT angiography. Neuroradiology
rhage: adequate to evaluate vasospasm-induced vascular narrowing? 2018;60:1141-50.
Neurosurg Rev 2010;33:431-9. 56. Lv F, Li Q, Liao J, et al. Detection and characterization of intracranial
38. Heit JJ, Wintermark M, Martin BW, et al. Reduced intravoxel inco- aneurysms with dual-energy subtraction CTA: comparison with DSA.
herent motion microvascular perfusion predicts delayed cerebral Acta Neurochir Suppl 2011;110:239-45.
ischemia and vasospasm after aneurysm rupture. Stroke 2018;49:741-5. 57. Mocanu I, Van Wettere M, Absil J, Bruneau M, Lubicz B, Sadeghi N.
39. Russin JJ, Montagne A, D’Amore F, et al. Permeability imaging as a Value of dual-energy CT angiography in patients with treated intra-
predictor of delayed cerebral ischemia after aneurysmal subarachnoid cranial aneurysms. Neuroradiology 2018;60:1287-95.
hemorrhage. J Cereb Blood Flow Metab 2018;38:973-9. 58. van Amerongen MJ, Boogaarts HD, de Vries J, et al. MRA versus
40. Kumar G, Shahripour RB, Harrigan MR. Vasospasm on transcranial DSA for follow-up of coiled intracranial aneurysms: a meta-analysis.
Doppler is predictive of delayed cerebral ischemia in aneurysmal AJNR Am J Neuroradiol 2014;35:1655-61.
subarachnoid hemorrhage: a systematic review and meta-analysis. 59. Schaafsma JD, Velthuis BK, van den Berg R, et al. Coil-treated an-
J Neurosurg 2016;124:1257-64. eurysms: decision making regarding additional treatment based on
41. Miller CM, Palestrant D, Schievink WI, Alexander MJ. Prolonged findings of MR angiography and intraarterial DSA. Radiology
transcranial Doppler monitoring after aneurysmal subarachnoid 2012;265:858-63.
hemorrhage fails to adequately predict ischemic risk. Neurocrit Care 60. Attali J, Benaissa A, Soize S, Kadziolka K, Portefaix C, Pierot L.
2011;15:387-92. Follow-up of intracranial aneurysms treated by flow diverter: com-
42. Thompson BG, Brown RD Jr, Amin-Hanjani S, et al. Guidelines for parison of three-dimensional time-of-flight MR angiography (3D-
the management of patients with unruptured intracranial aneurysms: TOF-MRA) and contrast-enhanced MR angiography (CE-MRA)
a guideline for healthcare professionals from the American Heart sequences with digital subtraction angiography as the gold standard.
Association/American Stroke Association. Stroke 2015;46:2368-400. J Neurointerv Surg 2016;8:81-6.
43. Malhotra A, Wu X, Forman HP, et al. Management of unruptured 61. Mine B, Tancredi I, Aljishi A, et al. Follow-up of intracranial aneu-
intracranial aneurysms in older adults: a cost-effectiveness analysis. rysms treated by a WEB flow disrupter: a comparative study of DSA
Radiology 2019;291:411-7. and contrast-enhanced MR angiography. J Neurointerv Surg 2016;8:
44. Villablanca JP, Duckwiler GR, Jahan R, et al. Natural history of 615-20.
asymptomatic unruptured cerebral aneurysms evaluated at CT angi- 62. Nawka MT, Sedlacik J, Frolich A, Bester M, Fiehler J, Buhk JH.
ography: growth and rupture incidence and correlation with epide- Multiparametric MRI of intracranial aneurysms treated with the
miologic risk factors. Radiology 2013;269:258-65. Woven EndoBridge (WEB): a case of Faraday’s cage? J Neurointerv
45. Li J, Shen B, Ma C, et al. 3D contrast enhancement-MR angiography Surg 2018;10:988-94.
for imaging of unruptured cerebral aneurysms: a hospital-based 63. Timsit C, Soize S, Benaissa A, Portefaix C, Gauvrit JY, Pierot L.
prevalence study. PLoS One 2014;9:e114157. Contrast-enhanced and time-of-flight MRA at 3T compared with
46. Golitz P, Struffert T, Ganslandt O, Lang S, Knossalla F, Doerfler A. DSA for the follow-up of intracranial aneurysms treated with the
Contrast-enhanced angiographic computed tomography for detection WEB device. AJNR Am J Neuroradiol 2016;37:1684-9.
of aneurysm remnants after clipping: a comparison with digital sub- 64. Agarwal N, Gala NB, Choudhry OJ, et al. Prevalence of asymp-
traction angiography in 112 clipped aneurysms. Neurosurgery tomatic incidental aneurysms: a review of 2,685 computed tomo-
2014;74:606-13; discussion 13-4. graphic angiograms. World Neurosurg 2014;82:1086-90.
47. Jamali S, Fahed R, Gentric JC, et al. Inter- and intrarater agreement 65. Malhotra A, Wu X, Matouk CC, Forman HP, Gandhi D, Sanelli P.
on the outcome of endovascular treatment of aneurysms using MRA. MR Angiography screening and surveillance for intracranial aneu-
AJNR Am J Neuroradiol 2016;37:879-84. rysms in autosomal dominant polycystic kidney disease: a cost-
48. Schaafsma JD, Velthuis BK, Majoie CB, et al. Intracranial aneurysms effectiveness analysis. Radiology 2019;291:400-8.
treated with coil placement: test characteristics of follow-up MR 66. Bor AS, Rinkel GJ, van Norden J, Wermer MJ. Long-term, serial
angiography—multicenter study. Radiology 2010;256:209-18. screening for intracranial aneurysms in individuals with a family

S302 Journal of the American College of Radiology


Volume 18 n Number 11S n November 2021
Descargado para Anonymous User (n/a) en Getafe University Hospital de ClinicalKey.es por Elsevier en octubre 25, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
history of aneurysmal subarachnoid haemorrhage: a cohort study. 86. Gross BA, Frerichs KU, Du R. Sensitivity of CT angiography, T2-
Lancet Neurol 2014;13:385-92. weighted MRI, and magnetic resonance angiography in detecting
67. Nurmonen HJ, Huttunen T, Huttunen J, et al. Polycystic kidney cerebral arteriovenous malformations and associated aneurysms. J Clin
disease among 4,436 intracranial aneurysm patients from a defined Neurosci 2012;19:1093-5.
population. Neurology 2017;89:1852-9. 87. Narvid J, Do HM, Blevins NH, Fischbein NJ. CT angiography as a
68. Flahault A, Trystram D, Nataf F, et al. Screening for intracranial screening tool for dural arteriovenous fistula in patients with pulsatile
aneurysms in autosomal dominant polycystic kidney disease is cost- tinnitus: feasibility and test characteristics. AJNR Am J Neuroradiol
effective. Kidney Int 2018;93:716-26. 2011;32:446-53.
69. Kim JH, Kwon TH, Kim JH, Chong K, Yoon W. Intracranial an- 88. Soize S, Bouquigny F, Kadziolka K, Portefaix C, Pierot L. Value of
eurysms in adult Moyamoya disease. World Neurosurg 2018;109: 4D MR angiography at 3T compared with DSA for the follow-up of
e175-82. treated brain arteriovenous malformation. AJNR Am J Neuroradiol
70. Jung WS, Kim JH, Ahn SJ, et al. Prevalence of intracranial aneurysms 2014;35:1903-9.
in patients with aortic dissection. AJNR Am J Neuroradiol 2017;38: 89. Hadizadeh DR, Kukuk GM, Steck DT, et al. Noninvasive evaluation
2089-93. of cerebral arteriovenous malformations by 4D-MRA for preoperative
71. Egbe AC, Padang R, Brown RD, et al. Prevalence and predictors of planning and postoperative follow-up in 56 patients: comparison with
intracranial aneurysms in patients with bicuspid aortic valve. Heart DSA and intraoperative findings. AJNR Am J Neuroradiol 2012;33:
2017;103:1508-14. 1095-101.
72. Rouchaud A, Brandt MD, Rydberg AM, et al. Prevalence of intra- 90. Oleaga L, Dalal SS, Weigele JB, et al. The role of time-resolved 3D
cranial aneurysms in patients with aortic aneurysms. AJNR Am J contrast-enhanced MR angiography in the assessment and grading of
Neuroradiol 2016;37:1664-8. cerebral arteriovenous malformations. Eur J Radiol 2010;74:e117-
73. Curtis SL, Bradley M, Wilde P, et al. Results of screening for intra- 21.
cranial aneurysms in patients with coarctation of the aorta. AJNR Am 91. Raoult H, Bannier E, Robert B, Barillot C, Schmitt P, Gauvrit JY.
J Neuroradiol 2012;33:1182-6. Time-resolved spin-labeled MR angiography for the depiction of ce-
74. Derdeyn CP, Zipfel GJ, Albuquerque FC, et al. Management of brain rebral arteriovenous malformations: a comparison of techniques.
arteriovenous malformations: a scientific statement for healthcare Radiology 2014;271:524-33.
professionals from the American Heart Association/American Stroke 92. Buis DR, Bot JC, Barkhof F, et al. The predictive value of 3D time-
Association. Stroke 2017;48:e200-24. of-flight MR angiography in assessment of brain arteriovenous mal-
75. Morris Z, Whiteley WN, Longstreth WT Jr, et al. Incidental findings formation obliteration after radiosurgery. AJNR Am J Neuroradiol
on brain magnetic resonance imaging: systematic review and meta- 2012;33:232-8.
analysis. BMJ 2009;339:b3016. 93. Azuma M, Hirai T, Shigematsu Y, et al. Evaluation of intracranial
76. Nishida T, Faughnan ME, Krings T, et al. Brain arteriovenous dural arteriovenous fistulas: comparison of unenhanced 3T 3D time-
malformations associated with hereditary hemorrhagic telangiectasia: of-flight MR angiography with digital subtraction angiography. Magn
gene-phenotype correlations. Am J Med Genet A 2012;158A:2829- Reson Med Sci 2015;14:285-93.
34. 94. Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ. Diag-
[77]. Kim H, Al-Shahi Salman R, McCulloch CE, Stapf C, Young WL, nostic accuracy of CTA and MRI/MRA in the evaluation of the
MARS Coinvestigators. Untreated brain arteriovenous malformation: cortical venous reflux in the intracranial dural arteriovenous fistula
patient-level meta-analysis of hemorrhage predictors. Neurology DAVF. Neuroradiology 2018;60:7-15.
2014;83:590-7. 95. Edjlali M, Roca P, Rabrait C, et al. MR selective flow-tracking
78. Gross BA, Du R. Natural history of cerebral arteriovenous malfor- cartography: a postprocessing procedure applied to four-dimensional
mations: a meta-analysis. J Neurosurg 2013;118:437-43. flow MR imaging for complete characterization of cranial dural
79. Mohr JP, Parides MK, Stapf C, et al. Medical management with or arteriovenous fistulas. Radiology 2014;270:261-8.
without interventional therapy for unruptured brain arteriovenous 96. Iryo Y, Hirai T, Kai Y, et al. Intracranial dural arteriovenous fistulas:
malformations (ARUBA): a multicentre, non-blinded, randomised evaluation with 3-T four-dimensional MR angiography using arterial
trial. Lancet 2014;383:614-21. spin labeling. Radiology 2014;271:193-9.
80. Gandhi D, Chen J, Pearl M, Huang J, Gemmete JJ, Kathuria S. 97. Nishimura S, Hirai T, Sasao A, et al. Evaluation of dural arteriove-
Intracranial dural arteriovenous fistulas: classification, imaging nous fistulas with 4D contrast-enhanced MR angiography at 3T.
findings, and treatment. AJNR Am J Neuroradiol 2012;33:1007- AJNR Am J Neuroradiol 2010;31:80-5.
13. 98. Amponsah K, Ellis TL, Chan MD, et al. Retrospective analysis of
81. Borden JA, Wu JK, Shucart WA. A proposed classification for spinal imaging techniques for treatment planning and monitoring of oblit-
and cranial dural arteriovenous fistulous malformations and implica- eration for gamma knife treatment of cerebral arteriovenous malfor-
tions for treatment. J Neurosurg 1995;82:166-79. mation. Neurosurgery 2012;71:893-9.
82. Cognard C, Gobin YP, Pierot L, et al. Cerebral dural arteriovenous 99. Hajj-Ali RA, Calabrese LH. Diagnosis and classification of central
fistulas: clinical and angiographic correlation with a revised classifi- nervous system vasculitis. J Autoimmun 2014;48-49:149-52.
cation of venous drainage. Radiology 1995;194:671-80. 100. American College of Radiology. ACR Appropriateness Criteria:
83. Mossa-Basha M, Chen J, Gandhi D. Imaging of cerebral arteriove- Noncerebral Vasculitis Available at: https://acsearch.acr.org/
nous malformations and dural arteriovenous fistulas. Neurosurg Clin docs/3158180/Narrative/. Accessed March 26, 2021.
N Am 2012;23:27-42. 101. Salvarani C, Brown RD Jr, Calamia KT, et al. Primary central
84. Huang YJ, Hsu SW, Lee TF, Ho JT, Chen WF. Consistency between nervous system vasculitis: analysis of 101 patients. Ann Neurol
targets delineated by angiography, computed tomography, and mag- 2007;62:442-51.
netic resonance imaging in stereotactic radiosurgery for arteriovenous 102. Calabrese LH, Mallek JA. Primary angiitis of the central nervous
malformation. Stereotact Funct Neurosurg 2017;95:236-42. system. Report of 8 new cases, review of the literature, and proposal
85. Veeravagu A, Hansasuta A, Jiang B, Karim AS, Gibbs IC, Chang SD. for diagnostic criteria. Medicine (Baltimore) 1988;67:20-39.
Volumetric analysis of intracranial arteriovenous malformations con- 103. de Boysson H, Boulouis G, Parienti JJ, et al. Concordance of time-of-
toured for CyberKnife radiosurgery with 3-dimensional rotational flight MRA and digital subtraction angiography in adult primary
angiography vs computed tomography/magnetic resonance imaging. central nervous system vasculitis. AJNR Am J Neuroradiol 2017;38:
Neurosurgery 2013;73:262-70. 1917-22.

Journal of the American College of Radiology S303


Ledbetter et al n CVD-Aneurysm, Vascular Malformation, and SAH
Descargado para Anonymous User (n/a) en Getafe University Hospital de ClinicalKey.es por Elsevier en octubre 25, 2024. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
104. de Boysson H, Zuber M, Naggara O, et al. Primary angiitis of the 108. Obusez EC, Hui F, Hajj-Ali RA, et al. High-resolution MRI vessel
central nervous system: description of the first fifty-two adults wall imaging: spatial and temporal patterns of reversible cerebral
enrolled in the French cohort of patients with primary vasculitis of the vasoconstriction syndrome and central nervous system vasculitis.
central nervous system. Arthritis Rheumatol 2014;66:1315-26. AJNR Am J Neuroradiol 2014;35:1527-32.
105. Powers WJ. Primary angiitis of the central nervous system: diagnostic 109. Swartz RH, Bhuta SS, Farb RI, et al. Intracranial arterial wall imaging
criteria. Neurol Clin 2015;33:515-26. using high-resolution 3-tesla contrast-enhanced MRI. Neurology
106. Lie JT. Classification and histopathologic spectrum of central nervous 2009;72:627-34.
system vasculitis. Neurol Clin 1997;15:805-19. 110. American College of Radiology. ACR Appropriateness Criteria radiation
107. Mossa-Basha M, Shibata DK, Hallam DK, et al. Added value of vessel dose assessment introduction Available at: https://www.acr.org/-/media/
wall magnetic resonance imaging for differentiation of nonocclusive ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf.
intracranial vasculopathies. Stroke 2017;48:3026-33. Accessed March 26, 2021.

S304 Journal of the American College of Radiology


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