Roumi Arnaud, Ben Hassen Wagih, Hmeydia Ghazi, Posener Sacha, Pallud Johan, Sharshar Tarek, Calvet David, Mas Jean-Louis, Baron Jean-Claude, Oppenheim Catherine, Naggara Olivier, Turc Guillaume
Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France.
Neuroradiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université Paris Cité, FHU Neurovasc, Paris, France.
Front Neurol. 2023 Jan 27;13:1085806. doi: 10.3389/fneur.2022.1085806. eCollection 2022.
Identification of treatable causes of intracranial hemorrhage (ICH) such as intracranial arteriovenous shunt is crucial to prevent recurrence. However, diagnostic approaches vary considerably across centers, partly because of limited knowledge of the diagnostic performance of first-line vascular imaging techniques. We assessed the diagnostic performance of dynamic three-dimensional magnetic resonance angiography (dynamic 3D MRA) in daily practice to detect intracranial arteriovenous shunts in ICH patients against subsequent digital subtraction angiography (DSA) as reference standard.
We reviewed all adult patients who underwent first-line dynamic 3D MRA and subsequent DSA for non-traumatic ICH between January 2016 and September 2021 in a tertiary center. Sensitivity, specificity, accuracy, positive and negative predictive values of dynamic 3D MRA for the detection of intracranial arteriovenous shunt were calculated with DSA as reference standard.
Among 104 included patients, 29 (27.9%) had a DSA-confirmed arteriovenous shunt [19 pial arteriovenous malformations, 10 dural arteriovenous fistulae; median onset-to-DSA: 17 (IQR: 3-88) days]. The sensitivity and specificity of dynamic 3D MRA [median onset-to-dynamic 3D MRA: 14 (3-101) h] for the detection of intracranial arteriovenous shunt were 66% (95% CI: 48-83) and 91% (95% CI: 84-97), respectively. The corresponding accuracy, positive and negative predictive values were 84% (95% CI: 77-91), 73% (95% CI: 56-90), and 87% (95% CI: 80-95), respectively.
This study suggests that although first-line evaluation with dynamic 3D MRA may be helpful for the detection of intracranial arteriovenous shunts in patients with ICH, additional vascular imaging work-up should not be withheld if dynamic 3D MRA is negative. Comparative prospective studies are needed to determine the best imaging strategy to diagnose arteriovenous shunts after non-traumatic ICH.
识别颅内出血（ICH）的可治疗病因，如颅内动静脉分流，对于预防复发至关重要。然而，各中心的诊断方法差异很大，部分原因是对一线血管成像技术诊断性能的了解有限。我们评估了动态三维磁共振血管造影（动态3D MRA）在日常实践中针对ICH患者检测颅内动静脉分流的诊断性能，并将后续数字减影血管造影（DSA）作为参考标准。
我们回顾了2016年1月至2021年9月在一家三级中心因非创伤性ICH接受一线动态3D MRA及后续DSA检查的所有成年患者。以DSA作为参考标准，计算动态3D MRA检测颅内动静脉分流的敏感性、特异性、准确性、阳性和阴性预测值。
在104例纳入患者中，29例（27.9%）经DSA证实存在动静脉分流[19例软脑膜动静脉畸形，10例硬脑膜动静脉瘘；DSA检查的中位发病时间：17（四分位间距：3 - 88）天]。动态3D MRA[动态3D MRA检查的中位发病时间：14（3 - 101）小时]检测颅内动静脉分流的敏感性和特异性分别为66%（95%置信区间：48 - 83）和91%（95%置信区间：84 - 97）。相应的准确性、阳性和阴性预测值分别为84%（95%置信区间：77 - 91）、73%（95%置信区间：56 - 90）和87%（95%置信区间：80 - 95）。
本研究表明，尽管采用动态3D MRA进行一线评估可能有助于检测ICH患者的颅内动静脉分流，但如果动态3D MRA结果为阴性，不应放弃额外的血管成像检查。需要进行比较性前瞻性研究以确定诊断非创伤性ICH后动静脉分流的最佳成像策略。
