J Cerebrovasc Endovasc Neurosurg.  2021 Jun;23(2):108-116. 10.7461/jcen.2021.E2020.10.002.

Utility of skull X-rays in identifying recurrence of coiled cerebral aneurysms

• Chen PR
• Lopez-Rivera V
• Conner CR
• Sanzgiri A
• Sheth SA
• Erkmen K
• Kim DH
• Day AL

• KMID: 2517023
• DOI: http://doi.org/10.7461/jcen.2021.E2020.10.002

Abstract

Objective
A high rate of cerebral aneurysm recurrence following endovascular coiling has prompted the use of digital subtraction angiography (DSA) for interval follow-up. However, the utility of skull x-rays as an alternative screening method for aneurysm recurrence is unproperly characterized.
Methods
Retrospective review of a prospective registry of ruptured and unruptured cerebral aneurysms. Anteroposterior and lateral skull x-rays were obtained immediately at the end of the procedure and at 6-month follow-up. Aneurysm recurrence was defined by comparing post-procedure and 6-month DSA imaging. A true positive was defined as a change in coil mass morphology on at least one projection with aneurysm recurrence on DSA, and a true negative defined as a stable coil mass on both projections and no recurrence on DSA. Receiver operating characteristic area under the curve (AUC) statistics was used to assess the performance of skull x-rays in identifying aneurysm recurrence.
Results
A total of 118 cerebral aneurysms were evaluated with DSA imaging and skull x-rays. A change in coil mass morphology on one projection of skull x-rays correctly detected all true recurrences with a sensitivity of 100% (95% confidence interval [CI], 91-100%). Skull x-rays failed to identify a stable aneurysm coil mass in 15 cases, with a specificity of 79% (68-88%). Skull x-rays performed with AUC 0.8958 (95% CI, 0.8490-0.9431) in identifying aneurysm recurrence.
Conclusions
The findings of our study suggest that skull x-rays may represent a lowcost, non-invasive screening tool to rule out aneurysm recurrence, which can potentially aid in decreasing the utilization of DSA in the follow-up of patients with coiled cerebral aneurysms.

Keyword

Coil mass; Aneurysm recurrence; Skull x-ray; Digital subtraction angiography

Figure

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  Fig. 1. Acquisition of skull x-rays at the end of the coil embolization procedure (A, C) and at 6-month follow-up (B, D). Anteroposterior projection (A, B) was obtained with the patient looking straight to the front. A lateral projection (C, D) was obtained with alignment of the external auditory canals.

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  Fig. 2. Illustrative case of aneurysm recurrence. Patient presented with an A1-A2 junction cerebral aneurysm treated with balloon assisted coil embolization as shown in the oblique AP and lateral views (1A and 1B, white arrow) on DSA. At the end of the coiling embolization procedure, AP and lateral projections of skull x-rays were taken showing a coil mass (C and D, white arrowhead). At 6-month follow-up, a set of skull x-rays and DSA were performed. Oblique AP and lateral views on DSA showed aneurysm recurrence (E and F, white arrow). On skull x-ray AP and lateral views (G and H, white arrowhead), there is changed shape (unwinding) of the coil mass, corresponding with aneurysm recurrence identified on DSA. DSA, digital subtraction angiography.

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  Fig. 3. Illustrative case of a false positive in a ruptured anterior communicating aneurysm. AP (A1) and lateral (A2) DSA projections showing the aneurysm prior to coil embolization. AP (B1) and lateral (B2) DSA projections and AP (B3) and lateral (B4) projections of skull x-ray obtained immediately after coiling. At 6-month follow-up, AP (C3) and lateral (C4) projections of skull x-ray both demonstrated the changed shape of the coil mass, but no evidence of recurrence or coil compaction was observed on angiography (C1 and C2). At the 2-year follow-up, AP (D3) and lateral (D4) skull x-ray projections showed changed coil shape on the lateral view, but this was not confirmed by angiography (D1 and D2). DSA, digital subtraction angiography.

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