title: Classification of cerebral arteriovenous malformations and intranidal flow patterns by color-encoded 4D-hybrid-MRA.
abstract: OBJECTIVE
  4D MRA has been evolving as a noninvasive supplement for DSA. The purpose of this study was to evaluate the feasibility of a newly developed blood flow visualization technique for the classification of cerebral AVMs. We hypothesized that 4D-hMRA allows detection of different flow patterns within the nidus as well as differentiation of feeders and draining veins and has very good agreement with DSA regarding the Spetzler-Martin grade.
  
  
  METHODS
  Thirty-one consecutive patients with AVMs were evaluated by using 4D-hMRA and DSA by 2 blinded raters. Rating criteria included Spetzler-Martin score and other morphologic variables together with a new scale for 3 intranidal flow patterns (homogeneous = 1, unidirectional = 2, heterogeneous = 3).
  
  
  RESULTS
  The Spetzler-Martin grades were rated different from DSA in 5 cases by rater 1 and in 3 cases by rater 2 with an excellent interrater reliability of κ = 0.96 (4/31, 1 by size and 3 by drainage). Each reader missed 5 feeders on 4D-hMRA. Draining veins were distinguished in the temporal course in 7 on DSA but in 8 and 12 on 4D-hybrid-MRA (raters 1 and 2 respectively), with κ = 0.79. A type 1 intranidal flow pattern was recognizable in 9 (30%) patients; type 2, in 19 (60%); and type 3, in 3 (10%).
  
  
  CONCLUSIONS
  4D-hMRA allows reliable Spetzler-Martin grading and detection of brain arteriovenous malformation feeding arteries and draining veins, with the drawback that for small vessels DSA is still needed. Draining veins might even be detected with higher sensitivity than on DSA. Discrimination of different intranidal flow patterns is possible, but their relevance for hemorrhage risk assessment and therapy planning requires further study.
authors.affiliation: Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. t.illies@uke.uni-hamburg.de
authors.forename: T
authors.initials: T
authors.lastname: Illies
authors.forename: N D
authors.initials: ND
authors.lastname: Forkert
authors.forename: T
authors.initials: T
authors.lastname: Ries
authors.forename: J
authors.initials: J
authors.lastname: Regelsberger
authors.forename: J
authors.initials: J
authors.lastname: Fiehler
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D002560:Cerebrovascular Circulation; D003116:Color; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D002538:Intracranial Arteriovenous Malformations / Q000175:diagnosis* / Q000503:physiopathology*; D018810:Magnetic Resonance Angiography / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016037:Single-Blind Method; D013382:Subtraction Technique; D055815:Young Adult