Clinical Benefits of 4D-DSA for Analyzing the Angioarchitecture of Brain AVMs Compared with Traditional DSA Techniques: A Systematic and Critical Review of the Literature.

BACKGROUND

4D-DSA has been developed and can be used to evaluate the angioarchitecture of brain arteriovenous malformations (bAVMs).

PURPOSE: The purpose of this systematic and critical review was to collect and synthesize the available evidence on the clinical benefits of 4D-DSA in evaluating bAVM angioarchitecture compared with traditional DSA techniques.

DATA SOURCES: Data sources were PubMed, Embase, Cochrane Library, Google Scholar, and the International Prospective Register of Ongoing Systematic Reviews (PROSPERO) website.

STUDY SELECTION: A total of 4264 records were identified through the search process. Following de-duplication and screening based on titles and abstracts, 11 studies underwent full-text review. Ultimately, 7 studies met the eligibility criteria.

DATA ANALYSIS: Information on study designs, technical aspects, and comprehensive evaluation of the angioarchitecture of bAVMs was analyzed.

DATA SYNTHESIS: All these studies used a commercially available flat panel detector angiography system and postprocessing software to generate 4D-DSA, albeit using different injection protocols. Through a synthesis of qualitative statements and quantitative statistical outcomes, it was found that 4D-DSA demonstrated either equivalent or superior diagnostic performances compared with traditional DSA techniques in assessing the intricate angioarchitecture of bAVMs. Specifically, arterial aneurysms and shunt zones could be better visualized by 4D-DSA because of its adjustable observation angles and time-frames. Challenges were noted in analyzing larger and more complex bAVMs, as well as in misinterpretations of venous phases.

LIMITATIONS: Most of the included studies were qualitative. According to the analysis by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool, biases could mainly be introduced in the bAVM selection process and image evaluation.

CONCLUSIONS

On the basis of current experience, 4D-DSA has demonstrated notable clinical benefits compared with traditional DSA techniques for analyzing the angioarchitecture of bAVMs. Further investigations should focus on enhancing the study design, optimizing image protocols, and increasing 4D-DSA capability, especially for larger bAVMs.