prior authorization review panel mco policy submission a ... · magnetic resonance angiography...

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:06/01/2020

Policy Number: 0094 Effective Date: Revision Date:

Policy Name: Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)

Type of Submission – Check all that apply:

New Policy Revised Policy* Annual Review – No Revisions Statewide PDL

*All revisions to the policy must be highlighted using track changes throughout the document.

Please provide any clarifying information for the policy below:

CPB 0094 Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)

Policy is new to Aetna Better Health of Pennsylvania. Evicore is using policy for review.

Name of Authorized Individual (Please type or print):

Benjamin Alouf, MD, MBA, FAAP

Signature of Authorized Individual:

Proprietary Revised July 22, 2019

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Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) ... Page 1 of 81

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Magnetic Resonance Angiography (MRA) and MagneticResonance Venography (MRV)

Policy History

Last Review

03/23/2020

Effective: 01/12/1996

Next

Review: 01/28/2021

Review History

Definitions

Ad d i t ion al Information

Clinical Policy Bulletin

Notes

Number: 0094

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Magnetic Resonance Angiography (MRA)

I. Aetna considers magnetic resonance angiography (MRA)

medically necessary according to the selection criteria

outlined below. MRA is considered appropriate when it

can replace a more invasive test (e.g., contrast

angiography) and reduce risk for members. While MRA

is a rapidly evolving technology, its clinical safety and

effectiveness for all anatomical regions have not been

established by the peer- reviewed medical literature.

Head and Neck

MRA of the head and neck is considered medically

necessary for any of the following conditions:

A. As a follow-up study for a known arterio-venous

malformation (AVM), and for a known non-ruptured

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intra-cranial aneurysm (ICA) that is greater than 3

mm in size; or

B. As a follow-up of ICA after coiling; or

C. To definitively establish presence of stenoses or

other abnormalities of the vertebrobasilar system in

members with symptoms highly suggestive of

vertebrobasilar syndrome (binocular vision loss,

diplopia, dysarthria, dysphagia, positional vertigo); or

D. To evaluate members with signs/symptoms highly

suggestive of leaking/ruptured ICA or AVM (i.e., blood

in the cerebral spinal fluid, stiff neck, sudden

explosive headache); or

E. To evaluate pulsatile tinnitus in members with signs

or symptoms suggestive of a vascular lesion; or

F. To rule out ICA, including aneurysms of the circle of

Willis, in members who are thought to be at higher

risk (e.g., history of ICA in a first-degree relative or

presence of polycystic kidney disease); or

G. To evaluate conditions of the carotid arteries such

as:

▪ Aneurysm tumor

▪ Cervicocranial arterial dissection in members with

suggestive signs or symptoms (e.g., amaurosis

fugax, oculo-sympathetic palsy, symptoms of

focal brain ischemia, and unilateral headache)

▪ Injury to the carotid artery

▪ Stenotic/occlusive disease in asymptomatic

members who are candidates for carotid

endarterectomy surgery (CEA) when a Duplex

Doppler scan is abnormal

▪ Stenotic/occlusive disease in symptomatic

members (e.g., cerebro-vascular disease or

transient ischemic attack).

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Note : As MRA is considered an alternative to

angiography for evaluation of the carotids, a

subsequent angiography would only be considered

medically necessary if there was a significant

discrepancy between the findings of Duplex

ultrasonography and MRA that would impact on surgical

planning.

Chest

MRA of the chest is considered medically necessary for

any of the following indications:

A. For diagnosis, treatment planning, and post

operative follow-up for conditions of the thoracic

aorta such as aneurysm (true or pseudoaneurysm),

dissection, or stenotic/occlusive vascular disease; or

B. For diagnosis, treatment planning, and post

operative surgical shunt evaluation in members with

congenital heart disease (CHD) or developmental

anomalies of the thoracic vasculature (e.g., atresia or

hypoplasia of the pulmonary arteries, coarctation of

the aorta, double aortic arch, interrupted inferior

vena cava, partial anomalous venous connection,

persistent left superior vena cava, right-sided aortic

arch, total anomalous pulmonary venous

connection, and truncus arteriosus); or

C. For diagnosing a suspected pulmonary embolism

when the use of intravascular iodinated contrast

material is contraindicated, or as a substitute for

pulmonary angiography when a

ventilation/perfusion (V/Q) scan does not provide

sufficient information for treatment decisions; or

D. For pulmonary venous and left atrial evaluation, pre

and post-radiofrequency ablation for atrial

fibrillation.

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Spine

MRA of the spinal canal is considered medically necessary for

individuals with known cases of spinal cord arterio-venous

fistula and arterio-venous malformation. MRA of the spinal

canal is considered experimental and investigational for all other

indications.

Abdomen

MRA of the abdomen is considered medically necessary

for any of the following indications:

A. To assess of the main renal arteries for the

evaluation of renal artery stenosis in persons with

refractory uncontrolled hypertension* not due to

pheochromocytoma; or

B. To assess persons with sickle cell disease; or

C. To assess pelvic (e.g., aorto-iliac) arteries for

stenoses in members with peripheral vascular

disease; or

D. To evaluate endoleaks following endovascular repair

of abdominal aortic aneurysm; or

E. To evaluate hepatic vasculature prior to transjugular

intrahepatic portosystemic shunt (TIPS); or

F. To determine the extent of an abdominal aortic

aneurysm and associated occlusive disease in

members undergoing elective repair; or

G. Evaluation of the body part from which the free

tissue transfer flap is being taken for breast

reconstruction preoperative planning (e.g., MRA of

the abdomen and pelvis for DIEP flap); or

H. To evaluate for chronic mesenteric ischemia.

* Refractory hypertension is defined as diastolic blood

pressure consistently greater than 100 mm Hg on 3 or

more blood pressure medications.

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Lower Extremity

MRA of the lower extremities is considered medically necessary

as an initial test for diagnosis and surgical planning in the

treatment of peripheral arterial disease of the lower extremity. A

subsequent angiography study is only required if the inflow

vessel is not identified on the MRA. If conventional catheter

angiography is performed first, doing a subsequent MRA may be

indicated if a distal run-off vessel is not identified. Both tests

should not be routinely performed.

Allergy, etc.

The use of MRA is considered medically necessary in members

with documented allergy to iodinated contrast material, and in

members who have accelerating hypertension and/or accelerating

renal insufficiency.

II. Aetna considers the use of gadofosveset trisodium

(Ablavar, previously marketed as Vasovist injection) an

appropriate agent for medically necessary contrast-

enhanced MRA of blood vessels in the abdomen and

lower extremities in adults.

III. Aetna considers MRA to be experimental and

investigational for all other indications because its

effectiveness for indications other than the ones listed

above has not been established, including any of the

following:

A. Cardiac MRI for velocity flow mapping; or

B. Diagnosing cerebral arteriovenous malformations; or

C. Evaluating accessory renal arteries in prospective

renal donors, including potential living kidney

donors; or

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D. Evaluating members with symptoms suggestive of

dural, sagittal or cavernous sinus

thrombosis/occlusion; or

E. Evaluating microvascular compression associated

with trigeminal neuralgia; or

F. Evaluating premature ventricular contraction; or

G. Evaluating recurrent cystic hygroma of the axilla; or

H. Evaluating varices at hepatico-jejunostomy after liver

transplantation; or

I. Evaluating vasa previa; or

J. Predicting pulmonary hypertension; or

K. Ruling out ICA in members who have vague central

nervous system symptoms (e.g., dizziness, headache,

non-specific sensory loss, or vertigo); or

L. Screening for renovascular hypertension; or

M. Screening of the general population for ICAs; or

N. Surveillance of individuals with brain cancer

following radiotherapy

IV. Aetna considers ferumoxytol-enhanced MRA for

evaluation of transplant renal artery stenosis

experimental and investigational because its

effectiveness has not been established.

Magnetic Resonance Venography (MRV)

I. Aetna considers MRV medically necessary for any of the

following indications:

A. For evaluation of thrombosis or compression by

tumor of the cerebral venous sinus in members who

are at risk (e.g., hyper-coagulable disorders,

meningitis, oral contraceptive use, otitis media,

sinusitis, underlying malignant process) or have signs

or symptoms (e.g., drowsiness and confusion

accompanying a headache, focal motor or sensory

deficits, papilledema, or seizures); or

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B. For evaluation of cerebral venous infarction

identified on CT or MRI of the head; or

C. For evaluation of venous thrombosis or occlusion in

the large systemic veins (e.g., superior vena cava,

subclavian, or other deep veins in the chest); or

D. For evaluation of venous thrombosis or occlusion in

the portal and/or hepatic venous system (e.g., Budd-

Chiari syndrome); or

E. For chronic pelvic pain, when pelvic congestion

syndrome is suspected and ultrasound findings are

equivocal.

II. Aetna considers MRV experimental and investigational

for diagnosis of deep vein thrombosis in the arms or

legs because the peer-reviewed medical literature has

not established MRV to be superior to Duplex

ultrasonography for this purpose. MRV is considered

experimental and investigational for all other

indications (e.g., diagnosis of chronic cerebrospinal

venous insufficiency, and prediction of outcome in

tuberculous meningitis) because its effectiveness for

indications other than the ones listed above has not

been established.

III. Aetna considers pelvic MRV for diagnostic evaluation of

cryptogenic stroke experimental and investigational

because its effectiveness for this indication has not been

established.

IV. Aetna considers quantitative MRV for measurement of

venous flow after cerebral venous sinus stenting

experimental and investigational because its

effectiveness has not been established.

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V. Aetna considers ferumoxytol-enhanced MRV for the

diagnosis of chronic kidney disease experimental and

investigational because its effectiveness has not been

established.

Background

Magnetic resonance angiography (MRA) is an application of

magnetic resonance imaging (MRI) that provides visualization

of blood flow, as well as images of normal and diseased blood

vessels. While MRA appears to be a rapidly developing

technology, the clinical safety and effectiveness of this

procedure for all anatomical regions has not been proven.

The use of MRA in evaluating flow in the carotid arteries, the

circle of Willis, the anterior, middle or posterior cerebral

arteries, the vertebral or basilar arteries, or the venous sinuses

have been the most well researched applications. Numerous

articles have demonstrated that MRA can image the vessels

with a high degree of sensitivity and specificity. However, the

appropriate use of MRA in this setting must be coordinated

with the use of the competing technologies,Duplex

ultrasonography and angiography. There is no mention in the

literature that all 3 technologies should be used routinely in the

work-up of carotid artery disease. In terms of screening

patients with symptoms suggestive of disease, duplex

ultrasonography has been shown to be equivalent to MRA,

and thus this test is recommended as the initial diagnostic

test. In terms of surgical planning, MRA has been shown to be

competitive with angiography, therefore this test can be the

second definitive test used for surgical planning. In this

scenario, an angiography would only be considered medically

necessary if the ultrasonography and MRA showed major

discrepancies. Finally, in a more limited role, MRA has been

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suggested as an alternative to angiography in those patients

unable to undergo an angiogram due to allergy to contrast

material.

Patients with transient ischemic attacks or strokes typically

undergo MRI as part of the initial work-up to identify infarcted

areas in the brain. An intra-cranial MRA can be easily

appended to the MRI and for that reason has been frequently

ordered. However, an intra-cranial MRA is considered not

medically necessary. MRI can adequately image any infarcted

areas, and in the case of transient ischemic attacks, by

definition, one would not expect to see any vascular

abnormalities. The use of MRA in the work-up of patients with

the vertebrobasilar syndrome must be considered on a case-

by-case basis. The MRA may be appropriate in patients when

other sources of emboli have been ruled out, and the MRA is

considered as an alternative to an angiogram in order to

establish the diagnosis of vertebral artery disease.

Although MRA provides additional imaging capabilities for intra-

cranial aneurysms (ICAs) and vascular lesions, it is not clear

from the literature how this information will impact on patient

management. In particular, patients who present subacutely

with symptoms consistent with aneurysm or vascular

malformations will probably undergo a conventional spin-echo

MRI followed by angiography, if indicated. It is unclear from the

literature how MRA would alter this imaging hierarchy. Several

authors commented that the anatomic detail provided by MRA

is not sufficient to replace an angiogram. Magnetic resonance

angiography has also been suggested as a novel screening

technique for patients at high risk for aneurysm; however, its

clinical relevance is unknown because of a lack of

understanding of the natural history of aneurysms and which

aneurysms represent a high risk of rupture. Due to its low

diagnostic yield, MRA is considered not medically necessary for

the routine work-up of patients with non-specific, non-focal

symptoms, such as headache or dizziness.

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Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 10 of 81

Magnetic resonance angiography is an effective non-invasive

technique for establishing a diagnosis and evaluating the

extent and severity of nearly all diseases of the thoracic aorta.

Studies have shown that MRA of the chest has a high level of

diagnostic accuracy for pre-operative and post-operative

evaluation of aortic dissection of aneurysm. Depending on the

clinical presentation, MRA may be used as an alternative to

other non-invasive imaging technologies (e.g., trans-

esophageal echocardiography and CT).

Saremi and Tafti (2009) noted that cardiac ablation procedures

have become the standard of therapy for various arrhythmias

including atrial fibrillation (AF). Understanding the

morphological characteristics of the left atrium (LA) and

pulmonary vein (PV) in detail and identification of its anatomic

variants is crucial to perform a successful ablation procedure

and minimize complications. The current techniques for

radiofrequency ablation of AF include targeting the PVs or the

tissue in the antrum of the LA. Localization of the anatomic

structures within the LA is performed by using fluoroscopy,

electro-anatomic mapping, and intra-cardiac

echocardiography. Multi-dimensional CT and MRA are

invaluable techniques for better visualization of the anatomic

landmarks that are essential for cardiac ablation procedures

as well as prompt diagnosis and, in selected cases, prevention

of procedure-related complications. Some of the

complications of ablation procedures may include cardiac

tamponade, PV stenosis, as well as esophageal and phrenic

nerve injuries.

Holmes et al (2009) stated that ablation procedures for AF are

being performed with increasing frequency. One of the most

serious complications is the development of pulmonary vein

stenosis, which occurs in 1 % to 3 % of current series. The

presentation of pulmonary vein stenosis varies widely. The

majority of patients are symptomatic although specific referral

bias patterns can affect this. Symptoms may include dyspnea

or hemoptysis or may be consistent with bronchitis. These

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symptoms are affected by the number of stenotic veins as well

as the severity of the stenosis. The more severe the stenosis

and the greater number of stenosed veins result in more

symptoms. Because of the variability in symptoms, clinicians

must have heightened sensitivity to the presence of the

condition. Diagnostic tests of value include MRA and

computed tomography. Although echocardiography has been

used, it does not usually provide adequate assessment.

Progression of stenosis is unpredictable and may be rapid.

The specific anatomy of the stenosis varies widely and affects

management. Because of the presence of antral fusion of the

origin of the left superior and left inferior pulmonary vein, a

stenosis involving 1 or the other can impinge and affect

outcome. In this setting, bifurcation techniques familiar to

interventional cardiology are very helpful. Controversy

currently exists about the optimal treatment approach. The

use of balloons and larger stents (approximately 10 mm)

results in more optimal results than just balloon angioplasty

alone; however, even with stent implantation, recurrent re-

stenosis may occur in 30 % to 50 % of patients. Follow-up of

these patients typically involves computed tomography

imaging to document re-stenosis. If significant re-stenosis is

identified, it should be treated promptly because of the

potential for progression to total occlusion.

Furthermore, a CMS decision memo (2010) noted that it has

received a position statement in the form of a combined

comment from the AmericanCollege of Cardiology (ACC),

American College of Radiology (ACR), American Society of

Neuroradiology (ASNR), North American Society for

Cardiovascular Imaging (NASCI), and the Society for

Cardiovascular Magnetic Resonance (SCMR). They were in

favor of combining the currently separate NCDs, allowing local

Medicare contractor discretion to cover use of MRA for

additional indications which are currently non-covered, and

they recommended national coverage for MRA of the

pulmonary veins before and after radiofrequency ablation for

AF.

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Current scientific data shows that diagnostic pulmonary MRAs

are improving due to recent developments such as faster

imaging capabilities and gadolinium-enhancement. However,

these advances in MRA are not significant enough to warrant

replacement of pulmonary angiography in the diagnosis of

pulmonary embolism for patients who have no contraindication

to receiving intravenous iodinated contrast material. The

tortuous pulsatile nature of the coronary arteries presents an

imposing technical challenge to MRA. The application of MRA

for this purpose is still in its infancy.

Studies have proven that MRA is considered a reliable

diagnostic tool for the pre-operative evaluation of patients who

will undergo elective abdominal aortic aneurysm (AAA) repair.

In addition, scientific data has revealed that MRA is

considered comparable to conventional angiography in

determining the extent of the AAA, as well as evaluation of

aorto-illiac occlusion disease and renal artery pathology that

may be necessary in the surgical planning for AAA repair. If pre-

operative angiography is not necessary, then patients are not

exposed to the risks associated with invasive contrast

procedures, namely allergic reactions, end-organ damage or

arterial injury. Magnetic resonance angiography has also

become accepted as a method to detect suspected stenosis in

the main renal arteries; its inability to image distal lesions and

accessory arteries limits its diagnostic abilities.

Although MRA assessment for the evaluation of renal artery

stenosis is acceptable, the accuracy of MRA as a screening

method for renovascular hypertension is unproven, and MRA

is inadequate in the identification of accessory renal arteries

because it has not achieved the level of accuracy needed to

replace conventional angiography in the evaluation of potential

living renal donors.

Surgical planning for peripheral arterial occlusive disease in

the lower extremities depends on identification of adequate

inflow and distal run off vessels. Magnetic resonance

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angiography has been shown to be a superior technique in

identifying distal run-off vessels and is competitive with

angiography in identifying appropriate inflow vessels.

Therefore, MRA can be used as an initial test for surgical

planning, with a subsequent angiography only if the inflow

vessel is not identified. If angiography is performed first, an

MRA may be appropriate if a distal run-off vessel is not

identified because MRA is capable of detecting a viable run-off

vessel for bypass not seen on traditional angiography,

especially when exploratory surgery is not believed to be a

reasonable medical course of action for the patient.

On December 24, 2008, the United States Food and Drug

Administration (FDA) approved Vasovist injection

(gadofosveset trisodium, now marketed as Ablavar), the first

contrast imaging agent for use in patients undergoing MRA.

Gadofosveset reversibly binds to albumin providing extended

intravascular enhancement compared with existing

extracellular magnetic resonance contrast agents.

Administration of gadofosveset provides a clearer image in

patients who are suspected of having blockages or other

problems with the blood vessels in their abdomen or

extremities. The safety and effectiveness of Vasovist was

established in 2 clinical trials of patients with known or

suspected aorto-iliac disease. In the studies, patients

underwent MRA with and without Vasovist and their scans

were compared to standard X-ray pictures using contrast.

Magnetic resonance angiography with Vasovist detected more

arterial disease than MRA performed without Vasovist and the

pictures were of improved technical quality.

Bosch et al (2008) evaluated the safety and effectiveness of

gadofosveset in patients with pedal arterial disease. A total of

185 adult patients with known or suspected pedal arterial

disease were randomized in a group receiving 0.03 mmol/kg

and a group receiving 0.05 mmol/kg of gadofosveset for MRA

of the pedal arteries. Gadofosveset-enhanced and

unenhanced time-of-flight MR angiograms were compared

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with conventional angiograms for the presence of vascular

stenosis. All patients underwent drug safety analysis. For

each of 3 blinded readers, the specificity (21 to 35 %) of

gadofosveset-enhanced MRA was a statistically significant (p

< 0.010) improvement over that of unenhanced MRA in the

detection of clinically significant (greater than 50 %) stenosis.

The sensitivities of the 2 techniques were similar. For all

blinded readers of MR angiograms, sensitivity, specificity, and

accuracy were higher with use of the 0.03-mmol/kg dose of

gadofosveset than with the 0.05-mmol/kg dose. In the 0.03-

mmol/kg group, 28 % of patients reported a total of 50 adverse

events, 96 % of which were reported as mild or moderate. In

the 0.05-mmol/kg group, 28 % of patients reported a total of 55

adverse events, 98 % of which were reported as mild or

moderate. No patients died; 1 patient left the study because of

myocardial infarction considered unrelated to the study drug.

The authors concluded that because of markedly better

efficacy than no contrast agent and a minimal and transient

side-effect profile, 0.03 mmol/kg of gadofosveset was found

safe and effective for MRA of patients with pedal arterial

disease.

In a multi-center, comparative, phase III single-dose clinical

study, McGregor et al (2008) examined the effectiveness of

gadofosveset-enhanced MRA for evaluation of renal artery

disease. Gadofosveset (0.03 mmol/kg) was administered to

adult patients with known or suspected renal arterial disease;

the drug allows collection of images in the first-pass and

steady-state phases. The combination of these images was

compared to non-contrast MRA, using catheter X-ray

angiography (XRA) as the standard of reference. All MRA

images were collected at 1.5 T in 1 imaging session for direct

comparison, and XRA within 30 days. Sensitivity, specificity,

and accuracy for diagnosing significant disease (stenosis

greater than or equal to 50 %) were calculated for MRA using

3 independent blinded readers. Patient safety was monitored

for 72 to 96 hours. A total of 145 patients were enrolled and

received gadofosveset; the 127 with complete efficacy data

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entered the primary efficacy analysis. Gadofosveset-

enhanced MRA led to significant improvement (p < 0.01) in

sensitivity (+25 %, +26 %, +42 %), specificity (+23 %, +25 %,

+29 %), and accuracy (+23 %, +28 %, +29 %) over non-

enhanced MRA for the 3 readers. The rate of uninterpretable

examinations decreased from 30 % to less than 2 %. There

were no serious adverse events, and the most common

adverse events were nausea, pruritis, and headache (8 %

each). No significant trends in clinical chemistry parameters,

nor significant changes in serum creatinine, were found

following administration of gadofosveset. The authors

concluded that in patients with known or suspected renal

arterial disease, gadofosveset-enhanced MRA significantly

improves sensitivity, specificity, and accuracy versus non-

enhanced MRA. Gadofosveset was safe and well-tolerated in

this patient population.

There is evidence that MRA, as an adjunct to conventional

MRI, is useful in the evaluation of the of spinal cord. Farb et al

(2002) described the cases of 9 patients with initial MRI and

clinical findings suggestive of spinal dural arterio-venous

fistula (AVF) who underwent spinal MRA with an auto-

triggered elliptic centric ordered three-dimensional (3-D)

gadolinium-enhanced technique (hereafter, this MRA

technique) before conventional intra-arterial angiography. In

all 9 patients, findings with this MRA technique correctly and

precisely localized the spinal dural AVF. Observer error

resulted in 1 case in which the site of the fistula was not

prospectively reported, but was easily identified retrospectively

on the spinal MR angiogram.

Saraf-Lavi E et al (2002) studied the sensitivity, specificity, and

accuracy of MRI alone compared with MRI plus MRA in

determining whether dural AVF are present and established

the accuracy of MRA in predicting fistula level. A total of

20 patients with surgically proven dural AVF (diagnosed with

radiographic digital subtraction angiography) and 11 control

patients who had normal digital subtraction angiography

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findings underwent routine MRI plus 3-D contrast-enhanced

MRA of the spine. Images were reviewed in 2 stages (stage I,

MRI only; stage II, MRI plus MRA) by 3 neuroradiologists who

were blinded to the final diagnoses. The sensitivity, specificity,

and accuracy of the 3 reviewers in detecting the presence of

fistulae ranged from 85 % to 90 %, from 82 % to 100 %, and

from 87 % to 90 %, respectively, for stage I, compared with

values of 80 % to 100 %, 82 %, and 81 % to 94 %,

respectively, for stage II. For each reviewer, there were no

significant differences between the values for stage I and

stage II; however, among the reviewers, one of the more

experienced neuroradiologists had significantly greater

sensitivity than a less experienced neuroradiologist for stage

II. On average, the percentage of true positive results for

which the correct fistula level was predicted increased from 15

% for stage I to 50 % for stage II, and the correct level +/- one

level was predicted in 73 % for stage II. MR evidence of

increased intra-dural vascularity was significantly greater in

patients with dural AVF. The authors concluded that the

addition of MRA to standard MRI of the spine may improve

sensitivity in the detection of spinal dural fistulae. The

principal benefit of MRA is in the improved localization of the

vertebral level of the fistula, which potentially expedites the

subsequent digital subtraction angiography study.

Luetmer et al (2005) tested the hypothesis that elliptic centric

contrast-enhanced MRA can be used to detect spinal dural

AVFs, predict the level of fistulas, and reduce the radiation

dose and volume of iodinated contrast material associated

with conventional angiography. These researchers examined

31 patients who presented with suspected spinal dural AVF.

All patients underwent MRA and conventional angiography.

The effect of MRA on subsequent conventional angiography

was assessed by analyzing total fluoroscopy time and volume

of iodinated contrast material used. At angiography, spinal

dural AVFs were diagnosed in 22 of 31 patients, and MRA

depicted an AVF in 20 of the 22 patients. Magnectic

resonance angiographic findings correctly predicted a negative

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angiogram in 7 of 9 cases. Of the 20 true-positive MRA

results, the level of the fistula was included in the imaging

volume in 14. In 13 of these 14 cases, MRA results correctly

predicted the side and the level of the fistula to within 1

vertebral level. Fluoroscopy time and the volume of contrast

agent was reduced by more than 50 % in the 13 patients with

a spinal dural AVF in whom MRA prospectively indicated the

correct level. The authors concluded that contrast-enhanced

MRA can be used to detect spinal dural AVFs, predict the level

of fistulas, and substantially reduce the radiation dose and

volume of contrast agent associated with catheter spinal

angiography.

Meckel et al (2007) stated that digital subtraction angiography

(DSA) is the method of reference for imaging of dural AVF

(DAVF). The goal of this study was to analyze the value of

different MR images including 3-D contrast-enhanced MRA

with a high temporal resolution in diagnostic and follow-up

imaging of DAVFs. A total of 18 MR/MRA examinations from

14 patients with untreated (n = 9) and/or treated (n = 9) DAVFs

were evaluated. Two observers assessed all MR and MRA

investigations for signs indicating the presence of a DAVF, for

fistula characteristics such as fistula grading, location of

fistulous point, and fistula obliteration after treatment. All

results were compared with DSA findings. On time-resolved

3-D contrast-enhanced (TR 3-D) MRA, the side and presence

of all patent fistulas (n = 13) were correctly indicated, and no

false-positive findings were observed in occluded DAVFs (n =

5). Grading of fistulas with this imaging technique was correct

in 77 % and 85 % of patent fistulas for both readers,

respectively. On T2-weighted images, signs indicative of a

DAVF were encountered only in fistulas with cortical venous

reflux (56 %), whereas on 3-D time-of-flight (TOF) MRA, most

fistulas (88 %) were correctly detected. In complete fistula

occlusion, false-positive findings were encountered on both T2-

weighted images and on TOF MRA images. The authors

concluded that TR 3-D MRA proved reliable in detecting

DAVFs and suitable for follow-up imaging. The technique

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allowed -- within limitations -- to grade DAVFs. Although 3-D

TOF MRA can depict signs of DAVFs, its value for follow-up

imaging is limited.

Mull et al (2007) examined the validity of MRA for identification

of spinal arterio-venous (AV) abnormalities. A total of 34

consecutive patients with suspicion of spinal vascular

abnormalities underwent digital subtraction angiography (DSA)

after MRA. The level and side of the suspected spinal DAVF

(SDAVF) and the feeding arteries in spinal AV malformations

(SAVMs) were determined from MRA and compared with

DSA. DSA revealed SDAVF in 20 abnormalities of which 19

were spinal and 1 was tentorial with spinal drainage, as well as

SAVM in 11 patients. In 3 patients, MRA and DSA were both

normal. For detection of spinal AV abnormalities, neither

false-positive nor false-negative MRA result was obtained.

The MRA-derived level of the feeding artery in SDAVF agreed

with DSA in 14 of 19 cases. In 5 cases, a mis-match of 1

vertebral level (not side) was noted for the feeding artery. For

the tentorial AVF, only the spinal drainage was depicted; the

feeding artery was outside the MRA field of view. In intra-dural

SAVM, the main feeding artery was identified by MRA in 10 of

11 patients. Magnetic resonance angiography could

differentiate between gl omerular and fistulous SAVM in 4 of 6

cases and between sacral SDAVF and filum terminale SAVM

in 2 of 5 cases. The authors concluded that MRA reliably

detects or excludes various types of spinal AV abnormalities

and localizes the (predominant) arterial feeder of most spinal

AV shunts. Although classification of the subtype of SAVMs

remains difficult, with MRA it greatly helps to focus subsequent

DSA.

Sharma and Westesson (2008) noted that contrast-enhanced

MRA has been increasingly used in the evaluation of spinal

vascular malformations. Furthermore, in a review on

advances in spinal cord MRA, Backes and Nijenhuis (2008)

noted that current fast contrast-enhanced MR techniques are

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able to (i) visualize vessels supplying or draining the spinal

cord and (ii) differentiate spinal cord arteries from veins.

The localization of the Adamkiewicz artery, the largest artery

supplying the thoraco-lumbar spinal cord, has become

possible in a reproducible and reliable manner. Knowledge of

the anatomic location of this artery and its arterial supplier may

be of benefit in the work-up for aortic aneurysm surgery to

reduce incidences of ischemic injury. Spinal cord MRA is

ready to become a diagnostic tool that can compete with

catheter angiography for detecting and localizing arterial

feeders of vascular lesions and is strongly advised for use

prior to invasive catheter angiography.

An UpToDate review on "Prevalence and evaluation of

ventricular premature beats" (Podrid, 2012) does not mention

the use of magnetic resonance angiography.

Lookstein et al (2004) compared the findings of time resolved-

MRA (TR-MRA) with conventional angiography for the

characterization of endoleaks. Between June 2002 and June

2003, 12 patients with documented endoleaks following

endovascular repair of aortic aneurysms (10 abdominal and 2

thoracic) underwent TR-MRA to identify and characterize the

endoleak. All patients had nitinol-based aortic stent grafts.

MRA was performed on a 1.5-Tesla magnet (Sonata class;

Siemens Medical Systems, Iselin, NJ). The TR-MRA studies

were reviewed under continuous observation as a "cine MR

angiogram". These MRA data sets were used to classify the

endoleaks into types 1 through 3. The patients underwent

conventional angiography following the MRA to confirm the

findings and to plan treatment. The MRA findings were

compared with the findings made at conventional

arteriography. TR-MRA identified 7 patients with type 1 leaks,

including 4 proximal and 3 distal. Four patients had type 2

leaks, including 2 arising from the inferior mesenteric artery

and 2 from an ilio-lumbar artery. One patient had a type 3

leak. Conventional angiography confirmed the type of

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endoleak in all 12 patients. The authors concluded that these

initial results demonstrated TR-MRA to be an effective non-

invasive method for classifying endoleaks. This technique

may allow for screening of patients with endoleaks to identify

those requiring urgent repair.

The American College of Radiology (ACR)/North American

Society for Cardiovascular Imaging (NASCI)/Society for

Pediatric Radiology (SPR)’s practice guideline on “The

performance of pediatric and adult body magnetic resonance

angiography (MRA)” (ACR-NASCI-SPR, 2010) stated that

abdominal and pelvic MRA can be used for post-procedure

assessment for detection of suspected leak following aortic

aneurysm surgery or MR-compatible aortic stent graft

placement”. Moreover, the ACR’s Appropriateness Criteria on

“Abdominal Aortic Aneurysm: Interventional Planning and

Follow-up” (2012) stated that “For detection and sizing of

endoleak, MRA is at least as sensitive as, and probably better

than CTA …. 3D contrast-enhanced MRA and time resolved

MRA are highly sensitive to endoleaks”. The ACR’s

recommendation was given a “7” rating; and 7, 8, and 9

“ratings” denote “Usually appropriate”.

Furthermore, an UpToDate review on “Endovascular repair of

abdominal aortic aneurysm” (Chaer, 2014) states that “CT

angiography with delayed images is the most widely used

modality for follow-up after endovascular aneurysm repair

(EVAR). It is accurate for maximal diameter measurement,

and for the detection of endoleak and other device-related

complications. However, CT angiography is costly and

repeated radiation exposure is associated with an increased

lifetime cancer risk. Repeated administration of intravenous

contrast may also contribute to a progressive decline in renal

function that has been observed following EVAR. The

guidelines for the management of abdominal aortic aneurysm

(AAA) from the Society for Vascular Surgery advocate CT

angiography at 1 and 12 months during the first year after

EVAR. Imaging at six months is no longer routinely

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recommended unless an endoleak or other device-related

abnormality is identified at the one-month imaging study after

EVAR. If an endoleak or aneurysm enlargement is not

documented during the first year after EVAR, DU [duplex

ultrasonography] is an alternative to CT angiography for

ongoing postoperative surveillance …. MR imaging is not a

standard modality for EVAR surveillance, but can be used in

specific situations where CT angiography is contraindicated.

The advantage of MR imaging is the lack of exposure to

ionizing radiation. Disadvantages are its lack of wide

availability and difficulty evaluating device integrity due to

artifact. The placement of stent-grafts made of nitinol does not

preclude MR imaging, though MR imaging is contraindicated

for stainless-steel-based grafts (e.g., Cook, Zenith)”.

Miller et al (2009) stated that neuro-vascular compression

(NVC) of the trigeminal nerve is associated with trigeminal

neuralgia (TN), but also occurs in many patients without facial

pain. These researchers identified anatomical characteristics

of NVC associated with TN. A total of 30 patients with type 1

TN (intermittent shock-like pain) and 15 patients without facial

pain underwent imaging for analysis of 30 trigeminal nerves

ipsilateral to TN symptoms, 30 contralateral to TN symptoms,

and 30 in asymptomatic patients were include in this study.

Patients underwent 3-T MRI including balanced fast-field echo

and MRA. Images were fused and reconstructed into virtual

cisternoscopy images that were evaluated to determine the

presence and degree of NVC. Reconstructed coronal images

were used to measure nerve diameter and cross-sectional

area. The incidence of arterial NVC in asymptomatic nerves,

nerves contralateral to TN symptoms, and nerves ipsilateral to

TN symptoms was 17 %, 43 %, and 57 %, respectively. The

difference between symptomatic and asymptomatic nerves

was significant regarding the presence of NVC, nerve

distortion, and the site of compression (p < 0.001, Fisher exact

test). The most significant predictors of TN were compression

of the proximal nerve (odds ratio 10.4) and nerve indentation

or displacement (odds ratio 4.3). There was a tendency for

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the development of increasingly severe nerve compression

with more advanced patient age across all groups. Decreased

nerve size was observed in patients with TN but did not

correlate with the presence or extent of NVC. The authors

concluded that trigeminal NVC occurs in asymptomatic

patients but is more severe and more proximal in patients with

TN. Moreover, they stated that this information may help

identify patients who are likely to benefit from micro-vascular

decompression (MVD).

Zacest et al (2010) stated that TN is a neuropathic pain

syndrome that is often associated with NVC of the TN and may

be effectively treated with MVD. The authors used high-

resolution MRI with 3D reconstruction in patients with constant

facial pain (type 2 TN) to determine the presence/absence of

NVC and thus a potential MVD benefit. They retrospectively

contacted patients to evaluate outcome. All patients who

reported spontaneous onset of constant facial pain (type 2

TN), which occurred at least 50 % of the time, who had

undergone high-resolution 3-TMRI with 3D reconstruction

were retrospectively selected for this study. Clinical history,

facial pain questionnaire data, physical examination findings,

and results from 3-T 3D MRI reconstruction were recorded for

all patients. Intra-operative findings and clinical pain outcome

were recorded for all patients who underwent MVD. Data

obtained in 27 patients were assessed. On the basis of history

and 3D MRI reconstruction findings, 13 patients were selected

for MVD (Group A) and 14 underwent conservative treatment

(Group B). Typical or suspected artery- or vein-induced NVC

was predicted pre-operatively in 100 % of Group A patients

and in 0 % of Group B patients.At the time of MVD, definitive

NVC was confirmed in 11 (84.6 %) of 13 Group A patients.

Following MVD, facial pain was completely relieved in 3 (23

%), improved in 7 (53.8 %), and no better in 3 (23 %) of 13

Group A patients. A history of episodic (type 1 TN) pain at any

time was reported in 100 % and 50 % of Group A and Group B

patients, respectively. A type 1 TN pain component was

reportedly improved/relieved in all Group A patients, but the

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type 2 TN pain component was improved in only 7 (53.8 %) of

13 patients. The mean post-operative follow-up duration was

13 months. The authors concluded that high-resolution 3D

MRI reconstruction in patients with constant facial pain (type 2

TN) can help determine the presence/absence of NVC. They

stated that surgical selection based on both clinical and

radiological criteria has the potential to improve surgical

outcome in patients with type 2 TN who may potentially benefit

from MVD. However, even in such selected patients, pain

relief is likely to be incomplete.

Leal et al (2014) prospectively evaluated atrophic changes in

trigeminal nerves (TGNs) using measurements of volume (V)

and cross-sectional area (CSA) from high-resolution 3-T MR

images obtained in patients with unilateral TN, and correlated

these data with patient and NVC characteristics and with

clinical outcomes. Anatomical TGN parameters (V and CSA)

were obtained in 50 patients (30 women and 20 men; mean

age of 56.42 years, range of 22 to 79 years) with classic TN

before treatment with MVD. Parameters were compared

between the symptomatic (ipsilateralTN) and asymptomatic

(contralateralTN) sides of the face; 20 normal control subjects

were also included. Two independent observers blinded to the

side of pain separately analyzed the images. Measurements

of V (from the pons to the entrance of the nerve into Meckel's

cave) and CSA (at 5 mm from the entry of the TGN into the

pons) for each TGN were performed using imaging software

and axial and coronal projections, respectively. These data

were correlated with patient characteristics (age, duration of

symptoms before MVD, side of pain, sex, and area of pain

distribution), NVC characteristics (type of vessel involved in

NVC, location of compression along the nerve, site of

compression around the circumference of the root, and degree

of compression), and clinical outcomes at the 2-year follow-up

after surgery. Comparisons were made using Bonferroni's

test. Inter-observer variability was assessed using the

Pearson correlation coefficient. The mean V of the TGN on

the ipsilateralTN (60.35 ± 21.74 mm(3)) was significantly

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smaller (p < 0.05) than those for the contralateralTN and

controls (78.62 ± 24.62 mm(3) and 89.09 ± 14.72 mm(3),

respectively). The mean CSA of the TGN on the ipsilateralTN

(4.17 ± 1.74 mm(2)) was significantly smaller than those for

the contralateralTN and controls (5.41 ± 1.89 mm(2) and 5.64

± 0.85 mm(2), respectively). The ipsilateralTN with NVC

Grade III (marked indentation) had a significantly smaller mean

V than the ipsilateralTN with NVC Grade I (mere contact),

although it was not significantly smaller than that of the

ipsilateralTN with NVC Grade II (displacement or distortion of

root). The ipsilateralTN with NVC Grade III had a significantly

smaller mean CSA than the ipsilateralTN with NVC Grades I

and II (p < 0.05). The TGN on the ipsilateralTN in cured

patients had a smaller mean CSA than that on the

ipsilateralTN of patients with partial pain relief or treatment

failure (p < 0.05). The same finding was almost found in

relation to measurements of V, but the p value was slightly

higher at 0.05. The authors concluded that the findings of this

study showed that TGN atrophy in patients with TN can be

demonstrated by high-resolution imaging. Moreover, they

stated that these data suggested that atrophic changes in

TGNs, which significantly correlated with the severity of

compression and clinical outcomes, may help to predict long-

term prognosis after vascular decompression.

An UpToDate review on “Trigeminal neuralgia” (Bajwa et al,

2014) states that “Neuroimaging with head CT or MRI is useful

for identifying the small proportion of patients who have a

structural lesion (e.g., tumor in the cerebellopontine angle,

demyelinating lesions including multiple sclerosis) as the

cause of painful trigeminal neuropathy. In addition, high

resolution MRI and magnetic resonance angiography (MRA)

may be useful for identifying vascular compression as the

etiology of classic TN, but the utility of these studies has not

been established …. The 2008 AAN/EFNS practice parameter

identified seven studies that performed high-resolution brain

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MRI and/or magnetic resonance angiography (MRA) to

demonstrate neurovascular compression in patients with TN.

The following observations were made:

▪ There was wide variation among the included studies

for both sensitivity (range 52 to 100 %) and specificity

(29 to 93 %).

▪ In 3 of the 5 highest-quality MRI studies (cohort surveys

with prospective data collection), the difference in rate

of neurovascular trigeminal nerve compression on the

symptomatic side compared with asymptomatic side

was statistically non-significant.

Given these inconsistent results, the AAN/EFNS concluded

that there is insufficient evidence to support or refute the utility

of MRI to identify neurovascular compression in classic TN, or

to indicate the most reliable MRI technique”.

Magnetic Resonance Angiography (MRA) for the Diagnosis of Cerebral Arteriovenous Malformation

In a retrospective, observational study, Chowdhury et al (2015)

compared MRA and DSA in diagnosis of cerebral arterio-

venous malformation (AVM). A total of 30 patients with

hemorrhagic stroke age ranging from 13 to 65 years were

selected on the basis of inclusion and exclusion criteria as the

study sample. MRA and DSA were done in all the selected

patients. The mean age of the patients of hemorrhagic stroke

was 30.3 ± 14.3 years and male to female ratio was 2.7:1.

Regarding the venous drainage of AVM 13 and 12 were

superficial and deep, respectively, and evaluated 100 % by

MRA. In the diagnosis of cerebral AVM nidus size S1: less

than 3 and S2: 3 to 6 cm sensitivity was 100 % but accuracy

was 100 % and 73.3 %, respectively. DSA was 100 %

sensitive in the diagnosis of superficial and deep venous

drainage AVM. Regarding the eloquence of brain area 15 had

no eloquence by both MRA and DSA and identification of

eloquence of brain area sensitivity was 73.3 % and accuracy

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was 86.7 %. The main feeding vessels were found (22, 73.3

%) in both DSA and MRA findings. Distal vessels was seen

(8, 26.7 %) in DSA butnot seen in MRA findings. Intra-nidal

aneurysm and angiopathic AVM were seen in 3 (10.0 %) and 4

(13.3 %), respectively in DSA. This study was carried out to

diagnose the patients presented with cerebral AVM by MRA

and DSA. The authors concluded that MRA could not be

evaluated flow status of AVM, distal feeding arteries, intra-

nidal aneurysm and angiopathic AVM, which could be

detected by DSA. So, DSA is superior to MRA in diagnosis of

cerebral AVM.

MRA for the Diagnosis and Treatment Response in Individuals with Moyamoya Disease

Uchino et al (2015) stated that noncontrast-enhanced time-

resolved 4-dimensional MRA using an arterial spin labeling

technique (ASL-4D MRA) is emerging as a next generation

angiography for the management of neurovascular diseases.

This study evaluated the feasibility of ASL-4D MRA for the

diagnosis of Moyamoya disease (MMD) and MMD staging by

using DSA and TOF MRA as current standards. A total of 11

consecutive non-operated patients who underwent DSA for the

diagnosis of MMD were recruited. Two independent observers

evaluated the 3 tests. The data were analyzed for inter-

observer and inter-modality agreements on MMD stage; 9 of

22 hemispheres underwent surgical re-vascularization and ASL-

4D MRA was repeated post-operatively. Time-resolved inflow of

blood through the cerebral vessels, including moyamoya

vessels, was visualized in all the 22 non-operated hemispheres.

MMD stages assessed by DSA and ASL-4D MRA were

completely matched in 18 hemispheres, with a significant

positive correlation between these modalities (r = 0.93, p <

0.001). Inter-observer agreement with ASL-4D MRA (κ = 0.91 ±

0.04, p < 0.001) and inter-modality agreement between ASL-4D

MRA and DSA (κ = 0.93 ± 0.04, p < 0.001)

were both excellent. MMD stages assessed by ASL-4D MRA

have also a significant positive correlation with those assessed

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by TOF MRA (r = 0.68, p = 0.004).Repeated ASL-4D MRA

clearly demonstrated the bypassed arteries and changes in

the dynamic flow patterns of cerebral arteries in all the 9

hemispheres after surgical re-vascularization. Of these, post-

operative focal hyper-perfusion was detected by single photon

emission tomography in 7 hemispheres. In 5 of the 7

hemispheres (71 %) with post-operative hyper-perfusion, ASL-

4D MRA demonstrated focal hyper-intense signals in the

bypassed arteries, although TOF MRA did not. The authors

concluded that noninvasive ASL-4D MRA is feasible for the

diagnosis of MMD staging. This next generation angiography

may be useful for monitoring disease evolution and treatment

response in cerebral arteries after revascularization surgery in

MMD. These preliminary findings need to be validated by well-

designed studies.

MRA for the Evaluation of Aneurysm Coiling

In a systematic review and meta-analysis, Ernst et al (2015)

examined the inter-rater reliability of visual rating of aneurysm

occlusion as study end-point. Electronic databases

(MEDLINE, EMBASE, PubMed, and the Cochrane Library)

were searched up to June 2014. Assessment of risk for bias

was based on the Quality Appraisal Tool for Studies of

Diagnostic Reliability and the Guidelines for Reporting

Reliability and Agreement studies. Inter-rater reliability

estimates were pooled across studies using meta-analysis,

and the influence of several factors (e.g., imaging methods,

grading scales, and occlusion rate) was tested with meta-

regression. From 1,193 titles, 644 abstracts and 87 full-text

versions were reviewed. A total of 26 articles met the inclusion

criteria and provided 77 reliability estimates; 21 different rating

scales were used, and statistical analysis varied. Mean inter-

rater agreementof the pooled studies was substantial (κ =

0.65; 95 % confidence interval [CI]: 0.60 to 0.69). Reliability

varied significantly as a function of imaging methods, grading

scales, occlusion rates, and their interaction. Observer

agreement substantially increased with increasing occlusion

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rate in digital subtraction angiography but not in MA.

Reliability was higher in studies using 2- or 3-value grading

scales than in studies with 4-value grading scales. The

authors concluded that there was significant heterogeneity

between studies evaluating the reliability of visual evaluation of

aneurysm coiling. On the basis of this analysis, these

researchers found that the combination of MRA, 3-value

grading scale, and 2 trained raters appeared most promising

for usage as surrogate study end-points.

Marciano and colleagues (2017) noted that data about non-

invasive follow-up of aneurysm after stent-assisted coiling is

scarce. In a retrospective, single-center study, these

investigators compared TOF MRA (3D-TOF-MRA) and contrast-

enhanced MRA (CE-MRA) at 3-Tesla, with DSA for evaluating

aneurysm occlusion and parent artery patency after stent-

assisted coiling. Patients were included if they had an

intracranial aneurysm treated by stent-assisted coiling

between March 2008 and June 2015, followed with both MRA

sequences (3D-TOF-MRA and CE-MRA) at 3-Tesla and DSA,

performed in an interval of less than 48 hours. A total of 35

aneurysms were included. Regarding aneurysm occlusion

evaluation, agreement with DSA was better for CE-MRA (K =

0.53) than 3D-TOF-MRA (K = 0.28). Diagnostic accuracies for

aneurysm remnant depiction were similar for 3D-TOF-MRA

and CE-MRA (p = 1). Both 3D-TOF-MRA (K = 0.05) and CE-

MRA (K = -0.04) were unable to detect pathological vessel

compared to DSA, without difference in accuracy (p = 0.68).

For parent artery occlusion detection, agreement with DSA

was substantial for 3D-TOF-MRA (K = 0.64) and moderate for

CE-MRA (K = 0.45), with similar good diagnostic accuracies (p

= 1). The authors concluded that after stent-assisted coiling

treatment, 3D-TOF-MRA and CE-MRA demonstrated good

accuracy to detect aneurysm remnant (but tended to over-

estimation). They stated that although CE-MRA agreement

with DSA was better, there was no statistical difference

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between 3D-TOF-MRA and CE-MRA accuracies. Both MRAs

were unable to provide a precise evaluation of in-stent status;

but could detect parent vessel occlusion.

Ernst and associates (2018) stated that understanding

aneurysm growth is critical for the appropriate follow-up of

patients after coil embolization and the need for re-treatment.

These researchers stratified the growth dynamics of aneurysm

recurrences after coiling by volumetric analysis and

determined predictive factors for aneurysm recurrences.

Source images of follow-up 3D-TOF-MRA scans were

compared with the first post-interventional TOF-MRA scan and

analyzed for residual flow after co-registration using ANALYZE-

software. In the event of incomplete occlusion, the residual

volume was segmented and calculated. Growth dynamic was

determined for each aneurysm after embolization. These

researchers analyzed 326 patients with 345 aneurysms from 2

centers. Each case had at least 2 TOF- MRA examinations after

endovascular therapy. The mean observation interval was 59

months. Volumetric analysis of 1,139 follow-up MRAs revealed

that 218/345 aneurysms (63.2

%) showed complete occlusion on initial follow-up imaging,

and of these 95.0 % remained stable. A steady increase in

intra-aneurysmal flow was observed in 83/345 (24.1 %). Less

frequent observations were a steep increase (21/345; 6.1 %)

and a decrease (27/345; 7.8 %). Independent predictors of

increasing residual flow were greatest aneurysm diameter,

total coil length, and incomplete occlusion. The authors

concluded that volumetric analysis of registered 3D-TOF-MRA

follow-up datasets allowed the detection of different growth

patterns with high precision, avoided the low inter-rater

reliability, and represented a promising approach for future

studies that include analysis of more complex predictors of

residual flow. In cases of aneurysm recurrence after coiling,

the major pattern appeared to be a steady increase in intra-

aneurysmal flow over several months.

MRA for the Evaluation of Varices at Hepatico-

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Jejunostomy after Liver Transplantation

Jimbo et al (20150 reported the case of a 7-year old Japanese

girl who had undergone living-donor liver transplantation (LT)

at the age of 10 months for decompensated liver cirrhosis

caused by biliary atresia presented with recurrent episodes of

obscure gastrointestinal bleeding (GIB) with anemia. Over the

following 6 years, she experienced 5 episodes of GIB requiring

hospitalization. Subsequent evaluations including repeat

esophagogastroduodenoscopy (EGD), colonoscopy (CS),

contrast-enhanced computed tomography (CT), and Meckel's

scan all failed to reveal a bleeding source. However, varices

at the site of hepatico-jejunostomy were detected on

abdominal ultrasonography and MRA at the age of 7 years.

The authors concluded that MRA might be more helpful than

contrast-enhanced C T for identifying s uch bleeding. These

preliminary findings need to be validated by well-designed

studies.

MRA for the Surveillance of Individuals with Brain Cancer Following Radiotherapy

In a feasibility study, Bullitt et al (2007) examined if MRA can

depict intracranial vascular morphologic changes during

treatment of brain metastases from breast cancer and if serial

quantitative vessel tortuosity measurements can be used to

predict tumor treatment response sooner than traditional

methods. Institutional review board approval and informed

consent were obtained for this HIPAA-compliant study. A total

of 22 women aged 31 to 61 years underwent brain MRA prior

to and 2 months after initiation of lapatinib therapy for brain

metastases from breast cancer. Vessels were extracted from

MR angiograms with a computer program. Changes in vessel

number, radius, and tortuosity were calculated mathematically,

normalized with values obtained in 34 healthy control subjects

(19 women, 15 men; age range of 19 to 72 years), and

compared with subsequent assessments of tumor volume and

clinical course. All patients exhibited abnormal vessel

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tortuosity at baseline. Nineteen (86 %) patients did notexhibit

improvement in vessel tortuosity at 2-month follow-up, and all

patients demonstrated tumor growth at 4-month follow-up.

Vessel tortuosity measurements enabled these researchers to

correctly predict treatment failure 1 to 2 months earlier than did

traditional methods. Three (14 %) patients had quantitative

improvement in vessel tortuosity at 2-month follow-up, with

drop-out of small abnormal vessels and straightening of large

vessels. Each of the 2 patients for whom further follow-up

data were available responded to treatment for more than 6

months. The authors concluded that these findings

established the feasibility of using MRA to quantify vessel

shape changes during therapy. Moreover, they stated that

although further research is required, results suggested that

changes in vessel tortuosity might enable early prediction of

tumor treatment response.

An Information Sheet on “Further tests for brain tumours” from

Cancer Research UK (Last updated November 25, 2013) did

not mention annual MRA as a surveillance tool for patients

with brain cancer.

A “Brain Tumor Glossary of Terms” from the Brain Tumor Trial

Collaborative (2015) states that “MRA does not have

significant application for the detection or definition of cancer

of the brain”.

Also, an UpToDate review on “Assessment of disease status

and surveillance after treatment in patients with brain

tumors” (Wen, 2015) does not mention MRA as a

management tool.

Furthermore, National Comprehensive Cancer Network

(NCCN)’s clinical practice guideline on “Central nervous

system cancers” (Version 1.2015) states that “Cerebral

angiography is occasionally performed, often for surgical

planning ….”; it does not mention MRA as a management tool.

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The use of an MRA/MRV as part of the work-up of a patient

with suspected cerebral thrombosis (i.e., dural sagittal or

cavernous sinus thrombosis) must be considered on a case by

case basis. Magnetic resonance imaging is considered the

imaging method of choice for establishing the diagnosis, but

MRA/MRV may be useful in following the course of the

disease.

Magnetic resonance venography (MRV) is now very effective

for the evaluation of diseases of larger veins. The specific

indications for using MRV for evaluating the vena cavae are

diagnosis of vena caval thrombus, differentiation of tumor

thrombus and blood clot of the vena cava, diagnosis of

superior vena caval syndrome, identification of superior vena

caval invasion or encasement by lung or mediastinal tumors,

diagnosis of the Budd-Chiari syndrome, diagnosis of caval

anomalies such as persistent left superior vena cava and

interrupted inferior vena cava, and identification of the

presence and cause of obstruction or occlusion of the

brachiocephalic, subclavian, and jugular veins.

Duplex ultrasonography is the typical initial diagnostic test for

deep vein thrombosis (DVT). Magnetic resonance venography

has not been shown to be superior to ultrasonography, except

in imaging the deep femoral and hypogastric vessels.

However, information about these vessels is frequently not

needed to make patient management decisions, except

perhaps in patients with pulmonary emboli where the source of

the emboli has not been identified by ultrasonography. McRae

and Ginsberg (2004) MRV has the potential to be used as a

stand-alone test for DVT but requires further evaluation.

Moreover, in a retrospective study (n = 973), Borer et al (2005)

found that discontinuation of screening by means of ultrasound

and MRV for the diagnosis of DVT did not change the rate of

pulmonary embolism in patients with closed fractures of the

pelvis or acetabulum.

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Bates et al (2012) stated that objective testing for DVT is

crucial because clinical assessment alone is unreliable and the

consequences of misdiagnosis are serious. This guideline

focused on the identification of optimal strategies for the

diagnosis of DVT in ambulatory adults. The methods of this

guideline followed those described in Methodology for the

Development of Antithrombotic Therapy and Prevention of

Thrombosis Guidelines: Antithrombotic Therapy and

Prevention of Thrombosis, 9th ed: American College of Chest

Physicians Evidence-Based Clinical Practice Guidelines.

These investigators suggested that clinical assessment of pre-

test probability of DVT, rather than performing the same tests

in all patients, should guide the diagnostic process for a first

lower extremity DVT (Grade 2B). In patients with a low pre-

test probability of first lower extremity DVT, these researchers

recommended initial testing with D-dimer or ultrasound (US) of

the proximal veins over no diagnostic testing (Grade 1B),

venography (Grade 1B), or whole-leg US (Grade 2B). In

patients with moderate pre-test probability, they recommended

initial testing with a highly sensitive D-dimer, proximal

compression US, or whole-leg US rather than no testing

(Grade 1B) or venography (Grade 1B). In patients with a high

pre-test probability, they recommended proximal compression

or whole-leg US over no testing (Grade 1B) or venography

(Grade 1B). The authors concluded that favored strategies for

diagnosis of first DVT combined use of pre-test probability

assessment, D-dimer, and US. There is lower-quality

evidence available to guide diagnosis of recurrent DVT, upper

extremity DVT, and DVT during pregnancy.

The role of chronic cerebrospinal venous insufficiency

(CCSVI) in the pathogenesis of multiple sclerosis (MS) is a

matter of debate. Chronic cerebrospinal venous insufficiency

was first diagnosed using specialized trans-cranial and extra-

cranial Doppler ultrasonography. Some have advocated the

use of MRV in place of trans-cranial Doppler because the

results of MRV are less operator dependent. However, there

are limited data to support the use of MRV in diagnosis of

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CCSVI. I n a pilot study, Hojnacki et al (2010) the value of

neck MRV for the diagnosis of CCSVI compared to Doppler

sonography (DS) and selective venography (SV) in patients

with MS and in healthy controls (HC). A total of 10 MS

patients and 7 HC underwent DS, 2D-Time-Of-Flight (TOF)

venography and 3D-Time Resolved Imaging of Contrast

Kinetics angiography (TRICKS). Patients with MS also

underwent SV. The internal jugular veins (IJVs) and the

vertebral veins (VVs) were assessed by both MRV sequences,

and the findings were validated against SV and DS; SV has

been considered the diagnostic gold standard for MS patients.

All MS patients and none of the HC presented CCSVI,

according to the DS criteria. This was confirmed by SV. For

CCSVI diagnosis, DS showed sensitivity, specificity, accuracy,

positive-predictive value (PPV) and negative-predictive value

(NPV) of 100 %, whereas the figures were 40 %, 85 %, 58 %,

80 % and 50 % for 3D-TRICKS, and 30 %, 85 %, 52 %, 75 %

and 46 % for 2D-TOF in the IJVs. In MS patients, compared to

SV, DS showed sensitivity, specificity, accuracy, PPV and

NPV of 100 %, 75 %, 95 %, 94 % and 100 %, whereas the

figures were 31 %, 100 %, 45 %, 100 % and 26 % for 3D-

TRICKS and 25 %, 100 %, 40 %, 100 % and 25 % for 2D-TOF

in the IJVs. The authors concluded that the use of MRV for

diagnosis of CCSVI in MS patients has limited value, and the

findings should be interpreted with caution and confirmed by

other imaging techniques such as DS and SV.

Abdalla et al (2015) searched the literature for further evidence

for the use of MRV in the detection of suspected DVT and re-

evaluated the accuracy of MRV in the detection of suspected

DVT. PubMed, EMBASE, Scopus, Cochrane, and Web of

Science were searched. Study quality and the risk of bias

were evaluated using the QUADAS 2. A random effects meta-

analysis including subgroup and sensitivity analyses were

performed. The search resulted in 23 observational studies all

from academic centers; 16 articles were included in the meta-

analysis. The summary estimates for MRV as a diagnostic non-

invasive tool revealed a sensitivity of 93 % (95 % CI: 89 %

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to 95 %) and specificity of 96 % (95 % CI: 94 % to 97 %). The

heterogeneity of the studies was high. Inconsistency (I2) for

sensitivity and specificity was 80.7 % and 77.9 %,

respectively. The authors concluded that further studies

investigating the use of MRV in the detection of suspected

DVT did not offer further evidence to support the replacement

of US with MRV as the first-line investigation. However, they

stated that MRV may offer an alternative tool in the

detection/diagnosis of DVT for whom US is inadequate or not

feasible (such as in the obese patient).

MRA for Evaluation of Vasa Previa

Iwahashi and associates (2016) noted that vasa previa is a

rare complication, and rupture of vasa previa during pregnancy

may lead to significant perinatal mortality. These investigators

reported a case of vasa previa evaluated prenatally using non-

contrast time-of-flight MRA (TOF-MRA). A 22-year old

primiparous woman was referred to the authors’ hospital due

to suspicion of vasa previa. Trans-vaginal US showed 2

vessels running over the internal os. To obtain further

information, MRI and TOF-MRA were performed. Caesarean

section was performed, and macroscopic findings of the

vascular distribution on the fetal membrane were consistent

with those identified by TOF-MRA. The authors concluded

that TOF-MRA in addition to MRI may be an option for prenatal

identification of the precise 3D vascular distribution in patients

with vasa previa. The role of MRA for evaluation of patients

with vasa previa needs to be further investigated.

Ferumoxytol-Enhanced MRA for Evaluation of Transplant Renal Artery Stenosis

Fananapazir and co-workers (2017) determined the accuracy

of ferumoxytol-enhanced MRA in assessing the severity of

transplant renal artery stenosis (TRAS), using digital

subtraction angiography (DSA) as the reference standard.

The authors’ Institutional Review Board approved this

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retrospective, Health Insurance Portability and Accountability

Act-compliant study. A total of 33 patients with documented

clinical suspicion for TRAS (elevated serum creatinine,

refractory hypertension, edema, and/or audible bruit) and/or

concerning sonographic findings (elevated renal artery velocity

and/or intra-parenchymal parvus tardus waveforms)

underwenta 1.5T MRA with ferumoxytolprior to DSA. All

DSAs were independently reviewed by an interventional

radiologist and served as the reference standard. The MRAs

were reviewed by 3 readers who were blinded to the US and

DSA findings for the presence and severity of TRAS.

Sensitivity, specificity, and accuracy for identifying substantial

stenoses (greater than 50 %) were determined. Intra-class

correlation coefficients (ICCs) were calculated among

readers. Mean differences between the percent stenosis from

each MRA reader and DSA were calculated. On DSA, a total

of 42 stenoses were identified in the 33 patients. The

sensitivity, specificity, and accuracy of MRA in detecting

substantial stenoses were 100 %, 75 to 87.5 %, and 95.2 to

97.6 %, respectively, among the readers. There was excellent

agreement among readers as to the percent stenosis (ICC =0.82);

MRA over-estimated the degree of stenosis by 3.9 to 9.6

% compared to DSA. The authors concluded that ferumoxytol-

enhanced MRA provided high sensitivity, specificity, and

accuracy for determining the severity of TRAS. They stated

that these findings suggested that ferumoxytol-enhanced MRA

can potentially be used as a non-invasive examination

following US to reduce the number of unnecessary

conventional angiograms. These preliminary findings need to

be validated by well-designed studies.

Ferumoxytol-Enhanced MRA for Evaluation of Potential Kidney Transplant Recipients

Stoumpos and associates (2018) stated that traditional

contrast-enhanced methods for scanning blood vessels using

MRI or CT carry potential risks for patients with advanced

kidney disease. Ferumoxytol is a super-paramagnetic iron

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oxide nanoparticle preparation that has potential as an MRI

contrast agent in assessing the vasculature. A total of 20

patients with advanced kidney disease requiring aorto-iliac

vascular imaging as part of pre-operative kidney transplant

candidacy assessment underwent ferumoxytol-enhanced MRA

(FeMRA) between December 2015 and August 2016. All

scans were performed for clinical indications where standard

imaging techniques were deemed potentially harmful or

inconclusive. Image quality was evaluated for both arterial

and venous compartments. First-pass and steady-state

FeMRA using incremental doses of up to 4 mg/kg body weight

of ferumoxytol as intravenous contrast agent for vascular

enhancement was performed. Good arterial and venous

enhancements were achieved, and FeMRA was not limited by

calcification in assessing the arterial lumen. The scans were

diagnostic and all patients completed their studies without

adverse events (AEs). The authors concluded that their

preliminary experience supported the feasibility and utility of

FeMRA for vascular imaging in patients with advanced kidney

disease due for transplant listing, which has the advantages of

obtaining both arteriography and venography using a single

test without nephrotoxicity. These preliminary findings need to

be validated by well-designed studies.

Ferumoxytol-Enhanced MRV for Diagnosis of Chronic Kidney Disease

Luhar and associates (2016) noted that ferumoxytol is an ultra-

small superparamagnetic iron oxide (USPIO) particle that is

FDA-approved for parenteral treatment of iron deficiency

anemia in adults with chronic kidney disease (CKD). Because

of the association between gadolinium-based contrast agents

and nephrogenic systemic fibrosis in patients with severe

CKD, these researchers evaluated the diagnostic role of

ferumoxytol-enhanced MRV in children with CKD. A total of 20

children underwent 22 high-resolution ferumoxytol-enhanced

MRV examinations at 3.0 T. High-resolution 3D contrast-

enhanced imaging was performed at a minimum of 3 time-

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points following injection of ferumoxytol at a total dose of 4

mg/kg of body weight. Two blinded pediatric radiologists

independently scored 6 named veins on ferumoxytol-

enhanced MRV examinations according to a 3-point subjective

score, where a score greater than or equal to 2 was

considered diagnostic. Additionally, all relevant venous

structures in the included field of view were analyzed for

occlusive or non-occlusive thrombosis, compression and

presence of collaterals. All patients underwent ferumoxytol-

enhanced MRV successfully and without adverse event (AE).

The overall scores of the reviewing radiologists for all venous

structures were 2.7 to 2.9. In all cases, the reviewers were

confident basing t heir diagnoses on the ferumoxytol-enhanced

MRV findings. In 12 of 22 examinations, findings on follow-up

imaging or invasive procedures were available to correlate

with the findings on ferumoxytol-enhanced M V. There was

complete concordance bet ween the findings from follow-up

imaging and invasive procedures with findings from

ferumoxytol-enhanced M V. The authors concluded that

ferumoxytol holds promise as a powerful alternative to

gadolinium-based contrast agents for reliable, high-resolution

MRV in children with CKD.

MRA for Prediction of Pulmonary Hypertension

Rengier and colleagues (2016) demonstrated the feasibility of

automated 3D volumetry of central pulmonary arteries based

on MRA to evaluate pulmonary artery volumes in patients with

pulmonary hypertension compared to healthy controls, and

examined the potential of the technique for predicting

pulmonary hypertension. Magnetic resonance angiography of

pulmonary arteries was acquired at 1.5T in 20 patients with

pulmonary arterial hypertension and 21 healthy normotensive

controls; 3D model-based image analysis software was used

for automated segmentation of main, right and left pulmonary

arteries (MPA, RPA and LPA). Volumes indexedto vessel

length and mean, minimum and maximum diameters along the

entire vessel course were assessed and corrected for body

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surface area (BSA). For comparison, diameters were also

manually measured on axial reconstructions and double

oblique multi-planar reformations. Analyses were performed

by 2 cardiovascular radiologists, and by 1 radiologist again

after 6 months. Mean volumes of MPA, RPA and LPA for

patients/controls were 5,508 ± 1,236/3,438 ± 749, 3,522 ±

934/1,664 ± 468 and 3,093 ± 692/1,812 ± 474 μl/(cm length x

m2 BSA) (all p < 0.001). Mean, minimum and maximum

diameters along the entire vessel course were also

significantly increased in patients compared to controls (all p <

0.001). Intra- and inter-observer agreement were excellent for

both volume and diameter measurements using 3D

segmentation (ICCs 0.971 to 0.999, p < 0.001). Area under

the curve for predicting pulmonary hypertension using volume

was 0.998 (95 % CI: 0.990 to 1.0, p < 0.001), compared to

0.967 using manually measured MPA diameter (95 % CI:

0.910 to 1.0, p < 0.001). The authors concluded that

automated MRA-based 3D volumetry of central pulmonary

arteries is feasible and demonstrated significantly increased

volumes and diameters in patients with pulmonary arterial

hypertension compared to healthy controls. They stated that

pulmonary artery volume may serve as a superior predictor for

pulmonary hypertension compared to manual measurements

on axial images; but verification in a larger study population is

needed.

MRA for Evaluation of Individuals with Blunt Vertebral Artery

Karagiorgas and colleagues (2017) noted that the role of MRA

in the evaluation of patients with blunt vertebral artery has not

been fully established. These researchers examined the

diagnostic accuracy of MRA in comparison to DSA for the

detection of blunt vertebral artery injury in trauma patients. A

computer-assisted literature search of the PubMed, Scopus,

Highwire, Web of Science, and LILACS was conducted, in

order to identify studies reporting on the sensitivity and

specificity of MRA in comparison to DSA for the detection of

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blunt vertebral artery injury in trauma patients. The Database

search retrieved 91 studies; 5 studies fulfilled the eligibility

criteria; 2 authors assessed the risk of bias and applicability

concerns using QUADAS-2. Two-by-two contingency tables

were constructed on a per-vessel level. Heterogeneity was

tested by the statistical significance of Cochran's Q, and was

quantified by the Higgins's I2 metric. The pooled estimates of

sensitivity and specificity for blunt vertebral artery injury

detection with MRA in comparison to DSA were calculated

based on the bi-variate model. The meta-analysis was

supplemented by subgroup and sensitivity analysis, as well as

analysis for publication bias. There was significant clinical

heterogeneity in the targeted population, inclusion criteria, and

MRA related parameters. The reporting bias and applicability

concerns were moderate and low, respectively. In the overall

analysis, the sensitivity ranged from 25 % to 85 %, while the

specificity varied from 65 % to 99 %, across studies.

According to the bi-variate model, the pooled sensitivity and

specificity of MRA in the evaluation of patients with blunt

vertebral artery was as high as 55 % (95 % CI: 32.1 % to 76.7

%), and 91 % (95 % CI: 66.3 % to 98.2 %), respectively.

Subgroup analysis in terms of MRA sequence sensitivity of

phase, the contrasted MRA (75 % [95 % CI: 43 % to 92 %])

appeared to be superior to the time-of-flight (TOF) MRA (46 %

[95 % CI: 20 % to 74 %]). The addition of contrast

enhancement did not appear to improve the diagnostic yield of

MRA. The Egger's test did not identify any significant

publication bias (p = 0.2). The authors concluded that MRA

had a moderate diagnostic accuracy in the diagnosis of blunt

vertebral artery injuries. They stated that further studies on

high-field magnetic resonance scanners are recommended.

The current meta-analysis had 2 major drawbacks: (i) the

small number of eligible studies, and (ii) the lack of studies

on newer, high-field MR scanners.

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MRA for Mapping of Perforators Prior to DIEP Flap Breast Reconstruction

Wade and colleagues (2018) stated that prior to DIEP flap

breast reconstruction, mapping the perforators of the lower

abdominal wall US, computed tomography angiography (CTA)

or MRA reduces the risk of flap failure. These investigators

examined the additional potential benefit of a reduction in

operating time. They systematically searched the literature for

studies concerning adult women undergoing D IEP flap breast

reconstruction, which directly compared the operating times

and adverse outcomes for those with and without pre-

operative perforator mapping by US, CTA or MRA. Outcomes

were extracted, data meta-analyzed and the quality of the

evidence appraised. A total of 14 articles were included. Pre-

operative perforator mapping by CTA or MRA significantly

reduced operating time (mean reduction of 54 mins [95 % CI:

3 to 105], p = 0.04), when directly compared to DIEP flap

breast reconstruction with no perforator mapping. Further,

perforator mapping by CTA was superior to US, as CTA saved

more time in theater (mean reduction of 58 mins [95 % CI: 25

to 91], p < 0.001) and was associated with a lower risk of

partial flap failure ( relative risk [RR] 0.15 [95 % CI: 0.04 to 0.6],

p = 0.007). All studies were at risk of methodological bias and

the quality of the evidence was very low. The authors

concluded that the quality of research regarding perforator

mapping prior to DIEP flap breast reconstruction was poor and

although pre-operative angiography appeared to save

operative time, reduce morbidity and confer cost savings,

higher quality research is needed.

MRA for Detection of Jugular Venous Reflux and Non-Pulsatile Subjective Tinnitus

Yildirim and colleagues (2019) examined if there is an

association between jugular venous reflux and non-pulsatile

subjective tinnitus (NPST) using real-time four-dimensional

(4D) MRA. Patients with unilateral NPST who underwent

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contrast-enhanced MRI with a special protocol were included

in the study. Thick slab dynamic maximum intensity projection

images were obtained including interleaved stochastic

trajectories (TWIST)-MRI examination. All patients were

requested to perform Valsalva maneuver during the

sequence . Jugular venous reflux grading was performed as

follows: absence of reflux or if reflux did not reach the base of

the skull: Grade 0; if reflux reached the jugular bulb, but no

intra-cranial contrast was observed: Grade 1; and if reflux

extended into the intra-cranial cortical veins and/or the

cavernous sinus above the jugular bulb: Grade 2. This trial

included a total of 30 patients, 23 male and 7 female; mean

age of 49 years (range of 17 to 74 years). Jugular venous

reflux was not identified (Grade 0) in 20 patients; Grade 1

reflux was determined in 7 cases and Grade 2 reflux was

observed in 3 cases. Notably, only patients with Grade 2

reflux described worsening of their tinnitus symptoms during

the examination and their daily activities as well. The authors

concluded that NST might also be associated with

hemodynamic problems of the venous system and the MRI

protocol starting with TWIST accompanied with Valsalva

maneuver is not well-known, yet appeared to be a feasible and

beneficial method to detect potential jugular venous reflux in

NPST patients.

The authors stated that this study had several drawbacks.

First, and most important according this trial consisted of

relatively small numbers of patients (n = 30). Thus, these

researchers considered this trial as a preliminary study.

Selection of patients who had only unilateral and reflux

disease caused this limitation. These investigators noted that

that they would work in a wider group as the series expands.

Second, MRI artifacts occurred secondary to movements of

the patients during Valsalva maneuver; however, the authors

substantially surpassed these artifacts with the high temporal

resolution of the MRI sequence that they used. These

preliminary findings need to be validated by well-designed

studies.

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MRA for Diagnosis of Intra-Cranial Artery Stenosis

Jaiswal and colleagues (2019) stated that one of the most

common causes of acute cerebral infarction (ACI) is intra-

cranial artery stenosis (ICAS). These researchers examined

the accuracy of trans-cranial Doppler (TCD) compared with

MRA for diagnosing I CAS in patients with ACI. Consecutive

patients presenting with ACI to the neurology department

underwent both MRA and TCD examination within 6 hours of

difference. To calculate the agreement between the results of

MRA and TCD, kappa coefficient test was used. Sensitivity,

specificity, PPV and NPV for TCD were calculated in

comparison with MRA. A total of 115 patients were included in

this trial. There were 77 men (66.95 %) and 38 women (33.04

%). The mean age of patients was 68.32 ± 10.66 years (range

of 29 to 80). The agreement between TCD and MRA in

detecting stenosis was 0.56 for anterior circulation artery

(ACA), and 0.40 for posterior circulation artery (PCA). For the

detection of ICAS, sensitivity, specificity, PPV, and NPV were

85.9, 90.0, 98.2, and 50.0 % for ACA and 73.5, 86.7, 96.2, and

40.0 % for PCA, respectively. The authors concluded that

moderate agreement of ACA stenosis and fair agreement for

PCA stenosis was found between TCD and MRA in the

evaluation of ICAS. In anterior circulation, the diagnostic

accuracy of TCD was higher compared with the posterior

circulation.

The authors stated that this study has several drawbacks.

First, this was a single-center study. Second, the sample size

was very small (n = 115). Third, some patients were excluded

because they did not have an acoustic bone window and

others had contraindications for MRA. Fourth, TCD is an

operator-dependent technique that requires considerable

experience in intra-cranial arterial anatomy and understanding.

MRA for Evaluation of Thoracic Outlet Syndrome

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Zhang and colleagues (2019) introduced a novel method

combining contrast-enhanced MRA (CE-MRA), short inversion

time inversion recovery sampling perfection with application-

optimized contrasts using different flip angle evolutions (T2-

STIR-SPACE) and volumetric interpolated breath-hold

examination (VIBE) sequences in the assessment of thoracic

outlet syndrome (TOS). CE-MRA, T2-STIR-SPACE, and VIBE

techniques were employed to evaluate neurovascular bundles

in 27 patients clinically suspected of TOS. Images were

evaluated to determine the cause of neurovascular bundle

compression. Surgical exploration was performed in patients

with abnormal MRI results. A total of 20 patients were found to

be abnormal: 6 cases showed only neurogenic TOS and the

correlates included infra-clavicular hemangiomas (n = 1) and

transverse cervical artery (n = 5). Arterial-neurogenic TOS

was found in 4 cases, including subclavian lymph node

metastasis from breast cancer (n = 3) and schwannoma (n =

1). Arterial-venous-neurogenic TOS was found in 1 subject,

and the correlates included a fibrous band from the cervical rib

and elongated C7 transverse process. In this case, the

subclavian artery/vein was compressed dynamically. Venous-

neurogenic TOS was noted in 1 subject; 9 patients were

considered as post-traumatic TOS, including brachial plexus

edema (n = 3), the brachial plexus rupture (n = 2), peri-

brachial plexus effusion (n = 3), and stenosis of the SCA (n =

1). In the remaining 7 patients, MRI did not detect

abnormalities. The authors concluded that TOS could be

evaluated by CE-MRA, T2-STIR-SPACE, and VIBE during a

single examination, with a reduced contrast material dose.

This imaging modality performed well in showing the

anatomical structure of the neurovascular bundle and the

cause of the compression.


First, bone abnormalities could be difficult to identify at MR

imaging but are best identified on plain radiograph. Second,

gadolinium is a contrast agent that is toxic to people with

kidney and liver disease; MRA cannot be performed in patients

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with low glomerular filtration rate. Third, these researchers did

not examine the differences in findings of MRI at neutral and

provocative locations. Lastly, these subjects had various

causes of brachial plexus diseases. The authors stated that

further prospective studies are recommended in future work to

focus on certain types of brachial plexus neuropathy.

Magnetic Resonance Venography (MRV) for Diagnosis of Pelvic Congestion Syndrome

Champaneria and colleagues (2016) stated that pelvic

congestion syndrome (PCS) is described as chronic pelvic

pain (CPP) arising from dilated and refluxing pelvic veins,

although the causal relationship between pelvic vein

incompetence (PVI) and CPP is not established. Non-invasive

screening methods such as Doppler US and MRV are used

before confirmation by venography. Percutaneous

embolization has become the principal treatment for PCS, with

high success rates often cited. These researchers

systematically reviewed the definitions and diagnostic criteria

of PCS, the association between PVI and CPP, the accuracy

of various non-invasive imaging techniques and the

effectiveness of embolization for PVI; and identified factors

associated with successful outcome. They also surveyed

clinicians and patients to assess awareness and management

of PCS and gauge the enthusiasm for further research. A

comprehensive search strategy encompassing various terms

for pelvic congestion, pain, imaging techniques and

embolization was deployed in 17 bibliographic databases,

including Medline, Embase and Web of Science. There was

no restriction on study design. Methodological quality was

assessed using appropriate tools. Online surveys were sent to

clinicians and patients. The quality and heterogeneity

generally precluded meta-analysis and so results were

tabulated and described narratively. These investigators

identified 6 association studies, 10 studies involving US, 2

studies involving MRV, 21 case series and 1 poor-quality

randomized trial of embolization. There were no consistent

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diagnostic criteria for PCS. These researchers found that the

associations between CPP and PVI were generally fairly

similar, with 3 of 5 studies with sufficient data showing

statistically significantassociations (OR of between 31 and

117). The prevalence of PVI ranged widely, although the

majority of women with PVI had CPP. Trans-vaginal Doppler

US and MRV are both useful screening methods, although the

data on accuracy were limited. Early substantial relief from

pain symptoms was observed in approximately 75 % of

women undergoing embolization, a figure which generally

increased over time and was sustained. Re-intervention rates

were generally low. Transient pain was a common occurrence

following foam embolization,while there was a less than 2 %

risk of coil migration. Confidence in the embolization

technique was reasonably high, although there was a desire to

strengthen the evidence base. Even among women with CPP,

fewer than 50 % had any knowledge about PCS. The authors

concluded that the data supporting the diagnosis and

treatment of PCS were limited and of variable methodological

quality. There is some evidence to tentatively support a

causative association, but it cannot be categorically stated that

PVI is the cause of CPP in women with no other pathology, as

the 6 most pertinent studies drew on clinically disparate

populations and defined PVI inconsistently. Embolization

appeared to provide symptomatic relief in the majority of

women and is safe. However, the majority of included studies

of embolization were relatively small case series and only the

randomized controlled trial (RCT) was considered at risk of

potential biases. The authors concluded that there is scope

and demand for considerable further research. They stated

that the question of the association of PVI and CPP requires a

well-designed and well-powered case-control study, which will

also provide data to derive a diagnostic standard. An

adequately powered randomized trial is essential to provide

evidence on the effectiveness of embolization, but this faces

methodological challenges.

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Steenbeek and colleagues (2018) stated that in the work-up of

patients with suspected pelvic congestion syndrome (PCS),

venography is currently the gold standard. Yet if non-invasive

diagnostic tools are found to be accurate, invasive venography

might no longer be indicated as necessary. These

investigators carried out a literature search in PubMed and

Embase from inception until May 6, 2017. Studies comparing

non-invasive diagnostic tools to a reference standard in the

work-up of patients with (suspected) PCS were included.

Relevant data were extracted and methodological quality of

individual included studies was assessed by the Quality

Assessment of Diagnostic Accuracy Studies (QUADAS-2)

tool. A total of 9 studies matched the inclusion criteria; 6

studies compared US to venography and 3 studies described

a MRI technique. In using transvaginal US (TVUS), the

occurrence of a vein greater than 5 mm crossing the uterine

body had a specificity of 91 % (95 % CI: 77 to 98 %) and

occurrence of pelvic varicoceles a sensitivity and specificity of

100 % (95 % CI: 89 to 100 %) and 83 % (95 % CI: 66 to 93 %),

respectively. In transabdominal US, reversed caudal flow in

the ovarian vein accounted for a sensitivity of 100 % (95 % CI:

84 to 100 %). Detection of PCS with MRI techniques resulted

in a sensitivity varying from 88 to 100 %. The authors

concluded that the sensitivity of US and MRI appeared to be

adequate, which indicated a role for both tests in an early

stage of the diagnostic work-up. However, these researchers

stated that due to methodological flaws and diversity in

outcome parameters, more high standard research is needed

to establish a clear advice for clinical practice. These

investigators discussed the study by Asciutto et al (2008),

which examined the application of MRV in the assessment of

women with PCS. They stated that MRV seemed to be highly

sensitive for insufficiency in pelvic plexus, ovarian or

hypogastric veins; especially hypogastric vein insufficiency

accounted for a high sensitivity (100 %), but the specificity was

low, which resulted in a high prevalence of false‐positive

results.

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MRV for the Diagnostic Evaluation of Cryptogenic Stroke

Liberman et al (2014) stated that paradoxical embolization is

frequently posited as a mechanism of ischemic stroke in

patients with patent foramen ovale (PFO). Several studies

have suggested that the deep lower extremity (LE) and pelvic

veins might be an embolic source in cryptogenic stroke (CS)

patients with PFO. In this single-center, retrospective,

observational study, consecutive adult patients with ischemic

stroke or transient ischemic attack (TIA) and a PFO who

underwent pelvic MRV as part of an inpatient diagnostic

evaluation were included in this study to determine pelvic and

LE DVT prevalence in CS versus non-CS stroke subtypes.

Among the 131 patients who met inclusion criteria, 126 (96.2

%) also had LE duplex US data. DVT prevalence overall was

7.6 % (95 % CI: 4.1 to 13.6), pelvic DVT 1.5 % (9 5 % CI: 0.1 to

5.8) , and LE DVT 7.1 % (95 % CI: 3.6 to 13.2). One patient

with a pelvic DVT also had a LE DVT. Comparing patients

with CS (n = 98) with non-CS subtypes (n = 33), there was no

significant difference i n the prevalence of pelvic DVT (2.1 %

versus 0 %, p = 1), LE DVT (6.2 % versus 10.3 %, p = 0.43),

or any DVT (7.2 % versus 9.1 %, p = 0.71). The authors

concluded that among patients with ischemic stroke/TIA and

PFO, the majority of detected DVTs were in LE veins rather

than the pelvic veins and did not differ by stroke subtype.

They stated that the routine inclusion of pelvic MRV in the

diagnostic evaluation of CS warrants further prospective

investigation.

Osgood et al (2015) noted that substantial proportion of

ischemic strokes has no identified underlying cause. Notably,

the prevalence of a PFO is increased in CS populations, which

may serve as a conduit for paradoxical emboli originating from

DVT including the pelvic veins. Yet, there are no published

guidelines for the assessment of pelvic veins as part of the

stroke work-up and few studies have systematically

investigated pelvic veins as a potential source for paradoxical

emboli in CS patients. Further, there is a relative paucity of

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data regarding pelvic DVT in CS and results have been

conflicting. These investigators determined the prevalence of

pelvic DVT in select CS patients with PFO who underwent

MRV. They retrospectively identified patients (n = 50) who

underwent contrast-enhanced pelvic MRV at the discretion of

the treating physician for the evaluation of CS in the presence

of a PFO during hospitalization at a single academic stroke

center between January 2011 through December 2013.

Multivariable logistic regression analyses were used to assess

for factors independently associated with the presence of an

abnormal MRV pelvis. Patients (47 ± 13 years of age) had

MRV performed 4 ± 3 days after their incident stroke; 9

patients had an abnormal MRV (18 %). Of these, 4 (8 %) had

pelvic vein thrombosis and 5 (10 %) a May-Thurner anatomic

variant. All patients with pelvic DVT were subsequently anti-

coagulated with warfarin (none had abnormal

hypercoagulability testing). Clinical clues suggesting

paradoxical embolism were present in as many as 40 % of

patients. On multivariable logistic regression, a history of any

risk factors predisposing to DVT (odds ratios [OR] 6.7;

coefficient1.9;BCa 95 % CI: 0.08 to 20.2; p = 0.014) as well

as the number of predisposing risk factors (OR 3.9; coefficient

1.4; BCa 95 % CI: 0.25-4.2; p = 0.005) predicted the presence

of pelvic vein pathology on MRV. The authors demonstrated a

relatively high prevalence of pelvic DVT among select CS

patients emphasizing the importance of considering the pelvic

veins as a potential source for emboli particularly in the

presence of risk factors known to predispose DVT. Because

patients were included at the treating physician's discretion,

these findings reflected “real-life” practice. They stated that

the results may be of clinical importance as inclusion of pelvic

vein imaging in CS patients with PFO had impactful

therapeutic and nosologic implications. These researchers

noted that further study is needed to define patients most likely

to benefit from pelvic vein imaging.

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MRV for Screening Venous Thromboembolism Following Mu sculoskeletal Trauma

On behalf of the Orthopaedic Trauma Association Evidence

Based Quality Value and Safety Committee, Sagi and

colleagues (2015) (i) provided a summation of the current

practice patterns of North American orthopedic surgeons for

venous thrombo-embolism (VTE) prophylaxis after

musculoskeletal trauma, and (ii) established a set of guidelines

and recommendations based on the most current and best

available evidence for VTE prophylaxis after musculoskeletal

trauma. A 24 item questionnaire titled "OTA VTE Prophylaxis

Survey" was sent to active members of the Orthopedic Trauma

Association. PubMed and OVID/MEDLINE were used to

search the current published literature regarding VTE

prophylaxis in trauma patients using the following search

terms: deep venous thrombosis, DVT, pulmonary embolism,

PE, venous thromboembolism, VTE, prophylaxis, trauma,

fracture, pneumatic compression device, PCD, sequential

compression device, SCD, screening, ultrasound, duplex,

ultrasonography, DUS, venography, magnetic resonance

venography, MRV, inferior vena cava, IVC, filter, and IVCF.

Each recommendation was graded using articles that were

considered by the subcommittee as "the best available

evidence" using the grading system adopted and endorsed by

the American Academy of Orthopedic Surgeons' Evidenced

Based Quality and Value committee. Overall, 185 of 1,545

members completed the online survey. The range and variety

of prophylaxis and screening methods used among orthopedic

trauma surgeons in North America is large, with a number of

agents or methods for which no literature exists to support

their use in musculoskeletal trauma. A set of

recommendations and guidelines were constructed based on

the results of the literature analysis and graded according to

guidelines mentioned above. The authors concluded that due

to the wide variability in practice patterns, poor scientific

support for various therapeutic regimens and important medical-

legal implications highlighted by the survey, a

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standardized set of guidelines and recommendations for VTE

prophylaxis after musculoskeletal trauma will be critical in

helping to improve patient care and minimize surgeons'

exposure to potentially litigious activity.

Quantitative MRV for Measurement of Venous Flow after Cerebral Venous Sinus Stenting

Esfahani et al (2015) stated that endovascular stenting is an

effective treatment for patients with clinically significant

cerebral venous sinus stenosis. Traditionally, stenting is

indicated in elevated intravenous pressures on conventional

venography; however, non-invasive monitoring is more

desirable. Quantitative MRV (qMRV) is an imaging modality

that measures blood flow non-invasively. Established in the

arterial system, applications to the venous sinuses have been

limited. These researchers examined qMRV in the

measurement of venous sinus flow in patients undergoing

endovascular stenting and identified a relationship with

intravenous pressures. A total of 5 patients with intra-cranial

hypertension secondary to venous sinus stenosis underwent

cerebral venous stenting between 2009 and 2013 at a single

institution. Pre-operatively, venous sinus flow was determined

by using qMRV, and intravenous pressure was measured

during venography. After stenting, intravenous pressure,

qMRV flow, and clinical outcomes were assessed and

compared. A mean pre-stenotic intravenous pressure of 45.2

mm Hg was recorded before stenting, which decreased to 27.4

mm Hg afterward (Wilcoxon signed rank testp = 0.04). Total

jugular outflow on qMRV increased by 260.2 ml/min. Analysis

of the change in intravenous pressure and qMRV flow

identified a linear relationship (Pearson correlation r = 0.926).

All patients displayed visual improvement at 6 weeks.The

authors concluded that venous outflow by qMRV increased

after endovascular stenting and correlated with significantly

improved intravenous pressures. They stated that these

findings introduced qMRV as a potential adjunct to measure

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venous flow after stenting, and as a plausible tool in the

selection and post-operative surveillance of the patient who

has cerebral venous sinus stenosis.

Non-Contrast-Enhanced MRV Using Magnetization - Prepared Rapid Gradient-Echo in the Pre-Operative Evaluation of Living Liver Donor Candidates

Yamashita and co-workers (2017) compared t he diagnostic

performance of non-contrast-enhanced magnetic resonance

venography using magnetization-prepared r apid gradient-echo

(MPRAGE-MRV) and conventional CT venography (CTV) in

pre-operative evaluation of venous tributaries for living donor

liver transplantation. Institutional review board approval and

written informed c onsent were obtained f or this prospective

study of 73 donor candidates. Of these, 23 underwent right-

sided graft hepatectomy without middle hepatic vein. One or

more tributaries, other than the right hepatic vein, were

reconstructed for 20 of the 23 grafts. For these 20 grafts, the

number and location of the tributaries requiring reconstruction

were evaluated based on venography, and diagnostic

performance was analyzed using surgical records as a

reference standard. For each candidate, the number of small

tributaries directly joining the inferior vena cava was counted in

each venographic image; a paired-sample t-test was used to

assess differences. The severity of respiratory artifacts in

MPRAGE-MRV was qualitatively evaluated, and compared

using Wilcoxon's rank-sum test. All reconstructed venous

tributaries were prospectively identified using both methods.

MPRAGE-MRV tended to provide a greater number of small

tributaries than conventional CTV (mean of 2; 95 % CI: [1.66 to

2.34], and 1.74; [1.44 to 2.04], respectively), although the

difference was not significant (p = 0.10); MPRAGE-MRV was

superior or equal to CTV in 52 subjects (71.2 %), and inferior

in 21 subjects (28.8 %). Respiratory artifacts were significantly

less severe in the former subjects (p < 0.0001). The authors

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concluded that MPRAGE-MRV has the potential to replace

conventional CTV in the pre-operative evaluation of living liver

donor candidates.

MRV for Prediction of Outcome in Tuberculous Meningitis

Bansod and colleagues (2018) evaluated the prevalence and

predictors of venographic abnormalities in tuberculous

meningitis. Consecutive patients of tuberculous meningitis

were included in the study. Clinical evaluation, cerebro-spinal

fluid (CSF) examination and contrast-enhanced MRI of brain

were carried out. Every participant was subjected to time of

flight MRV. Presence of filling defects at superior sagittal

sinus, dominant transverse or sigmoid sinus, and non-

visualization of deep venous system was considered

suggestive of thrombosis. The presence of filling defects at non-

dominant transverse or sigmoid sinus was considered

suggestive of thrombosis only in the presence of

corresponding changes in T1, T2, and GRE sequences,

parenchymal changes or presence of collaterals. Patients

were followed-up for 6 months. A modifiedBarthel index of

less than or equal to 12 at 6 months was taken as poor

outcome. Of the 107 patients, MRV was found to be abnormal

in 12 patients (11.2 %). The superior sagittal sinus was the

most commonly involved sinus. On uni-variate analysis, the

presence of vomiting (p = 0.004), altered sensorium

(p = 0.004), seizures (p < 0.001), vision impairment (p = 0.038),

papilledema (p < 0.001), diplopia, oculomotor palsies,basal

exudates (p = 0.004) and modified Barthel index (MBI) of less

than or equal to 12 at baseline (p = 0.004) were significantly

associated with an abnormal MRV. On multi-variate analysis,

none of the above factors was found to be significant. No

association was found between an abnormal MRV and poor

outcome. The authors concluded that MRV abnormalities

suggestive of venous sinus thrombosis could occur in

approximately 11 % patients; superior sagittal sinus is the

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most commonly involved sinus. Moreover, they stated that an

abnormal MRV may not predict a poor outcome in patients

with tuberculous meningitis.

MRV for Diagnosis of Central Venous Occlusion

Shahrouki and colleagues (2019) noted that although

cardiovascular MRV (CMRV) is generally regarded as the

technique of choice for imaging the central veins, conventional

CMRV is not ideal. Gadolinium-based contrast agents (GBCA)

are less suited to steady-state venous imaging than to first-

pass arterial imaging and they may be contraindicated in

patients with renal impairment where evaluation of venous

anatomy is frequently required. These researchers examined

the diagnostic performance of 3-dimensional (3D) ferumoxytol-

enhanced CMRV (FE-CMRV) for suspected central venous

occlusion (CVO) in patients with renal failure and to evaluate

its clinical impact on patient management. In this institutional

review board (IRB)-approved and HIPAA-compliant study, a

total of 52 consecutive adult patients (47 years, inter-quartile

range [IQR] 32 to 61; 29 men) with renal impairment and

suspected venous occlusion underwent FE-CMRV, following

infusion of ferumoxytol. Breath-held, high resolution, 3D steady-

state FE-CMRV was performed through the chest, abdomen and

pelvis. Two blinded reviewers independently scored 21 named

venous segments for quality and patency.

Correlative catheter venography in 14 patients was used as

the reference standard f or diagnostic accuracy. Retrospective

chart review was conducted to determine clinical impact of FE-

CMRV. Inter-observer agreement was determined using

Gwet's AC1 statistic. All patients underwent technically

successful FE-CMRV without any AEs; 99.5 % (1,033/1,038)

of venous segments were of diagnostic quality (score greater

than or equal to 2/4) with very good inter-observer agreement

(AC1 = 0.91). Inter-observer agreement for venous occlusion

was also very good (AC1 = 0.93). The overall accuracy of FE-

CMRV compared to catheter venography was perfect (100.0

%). No additional imaging w as needed before a clinical

Proprietary


management decision in any of the 52 patients; 24 successful

and uncomplicated venous interventions were performed

following pre-procedural vascular mapping with FE-CMRV.

The authors concluded that 3D FE-CMRV was a practical,

accurate and robust technique for high-resolution mapping of

central thoracic, abdominal and pelvic veins, and could be

used to inform image-guided therapy. It may play a pivotal

role in the care of patients in whom conventional contrast

agents may be contraindicated or ineffective.


First, the number of vessels used for the diagnostic accuracy

assessment was relatively low. The limiting f actor was the

number of catheter images because these were available only

for vessels that were injected and relevant to the clinical

procedure. Nonetheless, the analysis spanned t he majority of

venous segments and thus decreased the risk of a potential

selection bias. The long interval between the FE-CMRV and

some catheter studies (up to 98 days) could cause a length

time bias. Despite this, the agreement between both

modalities was very high. FE-CMRV of the central veins has

already shown promising r esults in small pediatric cohorts and

in patients with pelvic vein thrombosis, but this study

addressed a large adult cohort and established diagnostic

accuracy and value added to patient care and management.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

Ma gnetic Resonance Angiography (MRA) & Venography ( MRV):

Hea d and neck:

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CPT codes covered if selection criteria are met:

70544 Magnetic resonance angiography, head;

without contrast material(s)

70545 with contrast material(s)

70546 without contrast material(s), followed by

contrast material(s) and further sequences

70547 Magnetic resonance angiography, neck; without

contrast material(s)

70548 with contrast material(s)

70549 without contrast material(s), followed by

contrast material(s) and further sequences

ICD-10 codes covered if selection criteria are met for MRA:

A52.05 Other cerebrovascular syphilis [intracranial

aneurysm]

D43.0 -

D43.9

Neoplasm of uncertain behavior of brain and

central nervous system

G08 Intracranial and intraspinal phlebitis and

thrombophelbitis [intracranial aneurysm]

G44.1 Vascular headache, not elsewhere classified

[sudden explosive headache, unilateral

headache]

G45.0 -

G45.9

Transient cerebral ischemic attacks and related

syndromes

H34.00 -

H34.03

Transient retinal artery occlusion

H49.00 -

H49.03

Third [oculomotor] nerve palsy

H53.2 Diplopia

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H54.3 Unqualified v isual loss, both eyes

H81.10 -

H81.13

Benign paroxysmal vertigo

H81.41 -

H81.49

Vertigo of central origin

H93.11 -

H93.19

Tinnitus

H93.A1 -

H93.A9

Pulsatile tinnitus

I60.00 -

I 60.9

Nontraumatic subarachnoid hem orrhage

I67.0 -

I 67.9

Other cerebrovascular diseases

I71.02 -

I71.03

Dissection of abdominal or thoracoabdominal

aorta

I71.3 -

I 71.4

Abdominal aortic aneurysm, ruptured or without

rupture

I71.5 -

I 71.6

Thoracoabdominal aneurysm, ruptured or

without mention of rupture

I77.71 Dissection of carotid artery

I77.74 Dissection of vertebral artery

M43.6 Torticollis

Q28.2 Arteriovenous malformation of cerebral vessels

[not covered for magnetic resonance

angiography for diagnosis]

R13.10 -

R13.19

Dysphagia

R42 Dizziness and giddiness

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R43.0 -

R 43.9

Disturbances of smell and taste

R47.02 -

R 47.9

Speech disturbances, not elsewhere classified

R 51 Headache [sudden explosive headache,

unilateral headache]

R 55 Syncope and collapse

R 83.9 Unspecified abnormal findings in cerebrospinal

fluid [blood in CSF]

S15.001+

-

S15.099+

Injury of carotid artery of neck

Z82.3 Family history of stroke

ICD-10 codes not covered for indications listed in the CPB fo r MRA:

C71.0 -

C 71.9

Malignantneoplasm of brain

C 76.0 Malignant neoplasm of head, face and neck

C 79.31 Secondary malignant neoplasm of brain

D33.0 -

D33.2

Benign neoplasm of brain

G50.0 Trigeminal neuralgia [not covered for the

evaluation of microvascular compression]

T86.49 Other complications of liver transplant [varices

at hepatico-jejunostomy]

ICD-10 codes covered if selection criteria are met for MRV:

C71.0 -

C 71.9

Malignantneoplasm of brain

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C 76.0 Malignant neoplasm of head and neck

D33.0 -

D33.2

Benign neoplasm of brain

D43.0 -

D43.9

Neoplasm of uncertain behavior of brain and

central nervous system

G00.0 -

G03.9

Meningitis

G44.1 Vascular headache, not elsewhere classified

H47.10 -

H47.13

Papilledema

H65.00 -

H67.9

Otitis media

I 63.6 Cerebral infarction due to cerebral venous

thrombosis, nonpyogenic [identified by CT or

MRI of the head]

J01.00 -

J01.91

Acute sinusitis

J32.0 -

J 32.9

Chronic sinusitis

R29.810 -

R29.91

Other symptoms involving nervous and

musculoskeletal systems [focal or sensory

deficits]

R 51 Headache

R56.00 -

R 56.9

Convulsions, not elsewhere classified [seizures]

Z79.3 Long-term (current) use of hormonal

contraceptives

ICD-10 codes not covered for indications listed in the CPB fo r MRV:

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G45.0 -

G45.9

Transient cerebral ischemic attacks and rela ted

syndromes [diagnosis of chronic cerebro-spina l

venous insufficiency]

I67.0 -

I 67.9

Other cerebrovascular diseases [diagnosis of

chronic cerebro-spinal venous insufficiency]

Chest:


71555 Magnetic resonance angiography, chest

(excluding myocardium), with or without

contrast material(s)

Other CPT codes related to the CPB:

75557-

75564

Cardiac magnetic resonance imaging for

velocity flow mapping

HCP CS codes covered if selection criteria are met:

C 8909 Magnetic resonance angiography with contrast,

chest (excluding myocardium)

C 8910 Magnetic resonance angiography without

contrast, chest (excluding myocardium)


contrast followed by with contrast, chest

(excluding myocardium)


I26.01 -

I26.99

Pulmonary embolism

I48.0

I48.2,

I48.91

Atrial fibrillation

I71.01 Dissection of thoracic aorta

I 71.1 Thoracic aortic aneurysm, ruptured

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I 71.2 Thoracic aortic aneurysm, without rupture

Q20.0 -

Q28.9

Congenital malformations of the circulatory

system


I 49.3 Ventricular premature depolarization


I82.B11 -

I82.B29

Embolism and thrombosis of subclavian vein

I82.210 -

I82.211

Embolism and thrombosis of superior vena

cava

I82.290 Acute venous embolism and thrombosis of

other thoracic veins

Spine:


72159 Magnetic resonance angiography, spinal canal

and contents, with or without contrast materials

(s)


spinal canal and contents


contrast, spinal canal and contents


contrast followed by with contrast, spinal canal

and contents


I 77.0 Arteriovenous fistula, acquired [spinal cord]

Q27.9 Congenital malformation of peripheral vascular

system, unspecified [ spinal cord]

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Abdomen/Pelvis:


72198 Magnetic resonance angiography, pelvis, with

or without contrast material(s)

74185 Magnetic resonance angiography, abdomen,

with or without contrast material(s)

O ther CPT codes related to the CPB:

37182 Insertion of transvenous intrahepatic

portosystemic shunt(s) (TIPS) (includes venous

access, hepatic and portal vein catheterization,

portography with hemodynamic evaluation,

intrahepatic tract formation/dilatation, stent

placement and all associated imaging guidance

and documentation)


A9583 Injection, Gadofosveset Trisodium, 1 ml

[Ablavar, Vasovist]


abdomen


contrast, abdomen


contrast followed by with contrast, abdomen


D57.00 -

D57.819

Sickle-cell disorders

I10 - I16.2 Hypertensive diseases

I 70.1 Atherosclerosis of renal artery

I71.02 Dissection of abdominal aorta

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I71.03 Dissection of thoracoabdominal aorta

I74.01 -

I74.09

Embolism and thrombosis of abdominal aorta

I77.3 -

I 77.6

Other disorders of arteries and arterioles

[aortoiliac stenosis]

K55.011 -

K 55.9

Vascular disorders of intestine [chronic

mesenteric ischemia]

K 76.6 Portal hypertension

Z91.041 Radiographic dye allergy status [contrast

allergy, renal insufficiency]

ICD-10 codes not covered for indications listed in the CPB for MRA:

D35.00 -

D35.02

Benign neoplasm of adrenal gland

O69.4xx0

-

O69.4xx9

Labor and delivery complicated by vasa previa

Z13.6 Encounter for screening for cardiovascular

disorders

Z52.4 Kidney donor


D68.0 -

D68.9

Other coagulation defects

I 82.0 Budd-Chiari syndrome

I 82.1 Thrombophlebitis migrans

I82.220 -

I82.221

Embolism and thrombosis of inferior vena cava

I 82.3 Embolism and thrombosis of renal vein

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K 75.1 Phelbitis of portal vein

R 10.2 Pelvic and perineal pain [pelvic pain when

pelvic congestion syndrome is suspected and

pelvic ultrasound findings are equivocal]


I63.0 -

I 63.9

Cerebral infarction

Ferumoxytol-enhanced MRA and MRV - no specific code:


I 70.1 Atherosclerosis of renal artery

N18.1 -

N18.9

Chronic kidney disease (CKD)

Lower extremity:


73725 Magnetic resonance angiography, lower

extremity, with or without contrast material(s)


A9583 Injection, Gadofosveset Trisodium, 1 ml

[Ablavar, Vasovist]


lower extremity


contrast, lower extremity


contrast, followed by with contrast, lower

extremity


Proprietary



I 74.3 Embolism and thrombosis of arteries of the

lower extremities

I 79.8 Disorders of arteries, arterioles and capillaries

in diseases classified elsewhere


A17.0 Tuberculous meningitis

I80.10 -

I80.299

Phlebitis and thrombophlebitis of other and

unspecified deep vessels of lower extremities

I82.401 -

I82.5z9

Acute and chronic embolism and thrombosis of

deep veins of lower extremities

Upper extremity:

Other CPT codes related to the CPB:

72159 Magnetic resonance angiography, spinal canal

and contents, with or without contrast material

(s)

73225 Magnetic resonance angiography, upper

extremity, with or without contrast material(s)


A17.0 Tuberculous meningitis

I 80.8 Phlebitis and thrombophlebitis of other sites

I82.a11 -

I82.a19

Acute embolism and thrombosis of axillary

veins

I82.601 -

I82.729

Acute and chronic embolism and thrombosis of

superficial and deep veins of upper extremity

Proprietary


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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0094 Magnetic

Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania new 06/01/2020

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