Efficiency of Iterative Metal Artifact Reduction Algorithm (iMAR) Applied to Brain Volume Perfusion CT in the Follow-up of Patients after Coiling or Clipping of Ruptured Brain Aneurysms

Metal artifacts resulting from coiling or clipping of a brain aneurysm degrade image quality and reduce diagnostic usefulness of computed tomography perfusion CTP. Our aim was to assess the diagnostic value of the iterative metal artifact reduction algorithm (iMAR) in CTP studies after coiling or clipping of ruptured intracranial aneurysms. Fifty-eight CTP exams performed in 32 patients were analysed. iMAR was applied to the source images from the CT scanner. Perfusion maps were generated from datasets both with and without iMAR, and both datasets were compared qualitatively and quantitatively. Qualitative analysis included evaluation of intensity of artifacts, image quality, presence of new artifacts, and the reader’s confidence in their diagnosis as well as diagnostic impression. Quantitative analysis included evaluation of tissue attenuation curves, evaluation of region of interest (ROI)-based measurement of perfusion values at levels that do and do not contain metal, compared to previously published reference ranges of perfusion values. Our results showed that application of iMAR reduced artifacts and significantly improved image quality. New artifacts were observed adjacent to metallic implants, but did not limit the evaluation of other regions. After correction for artifact readers’ confidence in their diagnosis increased from 41.3% to 87.9%, and the diagnostic impression changed in 31% of the exams. No difference between tissue attenuation curves was found. For slices without metal, no difference was noted between values measured before and after iMAR, and the total number of ROIs in the reference range of perfusion values was unchanged. At the level of the metal implant, 89.85% of ROIs obtained before using iMAR showed calculation errors. After using iMAR, only 1.7% showed errors. Before iMAR 3.1% of values were in the reference range, whereas after iMAR this increased to 33.1%. In conclusion, our results show that iMAR is an excellent tool for reducing artifacts in CTP. It is therefore recommended for use in clinical practice, particularly when severe artifacts are present, or when hypoperfusion is suspected at the level of the coil or clip. After the application of iMAR, the perfusion values at the level of the metal can be better calculated, but may not lie within the reference range; therefore, quantitative analysis at the level of artifacts is not advisable.