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

Four-dimensional digital subtraction angiography (4D-DSA) has been developed and can be used to evaluate the angioarchitecture of brain arteriovenous malformations (bAVMs). The purpose of this systematic and critical review was to collect and synthesize the available evidence on the clinical benefits of 4D-DSA in evaluating bAVMs angioarchitecture compared with traditional DSA techniques. PubMed, Embase, Cochrane Library, Google Scholar, and International Prospective Register of Ongoing Systematic Reviews (PROSPERO) website. A total of 4264 records were identified through the search process. Following de-duplication and screening based on titles and abstracts, 11 studies underwent full-text review. Ultimately, 7 studies met the eligibility criteria. Information on study designs, technical aspects, and comprehensive evaluation of the angioarchitecture of bAVMs were analyzed. All these studies utilized a commercially available flat panel detector angiography system and post-processing software to generate 4D-DSA, albeit employing different injection protocols. Through a synthesis of qualitative statements and quantitative statistical outcomes, it was found that 4D-DSA demonstrated either equivalent or superior diagnostic performances compared with traditional DSA techniques in assessing the intricate angioarchitecture of bAVMs. Specifically, arterial aneurysms and shunt zones could be better visualized by 4D-DSA because of its adjustable observation angles and time frames. Challenges were noted in analyzing larger and more complex bAVMs, as well as in misinterpretations of venous phases. Most of the included studies were qualitative. According to the analysis by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool, biases could mainly be introduced in the bAVMs selection process and image evaluation. Based on current experience, 4D-DSA has demonstrated notable clinical benefits compared with traditional DSA techniques for analyzing the angioarchitecture of bAVMs. Further investigations should focus on enhancing study design, optimizing image protocols, and increasing 4D-DSA capability, especially for larger bAVMs. 4D-DSA = Four-Dimensional Digital Subtraction Angiography; ARUBA = A Randomized Trial of Unruptured Brain Arteriovenous Malformations; bAVMs = Brain Arteriovenous Malformations; CBCT = Cone Beam Computed Tomography; IQ = Image Quality; MIP = Maximum Intensity Projection; MPR = Multiplanar Reconstruction; PICO = Population, Intervention, Comparison, Outcome; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO = International Prospective Register of Ongoing Systematic Reviews; QUADAS-2 = Quality Assessment of Diagnostic Accuracy Studies-2; VRT = Volume Rendering Technique.