Device safety assessment of bronchoscopic microwave ablation of normal swine peripheral lung using robotic-assisted bronchoscopy.

INTRODUCTION: The aim of this study was to assess the safety of bronchoscopic microwave ablation (MWA) of peripheral lung parenchyma using the NEUWAVE™ FLEX Microwave Ablation System, and robotic-assisted bronchoscopy (RAB) using the MONARCH™ Platform in a swine model. METHODS: Computed tomography (CT)-guided RAB MWA was performed in the peripheral lung parenchyma of 17 Yorkshire swine (40-50 kg) and procedural adverse events (AEs) documented. The acute group (day 0, n = 5) received 4 MWAs at 100 W for 1, 3, 5, and 10 min in 4 different lung lobes. Subacute and chronic groups (days 3 and 30, n = 6 each) received one MWA (100 W, 10 min) per animal. RESULTS: The study was completed without major procedural complications. No postprocedural AEs including death, pneumothorax, bronchopleural fistula, hemothorax, or pleural effusions were observed. No gross or histological findings suggestive of thromboembolism were found in any organ. One 3-Day and one 30-Day swine exhibited coughing that required no medication (minor AEs), and one 30-Day animal required antibiotic medication (major AE) for a suspected lower respiratory tract infection that subsided after two weeks. CT-based volumetric estimates of ablation zones in the acute group increased in an ablation time-dependent (1-10 min) manner, whereas macroscopy-based estimates showed an increasing trend in ablation zone size. CONCLUSION: The NEUWAVE FLEX and MONARCH devices were safely used to perform single or multiple RAB MWAs. The preclinical procedural safety profile of RAB MWA supports clinical research of both devices to investigate efficacy in select patients with oligometastatic disease or primary NSCLC.

Augmented fluoroscopy guided transbronchial pulmonary microwave ablation using a steerable sheath.

Background: Transbronchial microwave ablation (MWA) is a promising novel therapy. Despite advances in bronchoscopy and virtual navigation, real time image guidance of probe delivery is lacking, and distal maneuverability is limited. Cone-beam computed tomography (CBCT) based augmented fluoroscopy guidance using steerable sheaths may help overcome these shortcomings. The aim of this study was to evaluate feasibility and accuracy of augmented fluoroscopy guided transbronchial MWA with a steerable sheath and without a bronchoscope. Methods: In this prospective study, procedures were performed under general anesthesia. Extra-bronchial lung synthetic targets were placed percutaneously. Target and airways extracted from CBCT, with planned bronchial parking point close to the target were overlaid on live fluoroscopy. Endobronchial navigation was solely performed under augmented fluoroscopy guidance. A 6.5 Fr steerable sheath was parked in the bronchus per plan, and a flexible MWA probe was inserted coaxially then advanced through the bronchus wall towards the target. Final in-target position was confirmed by CBCT. Only one ablation of 100 W-5 min was performed per target. Animals were euthanized and pathology analysis of the lungs was performed. Results: Eighteen targets with a median largest diameter of 9 mm (interquartile range, 7-11 mm) were ablated in 9 pigs. Median needle-target center distance was 2 mm (interquartile range, 0-4 mm), and was higher for lower/middle than for upper lobes [0 mm (interquartile range, 0-4 mm) vs. 4 mm (interquartile range, 3-8 mm), P=0.04]. No severe complications or pneumothorax occurred. Two cases of rib fractures in the ablation zone resolved after medical treatment. Median longest axis of the ablation zone on post-ablation computed tomography was 38 mm (interquartile range, 30-40 mm). Histology showed coagulation necrosis of ablated tissue. Conclusions: Transbronchial MWA under augmented fluoroscopy guidance using a steerable sheath is feasible and accurate.

Evaluation of a metal artifact reduction algorithm applied to post-interventional flat detector CT in comparison to pre-treatment CT in patients with acute subarachnoid haemorrhage.

OBJECTIVES: Metal artefacts can impair accurate diagnosis of haemorrhage using flat detector CT (FD-CT), especially after aneurysm coiling. Within this work we evaluate a prototype metal artefact reduction algorithm by comparison of the artefact-reduced and the non-artefact-reduced FD-CT images to pre-treatment FD-CT and multi-slice CT images. METHODS: Twenty-five patients with acute aneurysmal subarachnoid haemorrhage (SAH) were selected retrospectively. FD-CT and multi-slice CT before endovascular treatment as well as FD-CT data sets after treatment were available for all patients. The algorithm was applied to post-treatment FD-CT. The effect of the algorithm was evaluated utilizing the pre-post concordance of a modified Fisher score, a subjective image quality assessment, the range of the Hounsfield units within three ROIs, and the pre-post slice-wise Pearson correlation. RESULTS: The pre-post concordance of the modified Fisher score, the subjective image quality, and the pre-post correlation of the ranges of the Hounsfield units were significantly higher for artefact-reduced than for non-artefact-reduced images. Within the metal-affected slices, the pre-post slice-wise Pearson correlation coefficient was higher for artefact-reduced than for non-artefact-reduced images. CONCLUSION: The overall diagnostic quality of the artefact-reduced images was improved and reached the level of the pre-interventional FD-CT images. The metal-unaffected parts of the image were not modified. KEY POINTS: • After coiling subarachnoid haemorrhage, metal artefacts seriously reduce FD-CT image quality. • This new metal artefact reduction algorithm is feasible for flat-detector CT. • After coiling, MAR is necessary for diagnostic quality of affected slices. • Slice-wise Pearson correlation is introduced to evaluate improvement of MAR in future studies. • Metal-unaffected parts of image are not modified by this MAR algorithm.

Flat-Panel CT for Cochlear Implant Electrode Imaging: Comparison to Multi-Detector CT.

HYPOTHESIS: Flat-panel computed tomography (FPCT) will allow more accurate localization of cochlear implants with decreased metallic artifact and decreased radiation dose when compared with multi-detector CT (MDCT). BACKGROUND: The measurement of scalar location and intra-scalar position of cochlear implantation (CI) electrodes using computed tomography (CT) is complicated by metallic image artifact and insufficient scalar resolution. FPCT has been shown to improve upon the resolution of MDCT while reducing artifact. Previous studies of FPCT imaging employed isolated temporal bones and did not compare FPCT with MDCT. METHODS: A total of 11 CI electrodes (Flex-24, MED-EL Corp, Innsbruck, Austria) were intentionally placed into either the scala tympani (ST) or scala vestibule (SV) in whole cadaver heads and imaged with MDCT and FPCT. The relative radiation dose was measured at the ocular lens for each modality. The implanted cochleae were then isolated and imaged with micro-CT which was used to assess electrode position. Images were reviewed and scored according to electrode array scalar compartment (ST, SV, scala media [SM]), intra-scalar position within each compartment (perimodiolar, mid modiolor, lateral wall) and for the presence of artifact by five readers blinded to the imaging method and approach for electrode insertion. RESULTS: FPCT showed less metallic CI artifact (p = 0.002) and decreased radiation dosage when compared with MDCT. Reviewers were able to identify the scalar compartment and intra-scalar position of all electrodes more accurately with FPCT than with MDCT (p < 0.001). CONCLUSION: FPCT more accurately resolves the scalar compartment and intra-scalar position of CI electrodes with reduced radiation exposure and metallic artifact than MDCT.

Volumetric limiting spatial resolution analysis of four-dimensional digital subtraction angiography.

C-Arm CT three-dimensional (3-D) digital subtraction angiography (DSA) reconstructions cannot provide temporal information to radiologists. Four-dimensional (4-D) DSA provides a time series of 3-D volumes utilizing temporal dynamics in the two-dimensional (2-D) projections using a constraining image reconstruction approach. Volumetric limiting spatial resolution (VLSR) of 4-D DSA is quantified and compared to a 3-D DSA. The effects of varying 4-D DSA parameters of 2-D projection blurring kernel size and threshold of the 3-D DSA (constraining image) of an in silico phantom (ISPH) and physical phantom (PPH) were investigated. The PPH consisted of a 76-micron tungsten wire. An [Formula: see text] scan protocol acquired the projection data. VLSR was determined from MTF curves generated from each 2-D transverse slice of every (248) 4-D temporal frame. 4-D DSA results for PPH and ISPH were compared to the 3-D DSA. 3-D DSA analysis resulted in a VLSR of 2.28 and [Formula: see text] for ISPH and PPH, respectively. Kernel sizes of either [Formula: see text] or [Formula: see text] with a 3-D DSA constraining image threshold of 10% provided 4-D DSA VLSR nearest to the 3-D DSA. 4-D DSA yielded 2.21 and [Formula: see text] with a percent error of 3.1 and 1.2% for ISPH and PPH, respectively, as compared to 3-D DSA. This research indicates 4-D DSA is capable of retaining the resolution of 3-D DSA.

Measurement in the angiography suite: evaluation of vessel sizing techniques.

BACKGROUND: Accurate vessel size measurement is important for neurointervention. Modern angiographic equipment offers various two-dimensional (2D) and 3D measurement methods that have not been systematically evaluated for accuracy and reliability. OBJECTIVE: To evaluate these methods using anthropomorphic vessel phantoms. MATERIALS AND METHODS: Tubing of known sizes (2-5 mm, 1 mm increments) was embedded in 3D-printed skulls to simulate the middle cerebral artery, internal carotid artery, and basilar artery. Each phantom was imaged to gain 3D DSA, 2D DSA, and DynaCT images. Three identical measurement locations were identified on each simulated vessel. Eight measurement methods (four 2D, three 3D, and one DynaCT) were evaluated. Measurements were performed by three independent experienced users on three separate occasions. Intraclass correlation and independent non-parametric analysis were carried out to evaluate the reliability and accuracy of these measurement methods. RESULTS: Better reliability was noted for the automatic measurement methods than for the corresponding manual measurement methods. The mean differences with the ground truth for all methods ranged from -0.12 to 0.03 with small SEs (0.02-0.03) and SDs (0.10-0.18). The smallest absolute mean differences were achieved in two automatic measurement methods based on 2D manual calibration and 3D images. In comparison with these two methods, results of measurements based on 2D autocalibration were statistically different. CONCLUSIONS: In our study, automatic analysis using 3D or 2D was the preferred measurement method. Manual calibration on 2D angiograms is necessary to improve the measurement accuracy. It is not known how our results may pertain to other angiographic systems.

4D DSA a new technique for arteriovenous malformation evaluation: a feasibility study.

BACKGROUND: The angioarchitectural features of an arteriovenous malformation (AVM) provide key information regarding natural history and treatment planning. Because of rapid filling and vascular overlap, two-dimensional (2D) and three-dimensional (3D) digital subtraction angiography (DSA) are often suboptimal for evaluation of these features. We have developed an algorithm that derives a series of fully time-resolved 3D DSA volumes (four-dimensional (4D) DSA) at up to 30 frames/s from a conventional 3D DSA. The temporal/spatial resolution of 4D reconstructions is significantly higher than that provided by current MR angiography and CT angiography techniques. 4D reconstruction allows viewing of an AVM from any angle at any time during its opacification. This feasibility study investigated the potential of 4D DSA to improve the ability to analyze angioarchitectural features compared with conventional 2D and 3D DSA. METHODS: 2D, 3D, and 4D DSA reconstructions of angiographic studies of six AVMs were evaluated by three cerebrovascular neurosurgeons and one interventional neuroradiologist. These observers evaluated the ability of each modality to visualize the angioarchitectural features of the AVMs. They also compared the information provided using the combination of 2D and 3D DSA with that provided by a 4D DSA reconstruction. RESULTS: By consensus, 4D DSA provided the best ability to visualize the internal features of the AVM including intranidal aneurysms, fistulae, venous obstructions, and sequence of filling and draining. 2D and 3D images in comparison were limited because of overlap of the vasculature. CONCLUSIONS: In this small series, 4D DSA provided better ability to visualize the angioarchitecture of an AVM than conventional methods. Further experience is required to determine the ultimate utility of this technique.

C-arm cone beam CT perfusion imaging using the SMART-RECON algorithm to improve temporal sampling density and temporal resolution.

In this work, a newly developed reconstruction algorithm, Synchronized MultiArtifact Reduction with Tomographic RECONstruction (SMART-RECON), was applied to C-arm cone beam CT perfusion (CBCTP) imaging. This algorithm contains a special rank regularizer, designed to reduce limited-view artifacts associated with super-short scan reconstructions. As a result, high temporal sampling and temporal resolution image reconstructions were achieved using an interventional C-arm x-ray system. The algorithm was evaluated in terms of the fidelity of the dynamic contrast update curves and the accuracy of perfusion parameters through numerical simulation studies. Results shows that, not only were the dynamic curves accurately recovered (relative root mean square error ∈ [3%, 5%] compared with [13%, 22%] for FBP), but also the noise in the final perfusion maps was dramatically reduced. Compared with filtered backprojection, SMART-RECON generated CBCTP maps with much improved capability in differentiating lesions with perfusion deficits from the surrounding healthy brain tissues.

Time-Resolved C-Arm Computed Tomographic Angiography Derived From Computed Tomographic Perfusion Acquisition: New Capability for One-Stop-Shop Acute Ischemic Stroke Treatment in the Angiosuite.

BACKGROUND AND PURPOSE: Multimodal imaging using cone beam C-arm computed tomography (CT) may shorten the delay from ictus to revascularization for acute ischemic stroke patients with a large vessel occlusion. Largely because of limited temporal resolution, reconstruction of time-resolved CT angiography (CTA) from these systems has not yielded satisfactory results. We evaluated the image quality and diagnostic value of time-resolved C-arm CTA reconstructed using novel image processing algorithms. METHODS: Studies were done under an Institutional Review Board approved protocol. Postprocessing of data from 21 C-arm CT dynamic perfusion acquisitions from 17 patients with acute ischemic stroke were done to derive time-resolved C-arm CTA images. Two observers independently evaluated image quality and diagnostic content for each case. ICC and receiver-operating characteristic analysis were performed to evaluate interobserver agreement and diagnostic value of this novel imaging modality. RESULTS: Time-resolved C-arm CTA images were successfully generated from 20 data sets (95.2%, 20/21). Two observers agreed well that the image quality for large cerebral arteries was good but was more limited for small cerebral arteries (distal to M1, A1, and P1). receiver-operating characteristic curves demonstrated excellent diagnostic value for detecting large vessel occlusions (area under the curve=0.987-1). CONCLUSIONS: Time-resolved CTAs derived from C-arm CT perfusion acquisitions provide high quality images that allowed accurate diagnosis of large vessel occlusions. Although image quality of smaller arteries in this study was not optimal ongoing modifications of the postprocessing algorithm will likely remove this limitation. Adding time-resolved C-arm CTAs to the capabilities of the angiography suite further enhances its suitability as a one-stop shop for care for patients with acute ischemic stroke.

Flat-detector computed tomography evaluation in an experimental animal aneurysm model after endovascular treatment: A pilot study.

We compared flat-detector computed tomography angiography (FD-CTA) to multislice computed tomography (MS-CTA) and digital subtracted angiography (DSA) for the visualization of experimental aneurysms treated with stents, coils or a combination of both.In 20 rabbits, aneurysms were created using the rabbit elastase aneurysm model. Seven aneurysms were treated with coils, seven with coils and stents, and six with self-expandable stents alone. Imaging was performed by DSA, MS-CTA and FD-CTA immediately after treatment. Multiplanar reconstruction (MPR) was performed and two experienced reviewers compared aneurysm/coil package size, aneurysm occlusion, stent diameters and artifacts for each modality.In aneurysms treated with stents alone, the visualization of the aneurysms was identical in all three imaging modalities. Residual aneurysm perfusion was present in two cases and visible in DSA and FD-CTA but not in MS-CTA. The diameter of coil-packages was overestimated in MS-CT by 56% and only by 16% in FD-CTA compared to DSA (p < 0.05). The diameter of stents was identical for DSA and FD-CTA and was significantly overestimated in MS-CTA (p < 0.05). Beam/metal hardening artifacts impaired image quality more severely in MS-CTA compared to FD-CTA.MS-CTA is impaired by blooming and beam/metal hardening artifacts in the visualization of implanted devices. There was no significant difference between measurements made with noninvasive FD-CTA compared to gold standard of DSA after stenting and after coiling/stent-assisted coiling of aneurysms. FD-CTA may be considered as a non-invasive alternative to the gold standard 2D DSA in selected patients that require follow up imaging after stenting.

Patient-specific scatter correction for flat-panel detector-based cone-beam CT imaging.

A patient-specific scatter correction algorithm is proposed to mitigate scatter artefacts in cone-beam CT (CBCT). The approach belongs to the category of convolution-based methods in which a scatter potential function is convolved with a convolution kernel to estimate the scatter profile. A key step in this method is to determine the free parameters introduced in both scatter potential and convolution kernel using a so-called calibration process, which is to seek for the optimal parameters such that the models for both scatter potential and convolution kernel is able to optimally fit the previously known coarse estimates of scatter profiles of the image object. Both direct measurements and Monte Carlo (MC) simulations have been proposed by other investigators to achieve the aforementioned rough estimates. In the present paper, a novel method has been proposed and validated to generate the needed coarse scatter profile for parameter calibration in the convolution method. The method is based upon an image segmentation of the scatter contaminated CBCT image volume, followed by a reprojection of the segmented image volume using a given x-ray spectrum. The reprojected data is subtracted from the scatter contaminated projection data to generate a coarse estimate of the needed scatter profile used in parameter calibration. The method was qualitatively and quantitatively evaluated using numerical simulations and experimental CBCT data acquired on a clinical CBCT imaging system. Results show that the proposed algorithm can significantly reduce scatter artefacts and recover the correct CT number. Numerical simulation results show the method is patient specific, can accurately estimate the scatter, and is robust with respect to segmentation procedure. For experimental and in vivo human data, the results show the CT number can be successfully recovered and anatomical structure visibility can be significantly improved.

An indirect transmission measurement-based spectrum estimation method for computed tomography.

The characteristics of an x-ray spectrum can greatly influence imaging and related tasks. In practice, due to the pile-up effect of the detector, it's difficult to directly measure the spectrum of a CT scanner using an energy resolved detector. An alternative solution is to estimate the spectrum using transmission measurements with a step phantom or another CT phantom. In this work, we present a new spectrum estimation method based on indirect transmission measurement and a model spectra mixture approach. The estimated x-ray spectrum was expressed as a weighted summation of a set of model spectra, which can significantly reduce the degrees of freedom of the spectrum estimation problem. Next, an estimated projection was calculated with the assumed spectrum. By iteratively updating the unknown weights, we minimized the difference between the estimated projection data and the raw projection data. The final spectrum was calculated with these calibrated weights and the model spectra. Both simulation and experimental data were used to evaluate the proposed method. In the simulation study, the estimated spectra were compared to the raw spectra which were used to generate the raw projection data. For the experimental study, the ground truth measurement of the raw x-ray spectrum was not available. Therefore, the estimated spectrum was compared against the spectra generated using the SpekCalc software with tube configurations provided by the scanner manufacturer. The results show the proposed method has the potential to accurately estimate x-ray spectra using the raw projection data. The difference between the mean energy of the raw spectra and the mean energy of the estimated spectra was less than 0.5 keV for both the simulation and experimental data. Further tests show the method was robust with respect to the model spectra generator.

Effective dose to patient measurements in flat-detector and multislice computed tomography: a comparison of applications in neuroradiology.

PURPOSE: Flat-detector CT (FD-CT) is used for a variety of applications. Additionally, 3D rotational angiography (3D DSA) is used to supplement digital subtraction angiography (DSA) studies. The aim was to measure and compare the dose of (1) standard DSA and 3D DSA and (2) analogous FD-CT and multislice CT (MSCT) protocols. METHODS: Using an anthropomorphic phantom, the effective dose to patients (according to ICRP 103) was measured on an MSCT and a flat-detector angiographic system using standard protocols as recommended by the manufacturer. RESULTS: (1) Evaluation of DSA and 3D DSA angiography protocols: ap.-lat. Standard/low-dose series 1/0.8 mSv, enlarged oblique projection 0.3 mSv, 3D DSA 0.9 mSv (limited coverage length 0.3 mSv). (2) Comparison of FD-CT and MSCT: brain parenchyma imaging 2.9 /1.4 mSv, perfusion imaging 2.3/4.2 mSv, temporal bone 0.2 /0.2 mSv, angiography 2.9/3.3 mSv, limited to the head using collimation 0.5/0.5 mSv. CONCLUSION: The effective dose for an FD-CT application depends on the application used. Using collimation for FD-CT applications, the dose may be reduced considerably. Due to the low dose of 3D DSA, we recommend using this technique to reduce the number of DSA series needed to identify working projections. KEY POINTS: Effective dose of FD-CT in comparison to MSCT is in comparable range. Collimation decreases the dose of FD-CT effectively. Effective dose of 3-D angiography is identical to 2-D DSA. Different FD-CT programs have different dose.

Neuroangiography simulation using a silicone model in the angiography suite improves trainee skills.

PURPOSE: Simulation techniques in neurosurgical training are becoming more important. The purpose of this study was to determine whether silicone vascular models used in the angiography suite can render improvement in trainee performance and safety in neuroendovascular procedures. METHODS: 10 residents from neurosurgery and radiology training programs were asked to perform a diagnostic angiogram on a silicone based vascular model (United Biologics, Tustin, USA). This was done in the angiography suite with the full biplane fluoroscopy machine (Siemens, Munich, Germany). On their first attempt, they were coached by a faculty member trained in endovascular neurosurgery; on their second attempt, they received coaching only if the procedure had stalled. Technique was scored on multiple criteria by the faculty, and total time and fluoroscopy time were recorded on both attempts. RESULTS: In this group of 10 residents, overall procedure time significantly decreased from 51 to 42 min (p=0.01), and total fluoro time significantly decreased from 12 to 9 min (p=0.002) between the first attempt and the second attempt. Technical skill increased significantly in navigation, vessel selection, projection setup, and road map usage. CONCLUSIONS: Silicone vascular models used in the angiography suite, with the clinical working tools and biplane fluoroscopy, provide a valuable experience for training residents in diagnostic angiography, and improved performance and safety.

Dynamic iterative reconstruction for interventional 4-D C-arm CT perfusion imaging.

Tissue perfusion measurement using C-arm angiography systems capable of CT-like imaging (C-arm CT) is a novel technique with potentially high benefit for catheter guided treatment of stroke in the interventional suite. However, perfusion C-arm CT (PCCT) is challenging: the slow C-arm rotation speed only allows measuring samples of contrast time attenuation curves (TACs) every 5-6 s if reconstruction algorithms for static data are used. Furthermore, the peak values of the TACs in brain tissue typically lie in a range of 5-30 HU, thus perfusion imaging is very sensitive to noise. We present a dynamic, iterative reconstruction (DIR) approach to reconstruct TACs described by a weighted sum of basis functions. To reduce noise, a regularization technique based on joint bilateral filtering (JBF) is introduced. We evaluated the algorithm with a digital dynamic brain phantom and with data from six canine stroke models. With our dynamic approach, we achieve an average Pearson correlation (PC) of the PCCT canine blood flow maps to co-registered perfusion CT maps of 0.73. This PC is just as high as the PC achieved in a recent PCCT study, which required repeated injections and acquisitions.

Coating with a modular bone morphogenetic peptide promotes healing of a bone-implant gap in an ovine model.

Despite the potential for growth factor delivery strategies to promote orthopedic implant healing, there is a need for growth factor delivery methods that are controllable and amenable to clinical translation. We have developed a modular bone growth factor, herein termed "modular bone morphogenetic peptide (mBMP)", which was designed to efficiently bind to the surface of orthopedic implants and also stimulate new bone formation. The purpose of this study was to coat a hydroxyapatite-titanium implant with mBMP and evaluate bone healing across a bone-implant gap in the sheep femoral condyle. The mBMP molecules efficiently bound to a hydroxyapatite-titanium implant and 64% of the initially bound mBMP molecules were released in a sustained manner over 28 days. The results demonstrated that the mBMP-coated implant group had significantly more mineralized bone filling in the implant-bone gap than the control group in C-arm computed tomography (DynaCT) scanning (25% more), histological (35% more) and microradiographic images (50% more). Push-out stiffness of the mBMP group was nearly 40% greater than that of control group whereas peak force did not show a significant difference. The results of this study demonstrated that mBMP coated on a hydroxyapatite-titanium implant stimulates new bone formation and may be useful to improve implant fixation in total joint arthroplasty applications.

Aneurysm volume-to-ostium area ratio: a parameter useful for discriminating the rupture status of intracranial aneurysms.

BACKGROUND: Slow or stagnant flow is a hemodynamic feature that has been linked to the risk of aneurysm rupture. OBJECTIVE: To assess the potential value of the ratio of the volume of an aneurysm to the area of its ostium (VOR) as an indicator of intra-aneurysmal slow flow and, thus, in turn, the risk of rupture. METHODS: Using a sample defined from internal databases, a retrospective analysis of aneurysm size, aspect ratio (AR), and VOR was performed on a series of 155 consecutive aneurysms having undergone 3-dimensional digital subtraction angiography as a part of their evaluation. Measurements were obtained from 3-dimensional digital subtraction angiography studies using commercial software. Aneurysm size, AR, and VOR were correlated with rupture status (ruptured or unruptured). A multiple logistic regression model that best correlated with rupture status was generated to evaluate which of these parameters was the most useful to discriminate rupture status. This model was validated using an independent database of 62 consecutive aneurysms acquired outside the retrospective study interval. RESULTS: VOR showed better discrimination for rupture status than did size and AR. The best logistic regression model, which included VOR rather than size or AR, determined rupture status correctly in 80.6% of subjects. The reproducibility calculating AR and VOR was excellent. CONCLUSION: Determination of VOR was easily done and reproducible using widely available commercial equipment. It may be a more robust parameter to discriminate rupture status than AR.