Abstract
Background
To investigate the discrepancy between two-dimensional digital subtraction angiography and three-dimensional rotational angiography for small (<5 mm) cerebral aneurysms and the impact on decision making among neuro-interventional experts as evaluated by online questionnaire.
Materials and methods
Eight small (<5 mm) ruptured aneurysms were visually identified in 16 image sets in either two-dimensional or three-dimensional format for placement in a questionnaire for 11 invited neuro-interventionalists. For each set, two questions were posed: Question 1: “Which of the following is the preferred treatment choice: simple coiling, balloon remodeling or stent assisted coiling?”; Question 2: “Is it achievable to secure the aneurysm with pure simple coiling?” The discrepancies of angio-architecture parameters and treatment choices between two-dimensional-digital subtraction angiography and three-dimensional rotational angiography were evaluated.
Results
In all eight cases, the neck images via three-dimensional rotational angiography were larger than two-dimensional-digital subtraction angiography with a mean difference of 0.95 mm. All eight cases analyzed with three-dimensional rotational angiography, but only one case with two-dimensional-digital subtraction angiography were classified as wide-neck aneurysms with dome-to-neck ratio < 1.5. The treatment choices based on the two-dimensional or three-dimensional information were different in 56 of 88 (63.6%) paired answers. Simple coiling was the preferred choice in 66 (75%) and 26 (29.6%) answers based on two-dimensional and three-dimensional information, respectively. Three types of angio-architecture with a narrow gap between the aneurysm sidewall and parent artery were proposed as an explanation for neck overestimation with three-dimensional rotational angiography.
Conclusions
Aneurysm neck overestimation with three-dimensional rotational angiography predisposed neuro-interventionalists to more complex treatment techniques. Additional two-dimensional information is crucial for endovascular treatment planning for small cerebral aneurysms.
Keywords: Cerebral aneurysm, angiography, endovascular coiling
Introduction
Cerebral aneurysm geometry, such as neck diameter, dome-to-neck (D/N) ratio, and their relationship to the parent vessel, is an important determinant for treatment planning associated with endovascular embolization. 3-Dimensional (3D) rotational angiography (3DRA) is the preferred modality for thorough inspection of the complex angio-architecture of cerebral aneurysms that is able to provide relevant information for treatment planning.1–3 Moreover, 3DRA is also considered the gold standard for aneurysm detection.3,4 As compared with 2-dimensional digital subtraction angiography (2D-DSA) with higher spatial resolution, over-estimation of the aneurysm neck on the 3DRA had been addressed.5–8 These discordant measurements resulted in a larger proportion of “wide-neck” aneurysms classified with 3DRA, secondary to the lower D/N ratio.5,6 The treatment choices for these “pseudo” wide-neck aneurysms may be biased as a result of this misleading information.
With the advent of balloon remodeling technique (BRT) and stent assisted coiling (SAC), endovascular treatments could secure most cerebral aneurysms, even those with unfavorable morphology, such as those with wide neck (>4 mm), low D/N ratio (<1.5), and incorporation with major branches.9–12 The durability of BRT and SAC with decreases in the recurrence of post-coiling aneurysms as compared with a simple coiling (SC) has previously been established.13,14 However, the selection criteria of the optimal endovascular techniques for the aneurysms with different angio-architectures are still lacking, except SAC of a ruptured aneurysm is associated with increased morbidity and mortality (Class III, Level C).3,14,15 Overall, the technique choices of endovascular treatments for cerebral aneurysms are typically based on the detailed angio-architecture of cerebral aneurysms, personal experiences/operator preference, and aneurysm status (ruptured/symptomatic vs. unruptured/asymptomatic).3,9,11,16 However, the impact of discrepancies between 2D and 3D techniques for the planning of endovascular treatment remains to be elucidated.
The current investigation examines the discrepancy between 2D and 3D DSA for small (<5 mm) cerebral aneurysms and the impact on decision making for treating small cerebral aneurysms among neuro-interventional experts in different institutions.
Methods
Patients
This retrospective study was approved by the Institutional Review Board of our institution. The requirement to obtain informed consent was waived due the retrospective study design.
We retrospectively retrieved records from patients with a ruptured cerebral aneurysm who received endovascular treatment between January 2017 and December 2018 using the PACS of our institution. A total of 59 patient records with 63 ruptured cerebral aneurysms were reviewed by two experienced neuro-interventionalists (TCW and YKT with 13 and 14 years of experience, respectively) for detailed angio-architecture using 3DRA and 2D-DSA. Finally, eight small ruptured cerebral aneurysms (three anterior communicating artery (Acom) aneurysms, two paraophthalmic internal carotid artery (ICA) aneurysms, two posterior inferior cerebellar artery (PICA) aneurysms, and one posterior communicating artery (Pcom) aneurysm) were included with maximal diameter of aneurysm <5 mm and satisfactory image quality for both 2D-DSA and 3DRA for a clear demonstration of an aneurysm in the neck and parent artery. Eight dissecting aneurysms, 29 aneurysms with maximal diameter >5 mm, and 18 small aneurysms (<5 mm) without satisfactory 2D-DSA information for decision making were excluded by consensus.
Angiographic technique
For all eight small cerebral aneurysms, the diagnostic angiography was performed using a biplane angiographic suite (Axiom Artis dBC, Siemens, Erlangen, Germany). After a 6-Fr guiding catheter was placed into the distal cervical internal carotid artery, both biplane 2D-DSA images and 3DRA were obtained. The 3DRA was performed with a 5-s/200° rotational protocol with an acquisition of 200 images. Contrast agent (21 mL; Omnipaque 300; GE Healthcare, Princeton, NJ) was injected at a rate of 3 mL/s for 7 s. Two rounds of image acquisition were performed before contrast medium injection and after a delay of 2 s after contrast medium injection. The raw data were transferred to an X-Leonardo workstation (Siemens Medical Solutions) for image subtraction and 3D post-processing. According to the 3DRA results, a pair of the “working positions” for the biplane system was identified for demonstration of the aneurysm neck, parent artery, and the relevant branches. The roadmap images of the “working position” with a small (usually 5 × 7 in.) field of view (FOV) were recorded and used for microcatheter navigation and endovascular coiling. The working position was selected on a case-by-case basis by the treating interventional neuroradiologist. In most of the clinical cases at our institution, additional biplane DSA images using the working position with small FOVs were not performed. However, in all eight chosen cerebral aneurysms included in this study, there were satisfactory 2D-DSA images for adequate demonstration of the aneurysm neck and parent artery. The additional 2D-DSA at the working position was a result of the re-check of 2D-DSA due to the discordant information of the roadmap images (cases 1, 4, 7, and 8), similar projection angles between the working position and routine biplane angiography (cases 3, 5, and 6), and an incidental finding during coil embolization of another cerebral aneurysm (case 2).
Imaging preparation for the online questionnaire
In both 2D and 3D settings for the eight aneurysms, the detailed angio-architecture (neck, dome, height, D/N ratio, and aspect ratio (AR; defined as aneurysm height/aneurysm neck of cerebral aneurysm17,18)) was reviewed using the X-Leonardo workstation and verified by TCW and TYK with consensus. At least two key images representative of the aneurysm angio-architecture were selected for either 2D or 3D setting. Therefore, a total of 16 imaging sets were prepared for the online questionnaire using Google form. For each aneurysm, two questions were queried about the endovascular treatment. Question 1: “Which of the following is the preferred treatment choice for the assigned case? Simple coiling; Balloon remodeling technique; or Stent assisted coiling?” Question 2: “Is it achievable to secure the assigned aneurysm with simple coiling, but without a double catheter or wire/catheter protection technique?” To avoid the awareness of the paired 2D and 3D formats representative of the same case, the paired 2D and 3D image sets of the same aneurysm were separated to appear at least five different aneurysms apart on the questionnaire. The questionnaire also included a question regarding the frequency (never, seldom, usually, or always) to re-check the 2D-DSA of the target aneurysms at the working position just before endovascular coiling. A total of 11 domestic neuro-interventionalists (two with greater than 15 years of experience, four with 9–15 years of experience, four with three to eight years of experience, and one with less than three years of experience) were invited to answer the online questionnaire. The details of the 2D and 3D images of the chosen cases in the online questionnaire can be reviewed in Supplemental material.
Results
Discrepancies between 3D and 2D angioarchitecture parameters
The 2D and 3D angio-architecture parameters of the eight small cerebral aneurysms are summarized in Table 1. In all eight cases, the neck diameter based on 3DRA was larger than that observed using 2D-DSA. The average neck diameter difference and difference ratio was 0.95 mm and 62%, ranging from 0.45 to 2.25 mm and 23–136%, respectively. The average dome diameter difference and height difference was –0.2 and –0.05 mm, ranging from –1.01 to 0.97 mm and –0.54 to 0.72 mm, respectively. Consequently, the D/N ratio based on 3DRA was smaller than 2D-DSA in seven cases (mean difference and mean difference ratio of 0.76 and –36%, ranging from 0.05 to –1.4 and 4 to –66%, respectively). All eight cases were identified as wide-neck aneurysms based on 3DRA compared with only one wide-neck aneurysm based on 2D-DSA. There were similar findings for aspect ratio differences between 3DRA and 2D-DSA.
Table 1.
The angio-archiecture parameters of all 8 cases on 3DRA and 2D-DSA.
|
3D (mm) |
2D (mm) |
3D–2D difference (mm)/ difference ratio: (3D–2D)/2D |
||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Neck | Dome | Height | D/N ratio | AR | Neck | Dome | Height | D/N ratio | AR | Neck difference (%) | Dome difference (%) | Height difference (%) | D/N ratio difference (%) | AR difference (%) | ||
| Case 1 | 3.91 | 2.56 | 3.07 | 0.65 | 0.79 | 1.66 | 3.24 | 3.01 | 1.95 | 1.81 | 2.25 (136.2) | –0.68 (–21.2) | 0.06 (1.8) | –1.30 (–65.6) | –1.03 (–57.2) | |
| Case 2 | 2.40 | 3.26 | 2.29 | 1.36 | 0.95 | 1.86 | 4.27 | 2.83 | 2.3 | 1.52 | 0.54 (28.9) | –1.01 (–23.7) | –0.54 (–19.2) | –0.94 (–41.3) | –0.57 (–36.9) | |
| Case 3 | 2.13 | 2.13 | 2.02 | 1.00 | 0.95 | 1.03 | 1.96 | 2.05 | 1.9 | 1.99 | 1.10 (107.3) | 0.17 (9.3) | –0.03 (–1.3) | –0.9 (–47.4) | –1.04 (–52.3) | |
| Case 4 | 3.36 | 3.75 | 3.75 | 1.12 | 1.12 | 2.36 | 4.37 | 4.18 | 1.85 | 1.77 | 1.00 (42.1) | –0.62 (–14.2) | –0.43 (–9.8) | –0.74 (–39.7) | –0.66 (–36.5) | |
| Case 5 | 3.16 | 4.45 | 4.45 | 1.41 | 1.41 | 2.57 | 3.48 | 3.73 | 1.35 | 1.45 | 0.59 (22.8) | 0.97 (27.6) | 0.72 (19.3) | 0.05 (4.2) | –0.04 (–3.2) | |
| Case 6 | 2.93 | 3.71 | 4.52 | 1.27 | 1.54 | 2.24 | 4.38 | 4.76 | 1.96 | 2.13 | 0.69 (31.4) | –0.67 (–14.2%) | –0.24 (–5.4) | –0.69 (–34.8) | –0.58 (–27.4) | |
| Case 7 | 1.95 | 2.36 | 2.07 | 1.21 | 1.06 | 0.97 | 2.53 | 2.48 | 2.61 | 2.56 | 0.98 (101.2) | –0.17 (–7.3%) | –0.41 (–16.7) | –1.40 (–54.1%) | –1.50 (–57.9) | |
| Case 8 | 2.23 | 3.18 | 3.18 | 1.43 | 1.43 | 1.78 | 2.8 | 2.71 | 1.57 | 1.52 | 0.45 (24.7) | 0.38 (13.9%) | 0.47 (17.1) | –0.15 (–9.4) | –0.10 (–5.6%) | |
| Mean | 2.76 | 3.18 | 3.17 | 1.18 | 1.16 | 1.81 | 3.38 | 3.22 | 1.94 | 1.84 | 0.95 (62.2) | –0.2 (–4.1) | –0.05 (–2.1) | –0.76 (–35.6) | –0.69 (–35.3) | |
According to the angio-architecture of the eight small cerebral aneurysms, the cause of neck overestimation was classified into three types: Type I: a side-wall aneurysm (cases 2, 3, 7, and 8) with neck overestimation secondary to fusion of the proximal aneurysm sidewall with parent artery (Figure 1); Type II: a branch aneurysm (cases 1 and 6) with neck overestimation secondary to fusion of the proximal/lateral aneurysm sidewall with adjacent parent artery (Figure 2); Type III: a small aneurysm (cases 4 and 5) with neck overestimation secondary to fusion of the distal aneurysm sidewall with adjacent artery branch (Figure 3).
Figure 1.
Type I angio-architecture of a small supraclinoid ICA aneurysm (case 2): (a) 2D-DSA with D/N ratio of 2.3 (4.27/1.86 mm); (b) 3DRA with D/N ratio of 1.36 (3.26 mm/2.4 mm); (c) schematic drawing of 2D-DSA and (d) 3DRA. The paired answers of the preferred treatment choices were different in 10 out of 11 experts with two shift to BRT, seven shift to SAC, and one shift to SC based on 3DRA information. The initial treatment plan for this small ICA aneurysm was BRT based on 3DRA. Eventually, this aneurysm was secured by SC based on the re-checked 2D information. Another Acom aneurysm was also secured in a simultaneous procedure.
Figure 2.
Type II angio-architecture of a small Pcom aneurysm (case 1): (a) 2D-DSA with D/N ratio of 1.93 (3.21 mm/1.66 mm) and neck originating from the proximal Pcom; (b) 3DRA with D/N ratio of 0.65 (2.56 mm/3.91 mm) and neck originating from the junction between PcomA and ICA; (c) schematic drawing of 2D-DSA and (d) 3DRA. The paired answers of the preferred treatment choices were different in 9 out of 11 experts with three shift to BRT and six shift to SAC based on the 3D information. The initial treatment plan for this Pcom aneurysm was SAC based on 3DRA. Eventually, this aneurysm was secured by BRT based on the re-checked 2D information.
Figure 3.
Type III angio-architecture of a small Acom aneurysm (case 4): (a) 2D-DSA with D/N ratio of 1.85 (4.37/2.36 mm); (b) 3DRA with D/N ratio of 1.12 (3.75 mm/3.36 mm); (c) schematic drawing of 2D-DSA and (d) 3DRA; (e) 3DRA post stent-assisted coiling. The paired answers of the preferred treatment choices were different in 8 of 11 experts. The initial treatment plan for this small Acom aneurysm was coiling with Y-stenting based on 3DRA. Eventually, this aneurysm was secured by traditional SAC based on the re-checked 2D information.
Impact of discrepancies between 3DRA and 2D-DSA on the endovascular treatment planning of small cerebral aneurysms
The preferred treatment choices of all 11 invited neuro-interventionalists for the eight small cerebral aneurysms 2D-DSA are shown in Table 2. Herein, one pair of answers represents the two answer responses of one invited expert for one small aneurysm either presented in 3D or 2D format. Taken together, there were 88 paired answers in either question 1 or question 2. For question 1 about the preferred endovascular treatment choice, the paired answers based on either 3D RA or 2D-DSA for all eight small cerebral aneurysms were different in 63.6% of paired answers (56 out of 88). As compared with only 12 answers of SAC based on 2D-DSA, there were 46 answers of SAC if decision making was only based on 3DRA information. Based on 2D-DSA, the SC method was the preferred treatment choice in 66 out of 88 answers (75%). Based on 3DRA, however, 42 out of the 66 answers of “SC” (63.6%) would be shifted to “balloon-remodeling” or “stent-assisted” technique due to the overestimation of neck diameter and all aneurysms being classified as “wide-neck” based on the 3D information.
Table 2.
Impact of discrepancies between 3DRA and 2D-DSA on the endovascular treatment choices of these eight small aneurysms.
| Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | Case 6 | Case 7 | Case 8 | Total | Percentage | |
|---|---|---|---|---|---|---|---|---|---|---|
| Question 1 | Whether the paired answers are different or the same? | |||||||||
| Different | 9 | 9 | 9 | 8 | 1 | 2 | 10 | 8 | 56 | 63.6 |
| Same | 2 | 2 | 2 | 3 | 10 | 9 | 1 | 3 | 32 | 36.4 |
| Number of stent-assisted coiling based on 2DDSA and 3DRA | ||||||||||
| 2DDSA | 0 | 1 | 2 | 8 | 0 | 0 | 1 | 0 | 12 | 13.6 |
| 3DRA | 6 | 7 | 11 | 10 | 0 | 1 | 7 | 4 | 46 | 52.3 |
| Question 2 | Achievability of SC based on 2DDSA and 3DRA | |||||||||
| 2DDSA | 11 | 11 | 10 | 3 | 10 | 11 | 10 | 11 | 77 | 87.5 |
| 3DRA | 5 | 8 | 5 | 2 | 9 | 8 | 7 | 9 | 53 | 60.2 |
A pure SC technique was considered to be “achievable” in 77 out of 88 responses (87.5%) based on 2D-DSA information. The result was consistent with the relatively higher D/N ratio of these small cerebral aneurysms based on 2D information. There were 35 responses of “Not Achievable” (39.8%) based on 3DRA information. However, 24 out of these 35 answers of “Not Achievable” (68.6%) would be shifted to “achievable” based on 2D-DSA information.
Only 2 of 11 invited, neuro-interventionalists would always check up 2D-DSA images at the working projection before the start of microcatheter navigation and coil embolization. Most neuro-interventionalists rely on roadmap images at the working projection.
Inter-observer reliability of endovascular treatment choices for small aneurysms based on 3DRA or 2D-DSA
To evaluate agreement between 3DRA and 2D-DSA for endovascular treatment choices of these eight small aneurysms, the inter-observer reliability of the paired answers for questions 1 and 2 were determined using the Cohen κ coefficient. For question 1, the Cohen κ coefficient values of 0.139, 0.100, and 0.197 were obtained for all 11 invited experts (88 paired answer), 7 senior experts (56 paired answers) with more than nine-year experiences, and 4 young experts (32 paired answers) with less than nine-year experiences, all indicating slight agreement. For question 2, the Cohen κ coefficient values of 0.315, 0.392, and 0.224 were obtained for all 11 invited experts, 7 senior experts, and 4 young experts, all indicating fair agreement.
Discussion
The current study attempted to evaluate the effects of a discrepancy between 3D RA and 2D-DSA on the endovascular management of small cerebral aneurysms. The results demonstrated that decision making was different in 63.6% of treatment choices for eight small cerebral aneurysms as reported by 11 invited neuro-interventionalists. As compared with 66 answers of SC (75%) based on 2D information, there were only 26 answers of SC (29.6%) based on 3D information. The major discrepancies between 3DRA and 2D-DSA were neck overestimation and consequent smaller D/N ratio and AR based on 3DRA, both of whom were important determinants for endovascular treatment choices. The cause of neck overestimation on 3D RA may be due to the narrow gap between the proximal aneurysm lateral wall and parent artery.
In the previous studies, 3DRA overestimates of neck size had been proposed with emphasis to scrutinize the 2D-DSA information for the endovascular management.5,6 In clinical practice, however, this discrepancy between 2D and 3D images might be disregarded due to the development of the BRT and stent-assisted coiling to deal with the cerebral aneurysms with unfavorable configuration.9–11 The results of the current online questionnaire re-emphasize the impact of the discrepancies between 3DRA and 2D-DSA on the decision making of endovascular treatment of small cerebral aneurysms.
In the past 30 years, the percentage of small ruptured aneurysms (<5 mm) steadily rose from 29% to 50% in the most recent period.19 Even though there have been improvements in embolization devices and operator’s experience, endovascular treatments for small cerebral aneurysms remain challenging with not negligible20–23 even higher complication rates.24–28 In the current study, the average neck overestimation of 0.95 mm based on 3DRA had a great impact on the D/N ratio and aspect ratio of small aneurysms <5 mm. For a small aneurysm with neck of 2.45 mm and dome of 5 mm based on 2D-DSA, it would be mistaken for a wide-neck aneurysm based on 3DRA with a D/N ratio < 1.5. This mis-classification would not happen for a larger aneurysm with a dome of 7 mm. Only based on the 3D information, many small aneurysms with favorable configuration might be treated with more complex endovascular techniques or transferred to microsurgical clipping.
On the other hand, the dome and height differences of these eight small aneurysms between 2D-DSA and 3DRA were relatively small. The average dome diameter difference and height difference was –0.2 and –0.05 mm, ranging from –1.01 to 0.97 mm and –0.54 to 0.72 mm, respectively. As for small aneurysms <5 mm, however, this small discrepancy of 1 mm in aneurysm size measurement could be of crucial importance in the first coil selection. This issue was not evaluated in online questionnaire of our small case series. It might be elucidated in another study with large case series.
BRT has been proven to be a safe and effective treatment of choice for cerebral aneurysms with unfavorable configuration,9,13,29,30 although higher complication rates were observed in two case series.11,31 While intraoperative rupture happens, it could be inflated to temporarily stop the blood leakage until the ruptured site can be sealed. However, safety comparisons between standard coiling and remodeling technique for all cerebral aneurysms are still lacking. On the other hand, stent-assisted coiling has been shown to be associated with higher complication rates,10,15,32,33 especially in ruptured aneurysms.32 Moreover, the optimal anti-platelet medication for stent deployment in acute-ruptured aneurysms has yet to be determined. Therefore, stent-assisted coiling should only be considered when other less risky treatment options have been excluded.3
In the current study, we proposed three types of cerebral aneurysm angio-architecture according to the location of misleading information on 3DRA: type I for a side-wall aneurysm and type II for a branch aneurysm, both of them with small gap between the aneurysm proximal lateral wall and parent artery and type III for an aneurysm with small gap between the aneurysm distal lateral wall and adjacent parent artery. The small gap between the aneurysm lateral wall and adjacent parent artery will be effaced during 3D reformation with consequent neck diameter overestimation. Awareness of this phenomenon should prompt re-surveillance of the 2D-DSA.
Several limitations of our study should be addressed. First, the case number in this study was not large enough to represent all possible angio-architecture patterns of small cerebral aneurysms, such as MCA trifurcation aneurysm, terminal ICA bifurcation aneurysm, or basilar tip aneurysm. Second, the obvious neck overestimation based on 3DRA in the current study might result from the selection bias of small aneurysms with satisfactory 2D and 3D information. Third, the effect of 3D reformation algorithms on the measurement of cerebral aneurysm angio-architecture parameters was not addressed in this study. The 3D reformation algorithms varied from case to case. Measurement bias might come from operator’s preference and different reformation algorithms. Fourth, only static 3D and 2D key images were provided for the online questionnaire in this study. In clinical practice, however, the interactive information provided by the 3D workstation and complementary information of the original rotational angiogram images without reconstruction was also essential for endovascular treatment planning. The last, the impact of discrepancies between 3DRA and 2D-DSA of these small cerebral aneurysms on the referral to microsurgical clipping was not evaluated in this study.
Conclusions
The major discrepancies between 3DRA and 2D-DSA were neck overestimation and, consequently, smaller D/N ratio on 3DRA, both of which were important determinants for endovascular treatment choices. The misleading information associated with 3DRA of small cerebral aneurysms may predispose the neuro-interventionalists to initiate more complex treatment planning. The discrepancy might come from the narrow space between the aneurysmal sidewall and the adjacent parent artery. Being familiar with this phenomenon and careful scrutiny of 2D information are crucial for the optimal planning of endovascular treatment for small cerebral aneurysms.
Supplemental Material
Supplemental material, sj-pdf-1-ine-10.1177_1591019920925706 for Discrepancy between two-dimensional and three-dimensional digital subtraction angiography for the planning of endovascular coiling of small cerebral aneurysms <5 mm by Te-Chang Wu, Yu-Kun Tsui, Tai-Yuan Chen, Ching-Chung Ko, Chien-Jen Lin, Jeon-Hor Chen and Ching-Po Lin in Interventional Neuroradiology
Footnotes
Authors’ contribution: Conception and design: TCW, YKT, and TYC. Data acquisition: TCW, YKT, CCK, and CJL. Analysis: TCW, CCK, and CHC. Drafting the manuscript: TCW, CHC, and CPL. Critically revising the article: all authors. Final approval of the version to be published: all authors. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: all authors.
Ethical approval: IRB approval number: 10810-005
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Te-Chang Wu https://orcid.org/0000-0002-4408-4264
Supplemental material: Supplemental material for this article is available online.
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Supplementary Materials
Supplemental material, sj-pdf-1-ine-10.1177_1591019920925706 for Discrepancy between two-dimensional and three-dimensional digital subtraction angiography for the planning of endovascular coiling of small cerebral aneurysms <5 mm by Te-Chang Wu, Yu-Kun Tsui, Tai-Yuan Chen, Ching-Chung Ko, Chien-Jen Lin, Jeon-Hor Chen and Ching-Po Lin in Interventional Neuroradiology