Toward accurate volumetry of brain aneurysms: combination of an algorithm for automatic thresholding with a 3D eraser...

The present study describes a new approach for aneurysm volume quantification on three-dimensional angiograms, which focuses on solving three common technical problems: the variability associated with the use of manual thresholds, the irregular morphology of some aneurysms, and the imprecision of the limits between the parent artery and the aneurysm sac. The method consists of combining an algorithm for automatic threshold determination with a spherical eraser tool that allows the user to separate the image of the aneurysm from the parent artery. The accuracy of volumetry after automatic thresholding was verified with an in vitro experiment in which 57 measurements were performed using four artificial aneurysms of known volume. The reliability of the method was compared to that obtained with the technique of ellipsoid approximation in a clinical setting of 15 real angiograms and 150 measurements performed by five different users. The mean error in the measurement of the artificial aneurysms was 7.23%. The reliability of the new approach was significantly higher than that of the ellipsoid approximation. Limits of agreement between two measurements were determined with Bland-Altman plots and ranged from -14 to 13% for complex and from -10.8 to 11.03% for simple-shaped sacs. The reproducibility was lower (>20% of variation) for small aneurysms (<70 mm³) and for those presenting a very wide neck (dome-to-neck ratio<1). The method is potentially useful in the clinical practice, since it provides relatively precise, reproducible, volume quantification. A safety coiling volume can be established in order to perform sufficient but not excessive filling of the aneurysm pouch.