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Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: a Multicenter Study

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Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: a Multicenter Study Original Paper Neurointervention 2016;11:78-85 http://dx.doi.org/10.5469/neuroint.2016.11.2.78 ISSN (Print): 2093-9043 ISSN (Online): 2233-6273 Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: A Multicenter Study Yon Kwon Ihn, MD1, Bum-Soo Kim, MD2, Jun Soo Byun, MD3, Sang Hyun Suh, MD4, Yoo Dong Won, MD5, Deok Hee Lee, MD6, Byung Moon Kim, MD7, Young Soo Kim, MD8, Pyong Jeon, MD9, Chang-Woo Ryu, MD10, Sang-il Suh, MD11, Dae Seob Choi, MD12, See Sung Choi, MD13, Jin Wook Choi, MD14, Hyuk Won Chang, MD15, Jae-Wook Lee, MD16, Sang Heum Kim, MD17, Young Jun Lee, MD18, Shang Hun Shin, MD19, Soo Mee Lim, MD20, Woong Yoon, MD 21, Hae Woong Jeong, MD22, Moon Hee Han, MD23 Purpose: To assess patient radiation doses during cerebral angiography and embolization of intracranial aneurysms across multi-centers and propose a diagnostic reference level (DRL). 1Department of Radiology, St.Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Gyeonggi-do, Korea 2Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea 3Department of Radiology, Chung-Ang University Hospital, Seoul, Korea 4Department of Radiology, Gangnam Severance Hospital, Yonsei University, Seoul, Korea 5Department of Radiology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Gyeonggi-do, Korea 6Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea 7Department of Radiology, Severance Hospital Stroke Center, Yonsei Unviersity College of Medicine, Seoul, Korea 8Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University, Yangsan, Korea 9Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 10Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul, Korea 11Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea 12Department of Radiology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea 13Department of Radiology, Wonkwang University Hospital, Iksan, Korea 14Department of Radiology, Ajou University School of Medicine, Gyeonggi-do, Korea 15Department of Radiology, Keimyung University College of Medicine, Dongsan Medical Center, Daegu, Korea 16Department of Radiology, National Health Insurance Service Ilsan Hospital, Gyeonggi-do, Korea 17Department of Radiology, CHA Bundang Medical Center, CHA University, Gyeonggi-do, Korea 18Department of Radiology, Hanyang University College of Medicine, Seoul, Korea 19Department of Radiology, Ulsan University Hospital, University of Ulsan, College of Medicine, Ulsan, Korea 20Department of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea 21Department of Radiology, Chonnam National University Hospital, Gwangju, Korea 22Department of Radiology, Busan Paik Hospital, Inje University, Busan, Korea 23Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea Received April 19, 2016; accepted after revision August 11, 2016. Correspondence to: Bum-Soo Kim, MD, Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea. Tel. 82.2.2258.6239 Fax. 82.2.599.6771 E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 78 Neurointervention 11, September 2016 Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms Materials and Methods: We studied a sample of 490 diagnostic and 371 therapeutic procedures for intracranial aneurysms, which were performed at 23 hospitals in Korea in 2015. Parameters includ- ing dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time and total angiographic image frames were obtained and analyzed. Results: Total mean DAP, CAK, fluoroscopy time, and total angiographic image frames were 106.2 ± 66.4 Gy-cm2, 697.1 ± 473.7 mGy, 9.7 ± 6.5 minutes, 241.5 ± 116.6 frames for diagnostic proce- dures, 218.8 ± 164.3 Gy-cm2, 3365.7 ± 2205.8 mGy, 51.5 ± 31.1 minutes, 443.5 ± 270.7 frames for therapeutic procedures, respectively. For diagnostic procedure, the third quartiles for DRLs were 144.2 Gy-cm2 for DAP, 921.1 mGy for CAK, 12.2 minutes for fluoroscopy times and 286.5 for number of image frames, respectively. For therapeutic procedures, the third quartiles for DRLs were 271.0 Gy-cm2 for DAP, 4471.3 mGy for CAK, 64.7 minutes for fluoroscopy times and 567.3 for number of image frames, respectively. On average, rotational angiography was used 1.5 ± 0.7 times/session (range, 0-4; n=490) for diagnostic procedures and 1.6 ± 1.2 times/session (range, 0-4; n=368) for therapeutic procedures, respectively. Conclusion: Radiation dose as measured by DAP, fluoroscopy time and image frames were lower in our patients compared to another study regarding cerebral angiography, and DAP was lower with fewer angiographic image frames for therapeutic procedures. Proposed DRLs can be used for quali- ty assurance and patient safety in diagnostic and therapeutic procedures. Key Words : Cerebral angiography; Cerebral embolization; Diagnostic reference levels; Radiation dose Cerebrovascular disease is one of the leading causes which a facility should review its method and of death in Korea, and there has been a corresponding determine if an acceptable image quality can be increase in the number and complexity of interven- achieved at lower doses [4]. It is typically set as the tional neuroradiology (INR) procedures. This increase 75th percentile of measured patient or phantom data. is attributable to both technological advancements and Commonly used parameters for a DRL dose are dose evidence favoring endovascular techniques over area product (DAP), number of exposures and conventional surgery [1]. However, interventional fluoroscopy time. radiological procedures have the potential to exposure a Previous studies in Korea and other countries have patient to high doses of radiation, and, in particular, a investigated DRL levels, and reported a large variation high entrance surface dose of up to several Gy. Surface within hospitals using different DRL guidelines [5-7]. skin dose is important because of the potential for well- Recognizing the need for continuous monitoring of the documented deterministic effects, such as skin dose in INR procedures and the fact that no such multi- epilation, erythema and desquamation. Dose thresholds center study has ever been carried out in Korea so far, for these lesions are in the order of 3 Gy, 6 Gy and 15 the authors have collected data concerning the dose to Gy, respectively [2]. Additionally, INR procedures, like patients undergoing some of the most common all sources of radiation exposure, can cause stochastic diagnostic and therapeutic INR procedures performed risks by way of cancer. Direct measurement of surface in Korea. skin dose is desirable, but not practical because The purposes of present study were: (1) to obtain thermoluminescent dosimeters (TLD) are cumbersome baseline data by evaluation of patient exposure at multi- with limitations in terms of practical use [3]. An centers, (2) to compare these data with the recent litera- indirect estimate of the radiation dose using a dose-area ture from other studies, and (3) to propose DRLs. product (DAP) meter, which is common in modern angiographic systems, can be an alternative. MATERIALS AND METHODS A diagnostic reference level (DRL) is an investiga- tional level used to identify unusually high radiation This study was approved by our Institutional Review doses for common diagnostic medical X-ray imaging Board. A waiver of the need for consent was obtained procedures. DRLs are suggested action levels above for the Health Insurance Portability and Accountability Neurointervention 11, September 2016 79 Yon Kwon Ihn, et al. Act compliant survey research. compared for analysis. The number of rotational The study included patients undergoing INR angiographic acquisitions in each session of diagnostic procedures from October 2015 through to December and therapeutic procedures was also surveyed. Data 2015. Twenty-three university hospitals in Korea were were analysed to assess mean ± standard deviation for invited to participate in the study. Each center was each parameter. As collected radiation doses showed a asked to register 20 diagnostic and 15 therapeutic INR skewed distribution with extreme values and a long procedures. As the radiation doses show a wide distrib- upper tail, 75th percentile values were also analysed to ution with respect to pathology and type of INR propose DRLs. procedure, we focused on a more standardized examination, such as diagnostic cerebral angiography RESULTS and therapeutic embolization for an intracranial aneurysm. For each examination, the centers were A total of 861 patients were included in this survey, requested to fill out a questionnaire containing various with 490 diagnostic and 371 therapeutic procedures. information regarding radiation data. The X-ray The results, including
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