Aneurysm Specific Working Projections for the Endovascular Treatment of Intracranial Aneurysms-Same Aneurysm, Different Working Projections?"

PURPOSE: Despite decades of endovascular treatment (EVT) of intracranial aneurysms (IA), there are no studies regarding the ideal working projections. Possible correlations between suboptimal working projections and procedure-related complications therefore remain unknown. This study aims at investigating the level of consensus between different physicians proposed working projections for endosaccular treatment of IAs. MATERIALS AND METHODS: Five interventional neuroradiologists used a simulation software to select what they considered to be the optimal biplane working projections (BPW) for the intrasaccular treatment of 20 intracranial aneurysms. Five further raters evaluated these projections and either agreed or disagreed with the proposed working projection. Where necessary, reasons for rejecting the proposed working projection was provided. RESULTS: Overall, a substantial interobserver consensus was achieved (κ = 0.81), with at least one projection consistently agreed upon for 19 out of 20 aneurysms. Conversely, only one projection was unanimously rejected. Lack of clear delineation of the aneurysm neck, the parent vessel, and associated vessels were the most frequently cited reasons for rejection (39%, 39%, and 31%, respectively), while "other reasons" accounted for 19%. CONCLUSION: Although the specific working projections chosen for individual aneurysms were heterogeneous, there was still a broad consensus on at least one suitable projection for almost every case. Further research is required to explore the possible benefit of adjusting the patient's head position or making slight angle deviations in BWPs with physical restrictions and furthermore, to evaluate the risks associated with suboptimal BWPs in EVT.