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<meta name="DC.Title" content="Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome" />
<meta name="DC.Identifier" content="10.3174/ajnr.A6772" />
<meta name="DC.Date" content="2020-10-01" />
<meta name="DC.Publisher" content="American Journal of Neuroradiology" />
<meta name="DC.Rights" content="© 2020 by American Journal of Neuroradiology" />
<meta name="DC.AccessRights" content="restricted" />
<meta name="DC.Description" content="BACKGROUND AND PURPOSE: There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome.

MATERIALS AND METHODS: Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliberpost − Caliberpre) and the proportion of caliber change ([(Caliberpost − Caliberpre)/Caliberpre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold.

RESULTS: Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change ( P  &lt; .001), mean proportion of change ( P  = .002), maximal caliber difference ( P  = .004), and mean caliber difference ( P  = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change  ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of  ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%.

CONCLUSIONS: Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change  ≥32% has the best diagnostic performance.

AUC
:   area under the curve
CD
:   caliber difference
IA
:   intra-arterial
ICAD
:   intracranial atherosclerotic disease
DSA
:   digital subtraction angiography
PACNS
:   primary angiitis of the central nervous system
PC
:   proportion of change
RCVS
:   reversible cerebral vasoconstriction syndrome
ROC
:   receiver operating characteristic
TCH
:   thunderclap headache" />
<meta name="DC.Contributor" content="J.M. Sequeiros" />
<meta name="DC.Contributor" content="J.A. Roa" />
<meta name="DC.Contributor" content="R.P. Sabotin" />
<meta name="DC.Contributor" content="S. Dandapat" />
<meta name="DC.Contributor" content="S. Ortega-Gutierrez" />
<meta name="DC.Contributor" content="E.C. Leira" />
<meta name="DC.Contributor" content="C.P. Derdeyn" />
<meta name="DC.Contributor" content="G. Bathla" />
<meta name="DC.Contributor" content="D.M. Hasan" />
<meta name="DC.Contributor" content="E.A. Samaniego" />
<meta name="article:published_time" content="2020-10-01" />
<meta name="article:section" content="Interventional" />
<meta name="citation_title" content="Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome" />
<meta name="citation_abstract" lang="en" content="&lt;h3&gt;BACKGROUND AND PURPOSE:&lt;/h3&gt;
&lt;p&gt;There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome.&lt;/p&gt;&lt;h3&gt;MATERIALS AND METHODS:&lt;/h3&gt;
&lt;p&gt;Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliber&lt;sub&gt;post&lt;/sub&gt; − Caliber&lt;sub&gt;pre&lt;/sub&gt;) and the proportion of caliber change ([(Caliber&lt;sub&gt;post&lt;/sub&gt; − Caliber&lt;sub&gt;pre&lt;/sub&gt;)/Caliber&lt;sub&gt;pre&lt;/sub&gt;] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold.&lt;/p&gt;&lt;h3&gt;RESULTS:&lt;/h3&gt;
&lt;p&gt;Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change (&lt;i&gt;P &lt;/i&gt;&amp;lt; .001), mean proportion of change (&lt;i&gt;P &lt;/i&gt;= .002), maximal caliber difference (&lt;i&gt;P &lt;/i&gt;= .004), and mean caliber difference (&lt;i&gt;P &lt;/i&gt;= .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change  ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of  ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%.&lt;/p&gt;&lt;h3&gt;CONCLUSIONS:&lt;/h3&gt;
&lt;p&gt;Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change  ≥32% has the best diagnostic performance.&lt;/p&gt;" />
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<meta name="twitter:title" content="Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome" />
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<meta name="twitter:description" content="BACKGROUND AND PURPOSE: There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome.

MATERIALS AND METHODS: Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliberpost − Caliberpre) and the proportion of caliber change ([(Caliberpost − Caliberpre)/Caliberpre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold.

RESULTS: Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change ( P  &lt; .001), mean proportion of change ( P  = .002), maximal caliber difference ( P  = .004), and mean caliber difference ( P  = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change  ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of  ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%.

CONCLUSIONS: Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change  ≥32% has the best diagnostic performance.

AUC
:   area under the curve
CD
:   caliber difference
IA
:   intra-arterial
ICAD
:   intracranial atherosclerotic disease
DSA
:   digital subtraction angiography
PACNS
:   primary angiitis of the central nervous system
PC
:   proportion of change
RCVS
:   reversible cerebral vasoconstriction syndrome
ROC
:   receiver operating characteristic
TCH
:   thunderclap headache" />
<meta name="og-title" property="og:title" content="Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome" />
<meta name="og-url" property="og:url" content="http://ajnr-stage2.stage.highwire.org/content/41/10/1869" />
<meta name="og-site-name" property="og:site_name" content="American Journal of Neuroradiology" />
<meta name="og-description" property="og:description" content="BACKGROUND AND PURPOSE: There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome.

MATERIALS AND METHODS: Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliberpost − Caliberpre) and the proportion of caliber change ([(Caliberpost − Caliberpre)/Caliberpre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold.

RESULTS: Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change ( P  &lt; .001), mean proportion of change ( P  = .002), maximal caliber difference ( P  = .004), and mean caliber difference ( P  = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change  ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of  ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%.

CONCLUSIONS: Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change  ≥32% has the best diagnostic performance.

AUC
:   area under the curve
CD
:   caliber difference
IA
:   intra-arterial
ICAD
:   intracranial atherosclerotic disease
DSA
:   digital subtraction angiography
PACNS
:   primary angiitis of the central nervous system
PC
:   proportion of change
RCVS
:   reversible cerebral vasoconstriction syndrome
ROC
:   receiver operating characteristic
TCH
:   thunderclap headache" />
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    <div class="highwire-article-citation highwire-citation-type-highwire-article node78811--5" data-node-nid="78811" id="top-node-78811--61384234693" data-pisa="ajnr;41/10/1869" data-pisa-master="ajnr;ajnr.A6772" data-apath="/ajnr/41/10/1869.atom" data-hw-author-tooltip-instance="highwire_author_tooltip"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-article-title-complete clearfix has-author-tooltip highwire-citation-highwire-article-top-a">
  
  
      <div class="highwire-cite-overline"><span  class="highwire-cite-metadata-article-type highwire-cite-metadata">Research Article</span><span class="separator-pipe"></span><span  class="highwire-cite-metadata-art-cat highwire-cite-metadata"><span class="wrapper">Interventional</span></span></div>
  
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      <h1 class="highwire-cite-title" id="page-title">Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">J.M. Sequeiros</span>, <span class="highwire-citation-author" data-delta="1">J.A. Roa</span>, <span class="highwire-citation-author" data-delta="2">R.P. Sabotin</span>, <span class="highwire-citation-author" data-delta="3">S. Dandapat</span>, <span class="highwire-citation-author" data-delta="4">S. Ortega-Gutierrez</span>, <span class="highwire-citation-author" data-delta="5">E.C. Leira</span>, <span class="highwire-citation-author" data-delta="6">C.P. Derdeyn</span>, <span class="highwire-citation-author" data-delta="7">G. Bathla</span>, <span class="highwire-citation-author" data-delta="8">D.M. Hasan</span> and <span class="highwire-citation-author" data-delta="9">E.A. Samaniego</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">October 2020,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">41 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(10) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">1869-1875; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A6772 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-78811--61384234693" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">J.M. Sequeiros </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.M.%2BSequeiros%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Sequeiros%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AJ.M.%2BSequeiros%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-2687-8674" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for J.M. Sequeiros</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">J.A. Roa </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.A.%2BRoa%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Roa%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AJ.A.%2BRoa%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-4987-8853" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for J.A. Roa</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">R.P. Sabotin </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=R.P.%2BSabotin%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Sabotin%20R&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AR.P.%2BSabotin%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-0794-6029" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for R.P. Sabotin</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">S. Dandapat </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=S.%2BDandapat%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Dandapat%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AS.%2BDandapat%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-3744-7845" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for S. Dandapat</a></li></ul></div><div class="author-tooltip-4"><div class="author-tooltip-name">S. Ortega-Gutierrez </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=S.%2BOrtega-Gutierrez%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Ortega-Gutierrez%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AS.%2BOrtega-Gutierrez%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-3408-1297" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for S. Ortega-Gutierrez</a></li></ul></div><div class="author-tooltip-5"><div class="author-tooltip-name">E.C. Leira </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=E.C.%2BLeira%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Leira%20E&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AE.C.%2BLeira%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-3695-2946" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for E.C. Leira</a></li></ul></div><div class="author-tooltip-6"><div class="author-tooltip-name">C.P. Derdeyn </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=C.P.%2BDerdeyn%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Derdeyn%20C&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AC.P.%2BDerdeyn%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-5932-2683" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for C.P. Derdeyn</a></li></ul></div><div class="author-tooltip-7"><div class="author-tooltip-name">G. Bathla </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=G.%2BBathla%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Bathla%20G&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AG.%2BBathla%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-3170-242X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for G. Bathla</a></li></ul></div><div class="author-tooltip-8"><div class="author-tooltip-name">D.M. Hasan </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=D.M.%2BHasan%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Hasan%20D&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AD.M.%2BHasan%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-8335-5442" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for D.M. Hasan</a></li></ul></div><div class="author-tooltip-9"><div class="author-tooltip-name">E.A. Samaniego </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (J.M.S., J.A.R., R.P.S., S.D., S.O.-G., E.C.L., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Neurosurgery (J.A.R., S.O.-G., D.M.H., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa</div><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Radiology (S.O.-G., C.P.D., G.B., E.A.S.), University of Iowa Hospitals and Clinics, Iowa City, Iowa.</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=E.A.%2BSamaniego%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Samaniego%20E&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AE.A.%2BSamaniego%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-2764-2268" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for E.A. 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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" xmlns:xhtml="http://www.w3.org/1999/xhtml" class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-41.10.1869.1" data-doi="10.7326/0003-4819-146-1-200701020-00007"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Calabrese</span>  <span class="cit-name-given-names">LH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Dodick</span>  <span class="cit-name-given-names">DW</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Schwedt</span>  <span class="cit-name-given-names">TJ</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span 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</li><li><span class="cit-auth"><span class="cit-name-surname">Parmar</span>  <span class="cit-name-given-names">C</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Quackenbush</span>  <span class="cit-name-given-names">J</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Artificial intellience in radiology</span>. <abbr class="cit-jnl-abbrev">Nat Rev Cancer</abbr> <span class="cit-pub-date">2018</span>;<span class="cit-vol">18</span>:<span class="cit-fpage">500</span>–<span class="cit-lpage">10</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1038/s41568-018-0016-5</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>29777175</span></cite></div><div class="cit-extra"><a 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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 41</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 10 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Oct 2020 </div></div>
      
      
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">J.M.</span> <span class="nlm-surname">Sequeiros</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">J.A.</span> <span class="nlm-surname">Roa</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">R.P.</span> <span class="nlm-surname">Sabotin</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Dandapat</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Ortega-Gutierrez</span></span>, <span class="highwire-citation-author" data-delta="5"><span class="nlm-given-names">E.C.</span> <span class="nlm-surname">Leira</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">C.P.</span> <span class="nlm-surname">Derdeyn</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">G.</span> <span class="nlm-surname">Bathla</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">D.M.</span> <span class="nlm-surname">Hasan</span></span>, <span class="highwire-citation-author" data-delta="9"><span class="nlm-given-names">E.A.</span> <span class="nlm-surname">Samaniego</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Oct 2020, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">41 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(10) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">1869-1875; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A6772 </span></div>
  
  
  
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">J.M.</span> <span class="nlm-surname">Sequeiros</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">J.A.</span> <span class="nlm-surname">Roa</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">R.P.</span> <span class="nlm-surname">Sabotin</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Dandapat</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Ortega-Gutierrez</span></span>, <span class="highwire-citation-author" data-delta="5"><span class="nlm-given-names">E.C.</span> <span class="nlm-surname">Leira</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">C.P.</span> <span class="nlm-surname">Derdeyn</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">G.</span> <span class="nlm-surname">Bathla</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">D.M.</span> <span class="nlm-surname">Hasan</span></span>, <span class="highwire-citation-author" data-delta="9"><span class="nlm-given-names">E.A.</span> <span class="nlm-surname">Samaniego</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Oct 2020, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">41 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(10) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">1869-1875; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A6772 </span></div>
  
  
  
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