Radiation-Sparing Intravenous DSA and Augmented Reality Navigation in Pediatric Neurosurgery: A Quantitative Analysis of Perioperative Effective Dose and Workflow

Radiation-Sparing Intravenous DSA and Augmented Reality Navigation in Pediatric Neurosurgery: A Quantitative Analysis of Perioperative Effective Dose and Workflow | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Radiation-Sparing Intravenous DSA and Augmented Reality Navigation in Pediatric Neurosurgery: A Quantitative Analysis of Perioperative Effective Dose and Workflow Chih-Wei Huang, Chiu-Chun Chen, Kai-Chen Chung, Pei-Ying Tseng, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9167196/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Conventional intra-arterial angiography remains the standard for brain arteriovenous malformation surgery but carries inherent risks of arterial complications and significant radiation exposure in children. This study evaluates the feasibility and radiation-sparing benefits of an intravenous angiography protocol integrated with augmented reality navigation for pediatric brain malformation resection. We retrospectively analyzed three pediatric cases where Cases 1 and 2 utilized a tailored intravenous digital subtraction angiography protocol for augmented reality navigation, while Case 3 served as a comparative control using conventional perioperative intra-arterial angiography. The optimized intravenous protocol yielded a standardized effective dose of 0.83 mSv per session. In Case 1, the total effective dose for two intravenous sessions, covering both preoperative mapping and postoperative confirmation, was only 1.92 mSv. In contrast, the perioperative intra-arterial angiography in Case 3 resulted in a total dose of 12.70 mSv, representing an 85% reduction in radiation exposure. Furthermore, the intravenous workflow optimized operative time by eliminating invasive arterial maneuvers, and navigation accuracy was maintained even in the presence of severe intraoperative brain shift through manual realignment. This protocol provides a robust and radiation-efficient alternative for pediatric surgery, effectively implementing the principle of keeping radiation exposure as low as reasonably achievable. arteriovenous malformations augmented reality digital subtraction angiography Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Arteriovenous malformations (AVMs) are complex vascular anomalies characterized by direct connections between the arteries and veins without intermediary capillary networks, thereby disrupting blood circulation and oxygen transport. 1 Brain AVMs (bAVMs) can jeopardize the cerebral steal phenomenon, seizures, headache, aneurysm or venous stenosis formation, and intracerebral hemorrhage, 2 and are the leading cause of pediatric intracerebral hemorrhage, accounting for up to 55% of cases. 3 The annual hemorrhage risk due to pediatric bAVM ranges from 2%–10%, 4 which is higher than that in the adult population (1%–3%). 5 In one study, distribution in the posterior fossa or basal ganglion, which exhibits a greater rupture risk, was more frequently noted in pediatric AVMs than in adult AVMs. 6 The mortality rate of bAVM in children can be as high as 21%. 2 Therefore, this should be proactively addressed. Surgical resection remains the primary treatment option for bAVMs with low Spetzler–Martin grades 7 . First, surgical resection leads to an instant cure and a higher obliteration rate than pure radiosurgery or endovascular intervention. 4 Otherwise, non-surgical treatment is required, which is a long-term process for children and their guardians. Second, radiosurgery increases radiation exposure. Third, endovascular intervention is less feasible for children because of the limited sizes of catheters, wires, and coils. However, surgical resection of pediatric bAVM is linked to several challenges. Surgeons should consider the balance between complete AVM resection and preservation of neurological function, especially when the lesion is in a crucial neurovascular region. Additionally, pediatric hemodynamic fragility and variability significantly increase perioperative risks, as children have less total blood volume compared to adults. The body surface area of a child is greater than that of an adult; therefore, children are more susceptible to fluid loss and hypothermia induced by long surgery durations 8 ; in particular, hypothermia can induce coagulopathy and suppress cardiorespiration. Furthermore, hypotension is a late sign of hemorrhagic shock in children, which may reduce the ability to assess blood loss. 9 Consequently, comprehensive perioperative planning is required for pediatric AVM resections. Various imaging technologies have been introduced to deconstruct lesions and aid surgery, including intra-arterial digital subtraction angiography (IA-DSA), multidetector computed tomography (MDCT) angiography-based navigation, and augmented reality (AR). However, current imaging protocols documented in literature inevitably result in substantial radiation exposure and increased procedural risks, particularly in pediatric populations. Given the existing challenges of pediatric neurointervention—such as fragile vasculature, limited training resources, prolonged interventionalist standby, and high procedural costs—we extended our previously validated adult IV-DSA method to pediatric patients. Therefore, we adapted and implemented our established intravenous digital subtraction angiography (IV-DSA) technique, combined with AR navigation, for pediatric bAVM surgery, aiming to enhance surgical precision, reduce invasiveness, and minimize radiation exposure. This protocol provides an efficient and smooth surgical process with greater precision and adjustability but lower invasiveness and radiation exposure. METHODS This study was conducted in a hybrid operating room using an IV-DSA and AR-guided protocol for pediatric bAVM resection. The surgical workflow was adapted from previous protocols 10 , with modifications in contrast volume, injection rate, and timing tailored to pediatric physiology. Source imaging was acquired using an iFlow-tailored IV-DSA protocol with a biplane angiography system (ARTIS icono, Siemens Healthineers, Germany). A preliminary test injection was administered via a central venous catheter (CVC) at a flow rate of 3.5 mL/s, using a total contrast volume of 1 mL/kg, followed by a saline flush of double that volume. Optimal scan delay was determined using iFlow software (syngo, Siemens), which analyzes contrast kinetics and generates a color-coded intensity map 10 . To minimize cortical shift during craniotomy, patients were positioned using a radiolucent head holder. After dural opening, a formal 3D DSA scan was performed using 1–1.5 mL/kg of contrast at an injection rate of 2.5–3.5 mL/s. The angioarchitecture, including feeding arteries, draining veins, AVM nidus, and cortical surface landmarks, was segmented using SmartBrush (Brainlab, IL, USA). These labels were then coregistered with the navigation system and fused with intraoperative microscopy using the KINEVO surgical microscope (ZEISS, Germany). During resection, primary arterial feeders were identified and occluded with surgical clips applied as proximally to the nidus as feasible. The AVM nidus was subsequently removed under continuous AR guidance, allowing real-time orientation between the anatomical structures and projected vascular models. RESULTS We present two representative pediatric cases to demonstrate the applicability of IV-DSA AR-guided bAVM surgery in both elective and urgent settings. Case 1 involved a scheduled procedure for an unruptured lesion, while Case 2 required second-stage surgery for a previously ruptured AVM with significant cerebral edema. Detailed perioperative information is summarized in Table 1 . We also illustrated Case 3 , who received resection of a ruptured AVM under IA-DSA AR guided-guided surgery as comparison. Table 1 Summary of two representative cases reported herein Body weight Case 1 Case 2 30 kg 12 kg Presentation Unruptured, absence of seizures Intracerebral hemorrhage with brain edema AVM, SM grade, location SM = 1, left frontal lobe SM = 1, left parietal lobe IV route Right neck CVC Left neck CVC Protocol of the test round 10 mL contrast (3.5 mL/s), bolus with 50 mL saline 4 cc contrast (2.5 mL/s), bolus with 16 mL saline Timing of the test round Supine, before positioning Supine, before positioning Delayed time 9 s 8 s 3D DSA, 4 s 3D DSA, 4 s 3D DSA, 4 s 3D DSA protocol 30 mL contrast (3.5 mL/s), bolus with 30 mL saline 10 mL contrast (2.5 mL/s), bolus with 10 mL saline Fixation 3-pin radiolucent head holder Horseshoe radiolucent head supporter Timing of 3D DSA After dura opening Before dura opening Image quality for navigation Good Fair (peripheral, small-sized vessel, and brain edema) AVM, arteriovenous malformation; CVC, central venous catheter; DSA, digital subtraction angiography; SM, Spetzler–Martin. Case 1 A school-aged child with an unruptured left frontal AVM (Spetzler–Martin grade I) underwent surgery with intraoperative IV-DSA. Imaging identified two major feeders from the left anterior cerebral artery, several minor feeders from the left middle cerebral artery, and a single superficial draining vein (Fig. 1 ). Total blood loss was approximately 100 mL, and operative time was 6.5 hours, including IV-DSA setup. The effective radiation dose was 1.92 mSv. The patient had no postoperative neurological deficits and was discharged on postoperative day 6. Case 2 A preschool-aged child with a ruptured left parietal–occipital AVM and signs of increased intracranial pressure (GCS E3V1M5) underwent craniectomy and hematoma evacuation at an outside facility, followed by transfer. On postoperative day 8, a second-stage resection was performed. Due to anticipated brain shift from edema, IV-DSA was performed pre-craniotomy. Imaging revealed two major feeders from the left middle cerebral artery and one superficial draining vein. Brain swelling induced AR overlay deviation, requiring manual adjustment to realign with cortical structures. Resection and cranioplasty were completed within 4 hours (Fig. 2 ). The effective radiation dose was 7.91 mSv. The patient recovered full consciousness and limb strength by postoperative day 2 and was discharged on day 8. Case 3 A school-aged child with a ruptured right frontal-parietal AVM and left lower limb weakness (muscle power grade 4) underwent craniotomy with intraoperative IA-DSA. Imaging revealed main feeding arteries from right anterior cerebral artery. Brain swelling also led to AR overlay deviation, which was overcame by manual readjustment. Operative time was 8 hours, including IA-DSA operation. The effective radiation dose was 12.70 mSv. The patient recovered limb strength and was discharged on day 11. Calculation of the effective IV-DSA dose IV-DSA consisted of three steps: (i) the iFlow method was used as a test round; (ii) the required time window was calculated; and (iii) a time-specific 3D scan was performed. The effective radiation dose was calculated as: Effective radiation dose (mSV) = Dose area product (DAP) (µGy·m 2 ) × 0.055 mSv/Gy·cm² The conversion factor was 0.055 mSv/Gy·cm 2 for cerebral angiography based on previous studies 11 , 12 . In our setting, single-plane IV-DSA (4 frames/s) yielded DAP values of approximately 600–700µGy·m². A representative value of 650 µGy·m² was used for standardization. For 3D DSA (68 frames/s), DAP was approximately 850 µGy·m². The effective dose was calculated as follows: Test injection (using single plane): 650 µGy·m² × 0.055 mSv/Gy·cm² = 0.36 mSv 3D DSA acquisition: 850 µGy·m² × 0.055 mSv/Gy·cm² = 0.47 mSv Total IV-DSA per session: 0.36 + 0.47 = 0.83 mSv For cases in which only a preoperative IV-DSA was performed, the effective dose remained as low as 0.83 mSv, highlighting its radiation-sparing advantage. Comparison of radiation exposure between imaging protocols Table 2 summarizes the effective radiation doses associated with different imaging modalities across clinical settings. Preoperative IV-DSA involves both a test and formal round, resulting in a total dose of approximately 0.83 mSv. In contrast, intraoperative or postoperative evaluations typically require only a repeat 3D scan (0.47 mSv) to assess residual nidus. Table 2 Effective radiation doses of various imaging tools at different times Effective radiation dose of various imaging tools at different times Imaging tools Timing CTA (lowest dose) IA-DSA (lowest dose) IV-DSA Single plane Total iFlow 3D DSA Preoperative 3.3 mSv 2.8 mSv 0.83 mSv 0.36 mSv 0.47 mSv Intraoperative 3.3 mSv 2.8 mSv 0.47 mSv 0 0.47 mSv Postoperative 3.3 mSv 2.8 mSv 0.47 mSv 0 0.47 mSv Accumulation effective radiation dose Imaging tools Number of times CTA (lowest dose) IA-DSA (lowest dose) Single plane IV-DSA/CTA IV-DSA/IA-DSA 1 3.3 mSv 2.8 mSv 0.83 mSv 25.2% 29.6% 2 6.6 mSv 5.6 mSv 1.30 mSv 19.7% 23.2% 3 9.9 mSv 8.4 mSv 1.77 mSv 17.9% 21.1% CTA, computed tomography angiography; IA-DSA, intra-arterial digital subtraction angiography; IV-DSA, intravenous digital subtraction angiography. Contrastingly, the radiation doses of computed tomography angiography (CTA) and IV-DSA are fixed regardless of the preoperative, intraoperative, or postoperative settings. The effective dose of each type of MDCT angiography ranged approximately from 3.3–7 mSv in the published literature and data from our institute, 12–14 whereas the value of IA-DSA was between 2.8 and 14.4 mSv. 12 , 15 In Case 3 , the effective dose of IA-DSA was 12.70 mSv. Generally, the effective dose of IV-DSA is lower than that of MDCT angiography or IA-DSA. To quantify this benefit, we compared cumulative IV-DSA exposure to CTA and IA-DSA using the lowest reported values: 3.3 mSv for CTA and 2.8 mSv for IA-DSA. After one full IV-DSA session (0.83 mSv), the relative dose ratios were 25.2% (IV-DSA/CTA) and 29.6% (IV-DSA/IA-DSA). With repeated imaging—such as preoperative mapping, intraoperative confirmation, and postoperative surveillance—, the cumulated IV-DSA dose reached only 1.77 mSv, equivalent to only 17.9% and 21.1% of accumulative CTA and IA-DSA doses, respectively. These findings emphasize the radiation-sparing advantage of IV-DSA in pediatric AVM management. This trend is visualized in Fig. 3 , which compares the cumulative effective doses of each modality across 1–3 sessions. The graph clearly demonstrates that IV-DSA maintains a substantial dose advantage over CTA and IA-DSA at every time point. DISCUSSION Protocol Innovation and Pediatric Adaptation Few studies have proposed standardized IV-DSA protocols, particularly in children. Prior adult reports (e.g., Spetzler–Martin grade I parietal AVM 10 ) mentioned 15 mL (test) and 50 mL (formal) contrast injections at 5 mL/s, with a 19-second delay. However, critical imaging parameters such as timing methods or IV route were often unreported 16 . To adapt for pediatric physiology, we referenced Thust et al. 17 , which recommended 2.5–4.0 mL/s and 1–2 mL/kg in children. In our cases, we used 1 mL/kg at 3.5 mL/s for unruptured AVM, and 0.8 mL/kg at 2.5 mL/s for a 4-year-old with IICP. Despite image distortion from edema and peripheral vessels, vessel orientation remained clinically useful. The iFlow-guided test round and enhancement curve allowed individualized scan timing, improving upon pediatric CTA, which relies on aortic triggers often inaccurate due to cardiac variability. In Thust’s cohort 17 , one-third of CTA images were suboptimal. Our results show IV-DSA with iFlow provides more precise and pediatric-tailored imaging. Radiation Safety and Pediatric Considerations Radiation exposure in pediatric patients is not only linked to carcinogenesis 18 but also to neurocognitive impairment. According to the International Commission on Radiological Protection, 1 Sv of radiation carries an estimated cancer risk of 5.5% in the general population, and a heritable risk of 0.2% per Sv 19 . Childhood studies have shown that cumulative exposures exceeding 24 Gy in children under 3 years, and 36 Gy in those under 6 years, are associated with measurable reductions in IQ 20 . These statistics highlight the necessity of minimizing dose, particularly in children who may undergo multiple imaging sessions. In this study, our IV-DSA AR-guided protocol demonstrated a substantial reduction in radiation exposure compared to conventional CTA and IA-DSA. A full IV-DSA session delivered only 0.83 mSv—approximately 25.2% of CTA and 29.6% of IA-DSA dose equivalents. With three imaging sessions, the cumulative IV-DSA dose remained below 2 mSv, representing 17.9% and 21.1% of CTA and IA-DSA, respectively. These findings, supported visually by Fig. 3 , reinforce the dose-sparing potential of IV-DSA for pediatric cerebrovascular evaluation. While current guidelines emphasize radiation limits in adults, children are disproportionately vulnerable due to developing tissues and higher effective dose per organ mass. The cumulative effect is more pronounced when imaging is repeated over years for follow-up or residual lesion surveillance. In this context, even small reductions per imaging session compound into clinically meaningful benefits for pediatric patients. Furthermore, radiation-induced vascular changes, particularly in developing cerebral vasculature, may have long-term consequences not fully documented in current literature. These risks underscore the necessity of reducing unnecessary exposure in pediatric neurovascular procedures. Clinical Feasibility and Technical Adaptation of IV-DSA DSA remains a cornerstone in AVM surgical planning. However, conventional intra-arterial DSA (IA-DSA)—especially via the transfemoral route—is associated with procedural risks including groin hematoma, ischemic or hemorrhagic stroke, vasospasm, and arterial dissection. The complication rate of transfemoral DSA in pediatric groups ranges from 3.3% to 4.8% 21–23 , whereas the overall complication rate in adult groups ranges from 0.5% to 2.6% 24,25 . Transradial DSA, though preferred in adults for its reduced groin-related complications, is generally contraindicated in young children. Alehaideb et al. reported that the average radial artery diameter in children under 12 years is less than 2 mm 26 , below the minimum threshold for safe cannulation. Furthermore, pediatric patients show higher rates of radial artery spasm (23%), stenosis (7.7%), thrombotic occlusion (3.8%), and hematoma (7.7%) compared to adults, whose overall complication risk is around 1.8% 27,28 . Given these anatomical and physiological constraints, IV-DSA via CVC—routinely placed for pediatric anesthesia—offers a safer, less invasive, and more practical alternative. The technique allows angiographic acquisition from multiple vascular territories in a single session without repositioning the catheter and eliminates the need for intra-arterial navigation through tortuous vasculature. This minimizes vascular trauma and shortens procedure time. Furthermore, unlike IA-DSA which mandates a supine position, IV-DSA permits flexible patient positioning. This is particularly beneficial in pediatric bAVM surgeries involving posterior fossa lesions, where prone or lateral positioning is often required. In such cases, arterial catheter fixation can be difficult and time-consuming, further highlighting the procedural convenience of IV-DSA. While Table 2 establishes an optimized baseline where the minimum effective dose (ED) for IA-DSA is 2.8 mSv, our clinical cases illustrate a substantial divergence between idealized benchmarks and real-world neurosurgical practice. In Case 3 , the IA-DSA required a total dose of 12.70 mSv—more than 4.5 times its theoretical minimum—due to the inherent complexities of intraoperative arterial navigation and repeated roadmapping. Conversely, although the ED in Case 1 (1.92 mSv) and Case 2 (7.91 mSv) exceeded the idealized IV-DSA benchmark of 0.83 mSv, these values remained consistently lower than the corresponding IA-DSA requirements. This disparity underscores the superior "dose predictability" of our IV-DSA protocol. In pediatric patients, where anatomical fragility often complicates intra-arterial access, the IV-DSA approach ensures that even in urgent scenarios with significant brain shift (as demonstrated in Case 2 ), radiation exposure remains managed and significantly lower than the cumulative risks associated with traditional intra-arterial maneuvers. Importantly, this technique is not experimental. It is a mature protocol previously validated in adult populations, now demonstrated in a pediatric context. 10 , 16 The two presented cases were selected not as a typical case series, but rather to highlight the expanded utility and unique advantages of this protocol in children. Our analysis of radiation dose reduction is an original contribution that extends the utility of IV-DSA beyond workflow feasibility—quantifying its benefit through reproducible dose modeling. The IV-DSA protocol also streamlines intraoperative workflow across surgical and radiological teams. Because it does not require real-time catheter control by an interventional radiologist, the surgical team can operate with greater autonomy and less operative time. In Case 2 , IV-DSA-guided resection of a ruptured AVM cost only 6.5 hours while IA-DSA-guided surgery in Case 3 took 8 hours. This is particularly beneficial in pediatric centers with limited neurointerventional coverage. Reduced need for radiology personnel during navigation lowers coordination barriers, allows faster transitions between imaging and resection phases, and shortens anesthesia time—a critical advantage in pediatrics. Role of i-Flow Timing and AR Navigation Optimized imaging quality in our protocol was achieved through iFlow-based test rounds and delay time estimation. Unlike conventional CTA, which relies on aortic arch triggering or bolus tracking, iFlow enables real-time monitoring of intracranial vessel opacification, thus minimizing timing errors related to anatomical or cardiac variability. This benefit is particularly valuable in pediatric patients, who may exhibit non-standard hemodynamics. Our use of a 4 frames/s acquisition rate further limited unnecessary exposure while maintaining diagnostic quality. Augmented reality (AR) guidance enhanced intraoperative orientation by projecting color-coded 3D vascular reconstructions directly onto the surgical field. This integration improved spatial perception and reduced the cognitive load of switching between monitors and the microscope. 29 In unruptured AVMs, post-dural DSA allowed for accurate overlay alignment. In ruptured cases with brain edema and cortical shift (e.g., Case 2 , 3 ), manual adjustments of the AR overlay ensured persistent accuracy. Compared to preoperative MDCT angiography-based navigation, which lacks adaptability to intraoperative deformation, our AR-enhanced approach preserved real-time anatomical relevance. In Case 2 , IV-DSA performed before dural opening allowed adequate visualization despite severe cerebral edema. Although AR projection required manual adjustment due to cortical shift, intraoperative anatomical feedback confirmed alignment accuracy. Notably, IV-DSA provided sufficient spatial data for determining safe dissection planes without the need for repeat IA injections. This further illustrates the feasibility of IV-DSA navigation even in dynamically changing operative fields, where IA-DSA would require time-consuming repositioning and catheter manipulation. Limitations and Future Directions Radiation dosimetry may vary across imaging platforms due to differences in manufacturer settings, system generations, and acquisition protocols. While our estimates were based on measured DAP values and established conversion factors, some variability in effective dose is inevitable. Additionally, current findings reflect early-phase clinical experience; broader validation in diverse pediatric cohorts will be essential to confirm consistency in imaging quality, radiation sparing, and surgical outcomes over time. The IV-DSA AR protocol holds potential for broader application beyond AVMs, including dural sinus malformations, vein of Galen anomalies, and pediatric brain tumors with vascular involvement. Future investigations may incorporate real-time 4D flow mapping, AR drift correction, and artificial intelligence-driven vessel segmentation to further enhance intraoperative navigation. Multi-center studies will be necessary to assess reproducibility across platforms and teams, and to establish standardized pediatric IV-DSA guidelines. In conclusion, IV-DSA–based AR guidance provides a safe, adaptable, and radiation-efficient imaging strategy for pediatric neurovascular surgery. As clinical experience expands, this protocol may serve as a foundation for more personalized, lower-risk, and workflow-integrated surgical planning in children. Its adaptability, safety profile, and imaging quality suggest potential for broader integration into pediatric neurovascular practice. CONCLUSION This study demonstrates the feasibility and clinical value of a standardized IV-DSA protocol integrated with AR-guided navigation in pediatric brain AVM surgery. By quantifying radiation exposure across multiple imaging modalities and demonstrating protocol adaptability to pediatric physiology, we provide evidence supporting IV-DSA as a safer, less invasive, and workflow-efficient alternative to conventional angiographic methods. Our dosimetric modeling, technical workflow, and intraoperative outcomes highlight the potential for broader adoption of this technique beyond AVMs. As pediatric neurovascular surgery increasingly demands individualized, low-risk imaging strategies, the IV-DSA protocol offers a reproducible and scalable solution grounded in both imaging science and surgical practicality. Funding and disclosures This study was supported by the National Chung Hsing University, Chung Shan Medical University, Taiwan National Science and Technology Council (NSTC 113-2320-B-005-006), and Taichung Veterans General Hospital (Grant No. TCVGH-1134903B, TCVGH-CTUST1147702). Central Taiwan University of Science and Technology, Taiwan (114-OA080 TCVGH-CTUST1147702). The authors have no competing interests to declare. Declarations Acknowledgements The authors are grateful to the National Chung Hsing University, Chung Shan Medical University, and Taichung Veterans General Hospital for providing administrative, technical, and funding support. Funding and disclosures This study was supported by the National Chung Hsing University, Chung Shan Medical University, Taiwan National Science and Technology Council (NSTC 113-2320-B-005-006), and Taichung Veterans General Hospital (Grant No. TCVGH-1134903B, TCVGH-CTUST1147702). Central Taiwan University of Science and Technology, Taiwan (114-OA080 TCVGH-CTUST1147702). The authors have no competing interests to declare. Ethics approval This study was approved by the Ethics Review Committee of Taichung Veterans General Hospital, Taichung, Taiwan (IRB no: CE17182A). Patient consent for publication Informed consent was obtained from the patients' parents. Data availability statement The datasets used in this study are available from the Ministry of Health and Welfare Taiwan, on reasonable request. Funding and disclosures This study was supported by the National Chung Hsing University, Chung Shan Medical University, Taiwan National Science and Technology Council (NSTC 113-2320-B-005-006), and Taichung Veterans General Hospital (Grant No. TCVGH-1134903B, TCVGH-CTUST1147702). Central Taiwan University of Science and Technology, Taiwan (114-OA080 TCVGH-CTUST1147702). The authors have no competing interests to declare. Ethics approval This study was approved by the Ethics Review Committee of Taichung Veterans General Hospital, Taichung, Taiwan (IRB no: CE17182A). The research was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from the legal guardians of all pediatric participants for their participation in this study and for the publication of the clinical findings. Author Contributions C.W.H. and C.C.C. contributed to the study conception and design. Material preparation, data collection, and analysis were performed by C.W.H. and K.C.C.. The first draft of the manuscript was written by C.W.H. and C.C.C., and all authors (P.Y.T., C.H.L., B.S.L., Y.S.T., S.F.Y.) commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Nikolaev SI, Vetiska S, Bonilla X, et al. Somatic activating KRAS mutations in arteriovenous malformations of the brain. N Engl J Med. 2018;378(3):250–61. 10.1056/nejmoa1709449 . McDonald JS, McDonald RJ, Comin J, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. Radiology. 2013;267(1):119–28. 10.1148/radiol.12121460 . 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Comparison of transfemoral cerebral angiography and transradial cerebral angiography following a shift in practice during four years at a single center in China. Med Sci Monit. 2020;26:e921631. 10.12659/MSM.921631 . Alehaideb A, Ha W, Bickford S, et al. Can children be considered for transradial interventions? prospective study of sonographic radial artery diameters. Circ Cardiovasc Interv. 2020;13(7):e009251. 10.1161/CIRCINTERVENTIONS.120.009251 . Irving C, Zaman A, Kirk R. Transradial coronary angiography in children and adolescents. Pediatr Cardiol. 2009;30(8):1089–93. 10.1007/s00246-009-9502-6 . Lee SB, Cho YJ, Kim S-H, Lee S, Choi YH, Cheon J-E. Transradial cerebral angiography: is it feasible and safe for children? Cardiovasc Interv Radiol. 2022;45(4):504–9. 10.1007/s00270-022-03070-w . Li C-R, Shen C-C, Yang M-Y, Tsuei Y-S, Lee C-H. Intraoperative augmented reality in microsurgery for intracranial arteriovenous malformation: a case report and literature review. Brain Sci. 2023;13(4):653. 10.3390/brainsci13040653 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviews received at journal 09 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers invited by journal 29 Apr, 2026 Editor invited by journal 08 Apr, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 27 Mar, 2026 First submitted to journal 19 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9167196","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635741132,"identity":"53beceee-a08b-48a9-85ee-8e2b8eab8fe7","order_by":0,"name":"Chih-Wei Huang","email":"","orcid":"","institution":"Chung Shan Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chih-Wei","middleName":"","lastName":"Huang","suffix":""},{"id":635741133,"identity":"43668aaf-4853-4835-b793-2736ea268c85","order_by":1,"name":"Chiu-Chun Chen","email":"","orcid":"","institution":"Taichung Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chiu-Chun","middleName":"","lastName":"Chen","suffix":""},{"id":635741135,"identity":"e96dd138-69aa-4722-a67a-d62b07eb8bf7","order_by":2,"name":"Kai-Chen Chung","email":"","orcid":"","institution":"Taichung Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kai-Chen","middleName":"","lastName":"Chung","suffix":""},{"id":635741136,"identity":"1bca7b44-33cf-4690-8695-e24e85c5ce53","order_by":3,"name":"Pei-Ying Tseng","email":"","orcid":"","institution":"Asia University","correspondingAuthor":false,"prefix":"","firstName":"Pei-Ying","middleName":"","lastName":"Tseng","suffix":""},{"id":635741138,"identity":"befe72fc-50d5-41ec-b15a-c39b4f8f1587","order_by":4,"name":"Che-Hao Lin","email":"","orcid":"","institution":"Taichung Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Che-Hao","middleName":"","lastName":"Lin","suffix":""},{"id":635741139,"identity":"466cc6e1-2846-463d-b862-a99a38a852e6","order_by":5,"name":"Bai-Shuan Liu","email":"","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Bai-Shuan","middleName":"","lastName":"Liu","suffix":""},{"id":635741140,"identity":"43c68d51-4abf-407c-a49e-0564efae63f8","order_by":6,"name":"Yuang-Seng Tsuei","email":"data:image/png;base64,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","orcid":"","institution":"National Chung Hsing University","correspondingAuthor":true,"prefix":"","firstName":"Yuang-Seng","middleName":"","lastName":"Tsuei","suffix":""},{"id":635741143,"identity":"0a2290a3-c459-40ce-b605-c927ce9a9e65","order_by":7,"name":"Shun-Fa Yang","email":"","orcid":"","institution":"Chung Shan Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shun-Fa","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-03-19 08:53:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9167196/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9167196/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108956839,"identity":"dff71e57-f484-441a-8dd9-81c051ff51b1","added_by":"auto","created_at":"2026-05-11 08:15:27","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6158055,"visible":true,"origin":"","legend":"\u003cp\u003eA school-aged child (Case 1) was diagnosed with an unruptured left frontal arteriovenous malformation (AVM; Spetzler–Martin grade I) (A, B). Intravenous digital subtraction angiography (C, D) revealed two main feeding arteries originating from the left anterior cerebral artery, several minor feeding arteries from the left middle cerebral artery, and one superficial drainage vein. We used the iFlow system (ARTIS icono biplane angiography system; Siemens Healthineers, Erlangen, Germany) (E–H) to predict the triggering time by tracking the opacification of the intracranial vessels and nidus. We also employed 3D digital subtraction angiography (DSA), which outlined the AVM lesion and the location in the skull (I). We labeled the contours of the nidus (yellow), superficial drainage vein (green), superficial feeding arteries (blue), and deep feeding arteries (red) below the nidus. The AR image was precisely projected onto the brain surface where brain AVM (bAVM) was located (J, K). When we began to resect the caudal site of bAVM, augmented reality navigation guided us on the nidus margin and the direction of feeding arteries below (L).\u003c/p\u003e","description":"","filename":"Fig11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9167196/v1/b2c6ad4db69e2b94b3762954.jpg"},{"id":108956657,"identity":"45cc8f6e-04f0-4c36-91b3-ee7986a28127","added_by":"auto","created_at":"2026-05-11 08:14:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3796283,"visible":true,"origin":"","legend":"\u003cp\u003eA preschool-aged child (Case 2) presented with a ruptured left parietal–occipital arteriovenous malformation with altered consciousness and signs of increased intracranial pressure. Initial brain computed tomography revealed a left parietal–occipital intracerebral hemorrhage with a midline shift (A, B). Magnetic resonance angiography showed persistent brain swelling after decompressive craniectomy (C, D). bAVM resection was performed in a hybrid room equipped with an ARTIS icono biplane angiography system (E). We delineated the nidus (yellow), superficial drainage vein (green), and feeding arteries (pink and red) originating from the left middle cerebral artery and adjacent gyrus (light blue; F). Severe brain shift occurred after dural opening (G). After manual adjustment of the augmented reality projection, we regained a sense of direction and smoothly resected the bAVM as planned (H).\u003c/p\u003e","description":"","filename":"Fig21.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9167196/v1/8020964043836fbdd6c81071.jpg"},{"id":108956869,"identity":"8638f2ec-320a-464e-b7b0-b2e4c9499060","added_by":"auto","created_at":"2026-05-11 08:15:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74215,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of cumulative effective radiation doses. Comparison of the cumulative effective doses (mSv) among intravenous digital subtraction angiography (IV-DSA), computed tomography angiography (CTA), and intra-arterial digital subtraction angiography (IA-DSA) across one, two, and three imaging sessions. The graph illustrates the substantial radiation-sparing advantage of the IV-DSA protocol compared to conventional modalities at every time point.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-9167196/v1/cc32de5837bf1310cc834e97.png"},{"id":108957103,"identity":"3eaf624b-6979-4840-9b46-5bab02ce996f","added_by":"auto","created_at":"2026-05-11 08:16:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":10309779,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9167196/v1/8d29bfaf-afc1-4e4d-8e23-89405e8d48e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Radiation-Sparing Intravenous DSA and Augmented Reality Navigation in Pediatric Neurosurgery: A Quantitative Analysis of Perioperative Effective Dose and Workflow","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eArteriovenous malformations (AVMs) are complex vascular anomalies characterized by direct connections between the arteries and veins without intermediary capillary networks, thereby disrupting blood circulation and oxygen transport.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Brain AVMs (bAVMs) can jeopardize the cerebral steal phenomenon, seizures, headache, aneurysm or venous stenosis formation, and intracerebral hemorrhage,\u003csup\u003e2\u003c/sup\u003e and are the leading cause of pediatric intracerebral hemorrhage, accounting for up to 55% of cases.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The annual hemorrhage risk due to pediatric bAVM ranges from 2%\u0026ndash;10%,\u003csup\u003e4\u003c/sup\u003e which is higher than that in the adult population (1%\u0026ndash;3%).\u003csup\u003e5\u003c/sup\u003e In one study, distribution in the posterior fossa or basal ganglion, which exhibits a greater rupture risk, was more frequently noted in pediatric AVMs than in adult AVMs.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The mortality rate of bAVM in children can be as high as 21%.\u003csup\u003e2\u003c/sup\u003e Therefore, this should be proactively addressed.\u003c/p\u003e \u003cp\u003eSurgical resection remains the primary treatment option for bAVMs with low Spetzler\u0026ndash;Martin grades\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. First, surgical resection leads to an instant cure and a higher obliteration rate than pure radiosurgery or endovascular intervention.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Otherwise, non-surgical treatment is required, which is a long-term process for children and their guardians. Second, radiosurgery increases radiation exposure. Third, endovascular intervention is less feasible for children because of the limited sizes of catheters, wires, and coils. However, surgical resection of pediatric bAVM is linked to several challenges. Surgeons should consider the balance between complete AVM resection and preservation of neurological function, especially when the lesion is in a crucial neurovascular region. Additionally, pediatric hemodynamic fragility and variability significantly increase perioperative risks, as children have less total blood volume compared to adults. The body surface area of a child is greater than that of an adult; therefore, children are more susceptible to fluid loss and hypothermia induced by long surgery durations\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e; in particular, hypothermia can induce coagulopathy and suppress cardiorespiration. Furthermore, hypotension is a late sign of hemorrhagic shock in children, which may reduce the ability to assess blood loss.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConsequently, comprehensive perioperative planning is required for pediatric AVM resections. Various imaging technologies have been introduced to deconstruct lesions and aid surgery, including intra-arterial digital subtraction angiography (IA-DSA), multidetector computed tomography (MDCT) angiography-based navigation, and augmented reality (AR). However, current imaging protocols documented in literature inevitably result in substantial radiation exposure and increased procedural risks, particularly in pediatric populations.\u003c/p\u003e \u003cp\u003eGiven the existing challenges of pediatric neurointervention\u0026mdash;such as fragile vasculature, limited training resources, prolonged interventionalist standby, and high procedural costs\u0026mdash;we extended our previously validated adult IV-DSA method to pediatric patients. Therefore, we adapted and implemented our established intravenous digital subtraction angiography (IV-DSA) technique, combined with AR navigation, for pediatric bAVM surgery, aiming to enhance surgical precision, reduce invasiveness, and minimize radiation exposure. This protocol provides an efficient and smooth surgical process with greater precision and adjustability but lower invasiveness and radiation exposure.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study was conducted in a hybrid operating room using an IV-DSA and AR-guided protocol for pediatric bAVM resection. The surgical workflow was adapted from previous protocols\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, with modifications in contrast volume, injection rate, and timing tailored to pediatric physiology.\u003c/p\u003e \u003cp\u003eSource imaging was acquired using an iFlow-tailored IV-DSA protocol with a biplane angiography system (ARTIS icono, Siemens Healthineers, Germany).\u003c/p\u003e \u003cp\u003eA preliminary test injection was administered via a central venous catheter (CVC) at a flow rate of 3.5 mL/s, using a total contrast volume of 1 mL/kg, followed by a saline flush of double that volume. Optimal scan delay was determined using iFlow software (syngo, Siemens), which analyzes contrast kinetics and generates a color-coded intensity map\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. To minimize cortical shift during craniotomy, patients were positioned using a radiolucent head holder. After dural opening, a formal 3D DSA scan was performed using 1\u0026ndash;1.5 mL/kg of contrast at an injection rate of 2.5\u0026ndash;3.5 mL/s. The angioarchitecture, including feeding arteries, draining veins, AVM nidus, and cortical surface landmarks, was segmented using SmartBrush (Brainlab, IL, USA). These labels were then coregistered with the navigation system and fused with intraoperative microscopy using the KINEVO surgical microscope (ZEISS, Germany).\u003c/p\u003e \u003cp\u003eDuring resection, primary arterial feeders were identified and occluded with surgical clips applied as proximally to the nidus as feasible. The AVM nidus was subsequently removed under continuous AR guidance, allowing real-time orientation between the anatomical structures and projected vascular models.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe present two representative pediatric cases to demonstrate the applicability of IV-DSA AR-guided bAVM surgery in both elective and urgent settings. Case \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e1\u003c/span\u003e involved a scheduled procedure for an unruptured lesion, while Case \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e required second-stage surgery for a previously ruptured AVM with significant cerebral edema. Detailed perioperative information is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. We also illustrated Case \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e3\u003c/span\u003e, who received resection of a ruptured AVM under IA-DSA AR guided-guided surgery as comparison.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of two representative cases reported herein\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBody weight\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 kg\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 kg\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnruptured, absence of seizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntracerebral hemorrhage with brain edema\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAVM, SM grade, location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSM\u0026thinsp;=\u0026thinsp;1, left frontal lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSM\u0026thinsp;=\u0026thinsp;1, left parietal lobe\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV route\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight neck CVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft neck CVC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtocol of the test round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 mL contrast (3.5 mL/s), bolus with 50 mL saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 cc contrast (2.5 mL/s), bolus with 16 mL saline\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiming of the test round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupine, before positioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSupine, before positioning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 s\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3D DSA, 4 s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D DSA, 4 s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D DSA, 4 s\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3D DSA protocol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 mL contrast (3.5 mL/s), bolus with 30 mL saline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 mL contrast (2.5 mL/s), bolus with 10 mL saline\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3-pin radiolucent head holder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHorseshoe radiolucent head supporter\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiming of 3D DSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter dura opening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore dura opening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage quality for navigation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFair (peripheral, small-sized vessel, and brain edema)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAVM, arteriovenous malformation; CVC, central venous catheter; DSA, digital subtraction angiography; SM, Spetzler\u0026ndash;Martin.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 1\u003c/strong\u003e \u003cp\u003eA school-aged child with an unruptured left frontal AVM (Spetzler\u0026ndash;Martin grade I) underwent surgery with intraoperative IV-DSA. Imaging identified two major feeders from the left anterior cerebral artery, several minor feeders from the left middle cerebral artery, and a single superficial draining vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Total blood loss was approximately 100 mL, and operative time was 6.5 hours, including IV-DSA setup. The effective radiation dose was 1.92 mSv. The patient had no postoperative neurological deficits and was discharged on postoperative day 6.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003cp\u003eA preschool-aged child with a ruptured left parietal\u0026ndash;occipital AVM and signs of increased intracranial pressure (GCS E3V1M5) underwent craniectomy and hematoma evacuation at an outside facility, followed by transfer. On postoperative day 8, a second-stage resection was performed. Due to anticipated brain shift from edema, IV-DSA was performed pre-craniotomy. Imaging revealed two major feeders from the left middle cerebral artery and one superficial draining vein. Brain swelling induced AR overlay deviation, requiring manual adjustment to realign with cortical structures. Resection and cranioplasty were completed within 4 hours (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The effective radiation dose was 7.91 mSv. The patient recovered full consciousness and limb strength by postoperative day 2 and was discharged on day 8.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 3\u003c/strong\u003e \u003cp\u003eA school-aged child with a ruptured right frontal-parietal AVM and left lower limb weakness (muscle power grade 4) underwent craniotomy with intraoperative IA-DSA. Imaging revealed main feeding arteries from right anterior cerebral artery. Brain swelling also led to AR overlay deviation, which was overcame by manual readjustment. Operative time was 8 hours, including IA-DSA operation. The effective radiation dose was 12.70 mSv. The patient recovered limb strength and was discharged on day 11.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eCalculation of the effective IV-DSA dose\u003c/p\u003e \u003cp\u003eIV-DSA consisted of three steps: (i) the iFlow method was used as a test round; (ii) the required time window was calculated; and (iii) a time-specific 3D scan was performed. The effective radiation dose was calculated as:\u003c/p\u003e \u003cp\u003eEffective radiation dose (mSV) = Dose area product (DAP) (\u0026micro;Gy\u0026middot;m\u003csup\u003e2\u003c/sup\u003e) \u0026times; 0.055 mSv/Gy\u0026middot;cm\u0026sup2;\u003c/p\u003e \u003cp\u003eThe conversion factor was 0.055 mSv/Gy\u0026middot;cm\u003csup\u003e2\u003c/sup\u003e for cerebral angiography based on previous studies\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our setting, single-plane IV-DSA (4 frames/s) yielded DAP values of approximately 600\u0026ndash;700\u0026micro;Gy\u0026middot;m\u0026sup2;. A representative value of 650 \u0026micro;Gy\u0026middot;m\u0026sup2; was used for standardization. For 3D DSA (68 frames/s), DAP was approximately 850 \u0026micro;Gy\u0026middot;m\u0026sup2;.\u003c/p\u003e \u003cp\u003eThe effective dose was calculated as follows:\u003c/p\u003e \u003cp\u003eTest injection (using single plane): 650 \u0026micro;Gy\u0026middot;m\u0026sup2; \u0026times; 0.055 mSv/Gy\u0026middot;cm\u0026sup2; = 0.36 mSv\u003c/p\u003e \u003cp\u003e3D DSA acquisition: 850 \u0026micro;Gy\u0026middot;m\u0026sup2; \u0026times; 0.055 mSv/Gy\u0026middot;cm\u0026sup2; = 0.47 mSv\u003c/p\u003e \u003cp\u003eTotal IV-DSA per session: 0.36\u0026thinsp;+\u0026thinsp;0.47\u0026thinsp;=\u0026thinsp;0.83 mSv\u003c/p\u003e \u003cp\u003eFor cases in which only a preoperative IV-DSA was performed, the effective dose remained as low as 0.83 mSv, highlighting its radiation-sparing advantage.\u003c/p\u003e \u003cp\u003eComparison of radiation exposure between imaging protocols\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the effective radiation doses associated with different imaging modalities across clinical settings. Preoperative IV-DSA involves both a test and formal round, resulting in a total dose of approximately 0.83 mSv. In contrast, intraoperative or postoperative evaluations typically require only a repeat 3D scan (0.47 mSv) to assess residual nidus.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffective radiation doses of various imaging tools at different times\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eEffective radiation dose of various imaging tools at different times\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eImaging tools\u003c/p\u003e \u003cp\u003eTiming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCTA\u003c/p\u003e \u003cp\u003e(lowest dose)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIA-DSA\u003c/p\u003e \u003cp\u003e(lowest dose)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eIV-DSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eSingle plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eiFlow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3D DSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.83 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.36 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.47 mSv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.47 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.47 mSv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.47 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.47 mSv\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccumulation effective radiation dose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eImaging\u003c/p\u003e \u003cp\u003etools\u003c/p\u003e \u003cp\u003eNumber\u003c/p\u003e \u003cp\u003eof times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCTA\u003c/p\u003e \u003cp\u003e(lowest dose)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIA-DSA\u003c/p\u003e \u003cp\u003e(lowest dose)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eSingle plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIV-DSA/CTA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIV-DSA/IA-DSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.83 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.6 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.30 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.9 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.77 mSv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eCTA, computed tomography angiography; IA-DSA, intra-arterial digital subtraction angiography; IV-DSA, intravenous digital subtraction angiography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eContrastingly, the radiation doses of computed tomography angiography (CTA) and IV-DSA are fixed regardless of the preoperative, intraoperative, or postoperative settings. The effective dose of each type of MDCT angiography ranged approximately from 3.3\u0026ndash;7 mSv in the published literature and data from our institute,\u003csup\u003e12\u0026ndash;14\u003c/sup\u003e whereas the value of IA-DSA was between 2.8 and 14.4 mSv.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e In Case \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the effective dose of IA-DSA was 12.70 mSv. Generally, the effective dose of IV-DSA is lower than that of MDCT angiography or IA-DSA.\u003c/p\u003e \u003cp\u003eTo quantify this benefit, we compared cumulative IV-DSA exposure to CTA and IA-DSA using the lowest reported values: 3.3 mSv for CTA and 2.8 mSv for IA-DSA. After one full IV-DSA session (0.83 mSv), the relative dose ratios were 25.2% (IV-DSA/CTA) and 29.6% (IV-DSA/IA-DSA). With repeated imaging\u0026mdash;such as preoperative mapping, intraoperative confirmation, and postoperative surveillance\u0026mdash;, the cumulated IV-DSA dose reached only 1.77 mSv, equivalent to only 17.9% and 21.1% of accumulative CTA and IA-DSA doses, respectively. These findings emphasize the radiation-sparing advantage of IV-DSA in pediatric AVM management. This trend is visualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, which compares the cumulative effective doses of each modality across 1\u0026ndash;3 sessions. The graph clearly demonstrates that IV-DSA maintains a substantial dose advantage over CTA and IA-DSA at every time point.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eProtocol Innovation and Pediatric Adaptation\u003c/p\u003e \u003cp\u003eFew studies have proposed standardized IV-DSA protocols, particularly in children. Prior adult reports (e.g., Spetzler\u0026ndash;Martin grade I parietal AVM\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e) mentioned 15 mL (test) and 50 mL (formal) contrast injections at 5 mL/s, with a 19-second delay. However, critical imaging parameters such as timing methods or IV route were often unreported\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo adapt for pediatric physiology, we referenced Thust et al.\u003csup\u003e17\u003c/sup\u003e, which recommended 2.5\u0026ndash;4.0 mL/s and 1\u0026ndash;2 mL/kg in children. In our cases, we used 1 mL/kg at 3.5 mL/s for unruptured AVM, and 0.8 mL/kg at 2.5 mL/s for a 4-year-old with IICP. Despite image distortion from edema and peripheral vessels, vessel orientation remained clinically useful.\u003c/p\u003e \u003cp\u003eThe iFlow-guided test round and enhancement curve allowed individualized scan timing, improving upon pediatric CTA, which relies on aortic triggers often inaccurate due to cardiac variability. In Thust\u0026rsquo;s cohort\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, one-third of CTA images were suboptimal. Our results show IV-DSA with iFlow provides more precise and pediatric-tailored imaging.\u003c/p\u003e \u003cp\u003eRadiation Safety and Pediatric Considerations\u003c/p\u003e \u003cp\u003eRadiation exposure in pediatric patients is not only linked to carcinogenesis\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e but also to neurocognitive impairment. According to the International Commission on Radiological Protection, 1 Sv of radiation carries an estimated cancer risk of 5.5% in the general population, and a heritable risk of 0.2% per Sv \u003csup\u003e19\u003c/sup\u003e. Childhood studies have shown that cumulative exposures exceeding 24 Gy in children under 3 years, and 36 Gy in those under 6 years, are associated with measurable reductions in IQ \u003csup\u003e20\u003c/sup\u003e. These statistics highlight the necessity of minimizing dose, particularly in children who may undergo multiple imaging sessions.\u003c/p\u003e \u003cp\u003eIn this study, our IV-DSA AR-guided protocol demonstrated a substantial reduction in radiation exposure compared to conventional CTA and IA-DSA. A full IV-DSA session delivered only 0.83 mSv\u0026mdash;approximately 25.2% of CTA and 29.6% of IA-DSA dose equivalents. With three imaging sessions, the cumulative IV-DSA dose remained below 2 mSv, representing 17.9% and 21.1% of CTA and IA-DSA, respectively. These findings, supported visually by Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, reinforce the dose-sparing potential of IV-DSA for pediatric cerebrovascular evaluation.\u003c/p\u003e \u003cp\u003eWhile current guidelines emphasize radiation limits in adults, children are disproportionately vulnerable due to developing tissues and higher effective dose per organ mass. The cumulative effect is more pronounced when imaging is repeated over years for follow-up or residual lesion surveillance. In this context, even small reductions per imaging session compound into clinically meaningful benefits for pediatric patients. Furthermore, radiation-induced vascular changes, particularly in developing cerebral vasculature, may have long-term consequences not fully documented in current literature. These risks underscore the necessity of reducing unnecessary exposure in pediatric neurovascular procedures.\u003c/p\u003e \u003cp\u003eClinical Feasibility and Technical Adaptation of IV-DSA\u003c/p\u003e \u003cp\u003eDSA remains a cornerstone in AVM surgical planning. However, conventional intra-arterial DSA (IA-DSA)\u0026mdash;especially via the transfemoral route\u0026mdash;is associated with procedural risks including groin hematoma, ischemic or hemorrhagic stroke, vasospasm, and arterial dissection. The complication rate of transfemoral DSA in pediatric groups ranges from 3.3% to 4.8%\u003csup\u003e21\u0026ndash;23\u003c/sup\u003e, whereas the overall complication rate in adult groups ranges from 0.5% to 2.6%\u003csup\u003e24,25\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTransradial DSA, though preferred in adults for its reduced groin-related complications, is generally contraindicated in young children. Alehaideb et al. reported that the average radial artery diameter in children under 12 years is less than 2 mm\u003csup\u003e26\u003c/sup\u003e, below the minimum threshold for safe cannulation. Furthermore, pediatric patients show higher rates of radial artery spasm (23%), stenosis (7.7%), thrombotic occlusion (3.8%), and hematoma (7.7%) compared to adults, whose overall complication risk is around 1.8%\u003csup\u003e27,28\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGiven these anatomical and physiological constraints, IV-DSA via CVC\u0026mdash;routinely placed for pediatric anesthesia\u0026mdash;offers a safer, less invasive, and more practical alternative. The technique allows angiographic acquisition from multiple vascular territories in a single session without repositioning the catheter and eliminates the need for intra-arterial navigation through tortuous vasculature. This minimizes vascular trauma and shortens procedure time. Furthermore, unlike IA-DSA which mandates a supine position, IV-DSA permits flexible patient positioning. This is particularly beneficial in pediatric bAVM surgeries involving posterior fossa lesions, where prone or lateral positioning is often required. In such cases, arterial catheter fixation can be difficult and time-consuming, further highlighting the procedural convenience of IV-DSA.\u003c/p\u003e \u003cp\u003eWhile Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e establishes an optimized baseline where the minimum effective dose (ED) for IA-DSA is 2.8 mSv, our clinical cases illustrate a substantial divergence between idealized benchmarks and real-world neurosurgical practice. In Case \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the IA-DSA required a total dose of 12.70 mSv\u0026mdash;more than 4.5 times its theoretical minimum\u0026mdash;due to the inherent complexities of intraoperative arterial navigation and repeated roadmapping.\u003c/p\u003e \u003cp\u003eConversely, although the ED in Case \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e1\u003c/span\u003e (1.92 mSv) and Case \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e (7.91 mSv) exceeded the idealized IV-DSA benchmark of 0.83 mSv, these values remained consistently lower than the corresponding IA-DSA requirements. This disparity underscores the superior \"dose predictability\" of our IV-DSA protocol. In pediatric patients, where anatomical fragility often complicates intra-arterial access, the IV-DSA approach ensures that even in urgent scenarios with significant brain shift (as demonstrated in Case \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e), radiation exposure remains managed and significantly lower than the cumulative risks associated with traditional intra-arterial maneuvers.\u003c/p\u003e \u003cp\u003eImportantly, this technique is not experimental. It is a mature protocol previously validated in adult populations, now demonstrated in a pediatric context.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e The two presented cases were selected not as a typical case series, but rather to highlight the expanded utility and unique advantages of this protocol in children. Our analysis of radiation dose reduction is an original contribution that extends the utility of IV-DSA beyond workflow feasibility\u0026mdash;quantifying its benefit through reproducible dose modeling.\u003c/p\u003e \u003cp\u003eThe IV-DSA protocol also streamlines intraoperative workflow across surgical and radiological teams. Because it does not require real-time catheter control by an interventional radiologist, the surgical team can operate with greater autonomy and less operative time. In Case \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e, IV-DSA-guided resection of a ruptured AVM cost only 6.5 hours while IA-DSA-guided surgery in Case \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e3\u003c/span\u003e took 8 hours. This is particularly beneficial in pediatric centers with limited neurointerventional coverage. Reduced need for radiology personnel during navigation lowers coordination barriers, allows faster transitions between imaging and resection phases, and shortens anesthesia time\u0026mdash;a critical advantage in pediatrics.\u003c/p\u003e \u003cp\u003eRole of i-Flow Timing and AR Navigation\u003c/p\u003e \u003cp\u003eOptimized imaging quality in our protocol was achieved through iFlow-based test rounds and delay time estimation. Unlike conventional CTA, which relies on aortic arch triggering or bolus tracking, iFlow enables real-time monitoring of intracranial vessel opacification, thus minimizing timing errors related to anatomical or cardiac variability. This benefit is particularly valuable in pediatric patients, who may exhibit non-standard hemodynamics. Our use of a 4 frames/s acquisition rate further limited unnecessary exposure while maintaining diagnostic quality.\u003c/p\u003e \u003cp\u003eAugmented reality (AR) guidance enhanced intraoperative orientation by projecting color-coded 3D vascular reconstructions directly onto the surgical field. This integration improved spatial perception and reduced the cognitive load of switching between monitors and the microscope.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e In unruptured AVMs, post-dural DSA allowed for accurate overlay alignment. In ruptured cases with brain edema and cortical shift (e.g., Case \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e3\u003c/span\u003e), manual adjustments of the AR overlay ensured persistent accuracy. Compared to preoperative MDCT angiography-based navigation, which lacks adaptability to intraoperative deformation, our AR-enhanced approach preserved real-time anatomical relevance.\u003c/p\u003e \u003cp\u003eIn Case \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e2\u003c/span\u003e, IV-DSA performed before dural opening allowed adequate visualization despite severe cerebral edema. Although AR projection required manual adjustment due to cortical shift, intraoperative anatomical feedback confirmed alignment accuracy. Notably, IV-DSA provided sufficient spatial data for determining safe dissection planes without the need for repeat IA injections. This further illustrates the feasibility of IV-DSA navigation even in dynamically changing operative fields, where IA-DSA would require time-consuming repositioning and catheter manipulation.\u003c/p\u003e \u003cp\u003eLimitations and Future Directions\u003c/p\u003e \u003cp\u003eRadiation dosimetry may vary across imaging platforms due to differences in manufacturer settings, system generations, and acquisition protocols. While our estimates were based on measured DAP values and established conversion factors, some variability in effective dose is inevitable. Additionally, current findings reflect early-phase clinical experience; broader validation in diverse pediatric cohorts will be essential to confirm consistency in imaging quality, radiation sparing, and surgical outcomes over time.\u003c/p\u003e \u003cp\u003eThe IV-DSA AR protocol holds potential for broader application beyond AVMs, including dural sinus malformations, vein of Galen anomalies, and pediatric brain tumors with vascular involvement. Future investigations may incorporate real-time 4D flow mapping, AR drift correction, and artificial intelligence-driven vessel segmentation to further enhance intraoperative navigation. Multi-center studies will be necessary to assess reproducibility across platforms and teams, and to establish standardized pediatric IV-DSA guidelines.\u003c/p\u003e \u003cp\u003eIn conclusion, IV-DSA\u0026ndash;based AR guidance provides a safe, adaptable, and radiation-efficient imaging strategy for pediatric neurovascular surgery. As clinical experience expands, this protocol may serve as a foundation for more personalized, lower-risk, and workflow-integrated surgical planning in children. Its adaptability, safety profile, and imaging quality suggest potential for broader integration into pediatric neurovascular practice.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study demonstrates the feasibility and clinical value of a standardized IV-DSA protocol integrated with AR-guided navigation in pediatric brain AVM surgery. By quantifying radiation exposure across multiple imaging modalities and demonstrating protocol adaptability to pediatric physiology, we provide evidence supporting IV-DSA as a safer, less invasive, and workflow-efficient alternative to conventional angiographic methods. Our dosimetric modeling, technical workflow, and intraoperative outcomes highlight the potential for broader adoption of this technique beyond AVMs. As pediatric neurovascular surgery increasingly demands individualized, low-risk imaging strategies, the IV-DSA protocol offers a reproducible and scalable solution grounded in both imaging science and surgical practicality.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFunding and disclosures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study was supported by the National Chung Hsing University, Chung Shan Medical University, Taiwan National Science and Technology Council (NSTC 113-2320-B-005-006), and Taichung Veterans General Hospital (Grant No. TCVGH-1134903B, TCVGH-CTUST1147702). Central Taiwan University of Science and Technology, Taiwan (114-OA080 TCVGH-CTUST1147702). The authors have no competing interests to declare.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to the National Chung Hsing University, Chung Shan Medical University, and Taichung Veterans General Hospital for providing administrative, technical, and funding support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and disclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Chung Hsing University, Chung Shan Medical University, Taiwan National Science and Technology Council (NSTC 113-2320-B-005-006), and Taichung Veterans General Hospital (Grant No. TCVGH-1134903B, TCVGH-CTUST1147702). Central Taiwan University of Science and Technology, Taiwan (114-OA080 TCVGH-CTUST1147702). The authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Review Committee of Taichung Veterans General Hospital, Taichung, Taiwan (IRB no: CE17182A).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patients\u0026apos; parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used in this study are available from the Ministry of Health and Welfare Taiwan, on reasonable request.\u003cstrong\u003e\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and disclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Chung Hsing University, Chung Shan Medical University, Taiwan National Science and Technology Council (NSTC 113-2320-B-005-006), and Taichung Veterans General Hospital (Grant No. TCVGH-1134903B, TCVGH-CTUST1147702). Central Taiwan University of Science and Technology, Taiwan (114-OA080 TCVGH-CTUST1147702). The authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Review Committee of Taichung Veterans General Hospital, Taichung, Taiwan (IRB no: CE17182A). The research was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from the legal guardians of all pediatric participants for their participation in this study and for the publication of the clinical findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.W.H. and C.C.C. contributed to the study conception and design. Material preparation, data collection, and analysis were performed by C.W.H. and K.C.C.. The first draft of the manuscript was written by C.W.H. and C.C.C., and all authors (P.Y.T., C.H.L., B.S.L., Y.S.T., S.F.Y.) commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNikolaev SI, Vetiska S, Bonilla X, et al. Somatic activating KRAS mutations in arteriovenous malformations of the brain. N Engl J Med. 2018;378(3):250\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/nejmoa1709449\u003c/span\u003e\u003cspan address=\"10.1056/nejmoa1709449\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcDonald JS, McDonald RJ, Comin J, et al. Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis. 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Brain Sci. 2023;13(4):653. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/brainsci13040653\u003c/span\u003e\u003cspan address=\"10.3390/brainsci13040653\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"arteriovenous malformations, augmented reality, digital subtraction angiography","lastPublishedDoi":"10.21203/rs.3.rs-9167196/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9167196/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eConventional intra-arterial angiography remains the standard for brain arteriovenous malformation surgery but carries inherent risks of arterial complications and significant radiation exposure in children. This study evaluates the feasibility and radiation-sparing benefits of an intravenous angiography protocol integrated with augmented reality navigation for pediatric brain malformation resection. We retrospectively analyzed three pediatric cases where Cases 1 and 2 utilized a tailored intravenous digital subtraction angiography protocol for augmented reality navigation, while Case 3 served as a comparative control using conventional perioperative intra-arterial angiography. The optimized intravenous protocol yielded a standardized effective dose of 0.83 mSv per session. In Case 1, the total effective dose for two intravenous sessions, covering both preoperative mapping and postoperative confirmation, was only 1.92 mSv. In contrast, the perioperative intra-arterial angiography in Case 3 resulted in a total dose of 12.70 mSv, representing an 85% reduction in radiation exposure. Furthermore, the intravenous workflow optimized operative time by eliminating invasive arterial maneuvers, and navigation accuracy was maintained even in the presence of severe intraoperative brain shift through manual realignment. This protocol provides a robust and radiation-efficient alternative for pediatric surgery, effectively implementing the principle of keeping radiation exposure as low as reasonably achievable.\u003c/p\u003e","manuscriptTitle":"Radiation-Sparing Intravenous DSA and Augmented Reality Navigation in Pediatric Neurosurgery: A Quantitative Analysis of Perioperative Effective Dose and Workflow","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 08:11:02","doi":"10.21203/rs.3.rs-9167196/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T23:17:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T05:34:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319087772909394821839645824351902991345","date":"2026-05-06T19:58:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331234596905246651617504672231805845786","date":"2026-05-06T18:06:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T05:54:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208527898880024717052629704182074447760","date":"2026-05-04T10:29:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-29T08:18:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-08T10:51:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T10:49:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-27T10:49:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Imaging","date":"2026-03-19T08:46:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3be82f3f-78aa-4196-b20e-fe9e1dc31b4d","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T23:17:59+00:00","index":71,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T05:34:57+00:00","index":70,"fulltext":""},{"type":"reviewerAgreed","content":"319087772909394821839645824351902991345","date":"2026-05-06T19:58:10+00:00","index":66,"fulltext":""},{"type":"reviewerAgreed","content":"331234596905246651617504672231805845786","date":"2026-05-06T18:06:26+00:00","index":63,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T05:54:29+00:00","index":47,"fulltext":""},{"type":"reviewerAgreed","content":"208527898880024717052629704182074447760","date":"2026-05-04T10:29:15+00:00","index":46,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T08:11:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 08:11:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9167196","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9167196","identity":"rs-9167196","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}