A systematic review and meta-analysis of the diagnostic accuracy of angiographic techniques in spinal vascular malformations

PURPOSE: Spinal vascular malformations (SVMs) are rare lesions requiring accurate imaging. Two-dimensional digital subtraction angiography (2D DSA) remains the diagnostic gold standard but is invasive and limited in three-dimensional localization. Magnetic resonance angiography (MRA), computed tomography angiography (CTA), and three-dimensional rotational angiography (3D RA) represent alternative techniques. This study aimed to assess the diagnostic accuracy of MRA, CTA, and 3D RA versus 2D DSA in SVMs and to provide an overview of misdiagnoses and advances in image processing. METHODS: A systematic review and bivariate meta-analysis of diagnostic studies was conducted in accordance with PRISMA and following a predefined protocol. Pooled sensitivity and specificity were calculated, and risk of bias was assessed using the QUADAS-2 tool. RESULTS: MRA, CTA and 3D RA demonstrated high diagnostic sensitivity (86.6%, 87.7% and 86.7%, respectively) and variable specificity (64.2%, 73.1% and 85%, respectively). Delayed or missed diagnoses were frequently related to incomplete angiographic coverage or technical limitations of 2D DSA. Image fusion and advanced post-processing techniques improved diagnostic confidence. CONCLUSION: Alternative modalities show substantial potential as adjuncts to 2D DSA, particularly when combined with advanced post-processing. Standardized imaging protocols and prospective studies are needed to define their role in clinical practice.