Evaluation of carotid artery stenosis: contrast-enhanced magnetic resonance angiography compared with conventional digital subtraction angiography.

OBJECTIVE: To compare retrospectively high-resolution contrast-enhanced magnetic resonance angiography with centric k-space filling and digital subtraction angiography in the assessment of degree of carotid artery stenosis. METHODS: Two neuroradiologists independently evaluated 14 carotid arteries (in 7 patients), and the degree of carotid stenosis determined was compared to calculate interobserver reliability. Thirty-six carotid arteries (in 18 patients) were then assessed with both contrast-enhanced magnetic resonance angiography and digital subtraction angiography. The degree of stenosis was determined by consensus, and the findings of the 2 modalities were compared. RESULTS: Close interobserver agreement was found with an intraclass correlation coefficient of 0.98 (95% confidence interval 0.95-0.99). Sensitivity of 86% and specificity of 91% were found for contrast-enhanced magnetic resonance angiography detection of surgically significant carotid stenosis compared with digital subtraction angiography. The Spearman rank correlation test also found a significant correlation (R(s) = 0.90, p < 0.001) in the comparison of the classifications of degree of carotid artery stenosis. CONCLUSION: Contrast-enhanced magnetic resonance angiography shows excellent correlation with digital subtraction angiography for the evaluation of carotid artery disease and has the potential to replace it in the assessment of degree of carotid artery stenosis.     

Comparison of Doppler ultrasound, magnetic resonance angiographic techniques and catheter angiography in evaluation of carotid stenosis

AIM: To compare the accuracy of ultrasound and two magnetic resonance (MR) angiographic techniques with catheter angiography in assessing atherosclerosis at the carotid bifurcation.MATERIALS AND METHODS: Forty patients with symptomatic carotid stenosis were studied by Doppler ultrasound, time-of-flight MR angiography, contrast-enhanced MR angiography and conventional catheter angiography. The degree of stenosis found on ultrasound and MR angiography was compared with the results of catheter angiography. Four different assessment methods were conducted for the MR angiographic data. Kappa, sensitivity and specificity (with confidence intervals) values were calculated for the US and MR angiography results compared to catheter angiography.RESULTS: Catheter angiography showed 12 internal carotid artery occlusions (15%), 34 severe (44%), 12 moderate (15%) and 20 mild stenoses (26%), using NASCET criteria.Ultrasound showed 65% sensitivity and 95% specificity in detecting surgically amenable lesions, whilst the MR angiographic techniques had sensitivities varying from 82-100%, and specificities from 95-100%.A moderate kappa value was calculated for the US data, whilst all MR techniques were found to show very good agreement with catheter angiography.CONCLUSION: This data suggests that MR angiography is more accurate than Doppler ultrasound in defining surgical lesions and has comparable accuracy to catheter angiography. The use of contrast-enhanced MR angiography is useful in certain situations but is not essential in all cases.     

Prevalence study of proximal vertebral artery stenosis using high-resolution contrast-enhanced magnetic resonance angiography

PURPOSE: To evaluate the prevalence of proximal vertebral artery stenosis, compared wiith those of the distal vertebral/basilar artery and extracranial internal carotid artery, in a large population of stroke and non-stroke patients. MATERIAL AND METHODS: Nine-hundred-and-thirty-five patients who underwent high-resolution contrast-enhanced magnetic resonance angiography in a regional general hospital were categorized into six groups based on neurological symptoms and disease: an asymptomatic group (n = 182), a minor symptom group with headache or dizziness (n = 519), a cardiac group with coronary artery steno-occlusive disease (n = 15), a hemorrhagic group with old cerebral hemorrhage (n=26), an anterior circulation infarct group (n = 121), and posterior circulation infarct group (n = 72). Prevalence of stenosis of the proximal vertebral artery, distal vertebral/basilar artery, and internal carotid artery was analyzed. RESULTS: The prevalence of stenosis of the proximal vertebral artery, distal vertebral/ basilar artery, and internal carotid artery was 12.9%, 5.5%, and 7.2%, respectively, in the study population, and rose as the age increased (P < 0.0001 for all arteries). The prevalence of stenosis of the proximal vertebral artery, distal vertebral/basilar artery, and internal carotid artery was 3.3%, 0.5%, and 1.1%, respectively, in the asymptomatic group; 8.3%, 2.1%, and 3.7%, respectively, in the minor symptom group; 13.3%, 6.7% and 6.7%, respectively, in the cardiac group; 19.2%, 7.7%, and 7.7%, respectively, in the hemorrhagic group; 27.3%, 8.3%, and 25.6%, respectively, in the anterior circulation infarct group; and 44.4%, 36.1%, and 16.7%, respectively, in the posterior circulation infarct group. This increasing tendency of stenosis accordingly was statistically significant (P < 0.0001 for all arteries). CONCLUSION: The prevalence of proximal vertebral artery stenosis was highest, compared with those of the distal vertebral/basilar artery and internal carotid artery, although the clinical significance of proximal vertebral artery stenosis should be investigated in further studies.     

Evaluation of semiautomated internal carotid artery stenosis quantification from 3-dimensional contrast-enhanced magnetic resonance angiograms

RATIONALE AND OBJECTIVES: The performance of a semiautomatic technique for internal carotid artery (ICA) stenosis quantification of the internal carotid artery in contrast-enhanced magnetic resonance angiography was evaluated. MATERIALS AND METHODS: The degree of stenosis of 52 ICAs was quantified by measuring the cross-sectional area along the center lumen line. This was performed both by 3 independent observers and the semiautomated method. The degree of stenosis was defined as the amount of cross-sectional lumen reduction. RESULTS: Agreement between the method and observers was good (weighted-kappa, kappaW = 0.89). Reproducibility of measurements of the semiautomated technique was better (kappaW = 0.97) than that of the observers (kappaW = 0.76), and the evaluated technique was considerably less time-consuming. CONCLUSIONS: Because the user interaction is limited, this technique can be used to replace an expert observer in 3-dimensional stenosis quantification of the ICA at CE-MRA in clinical practice.     

Accuracy of normal-dose contrast-enhanced MR angiography in assessing renal artery stenosis and accessory renal arteries

OBJECTIVE: The purpose of this study was to evaluate the accuracy of breath-hold contrast-enhanced MR angiography in the assessment of renal artery stenosis and accessory renal arteries using a standard dose of gadolinium. SUBJECTS AND METHODS: Thirty-eight patients suspected of having renal artery stenosis underwent MR angiography and intraarterial digital subtraction angiography, which was the method of reference. Three-dimensional gradient-echo MR subtraction angiography (TR/TE, 5.8/1.8 msec) was performed on a 1.5-T imager using a phased array body coil. Before imaging, a separate timing bolus sequence was used, administering 1.0 ml of contrast agent. Gadopentetate dimeglumine (15 ml) was injected using an MR power injector. Two observers, who were unaware of each other's interpretation and of MR findings, assessed digital subtraction angiography. Likewise, two other observers assessed MR angiography. RESULTS: Digital subtraction angiography depicted 75 main and 17 accessory renal arteries (n = 92). All main renal arteries and 13 accessory renal arteries were identified on MR angiography. Compared with digital subtraction angiography, MR imaging correctly classified 57 of 66 arteries without a hemodynamically significant stenosis (0-49%), 22 of 22 arteries as significantly stenotic (50-99%), and four of four occluded arteries; five stenoses were overestimated. There was one false-positive finding of an accessory renal artery on MR angiography that was identified retrospectively on digital subtraction angiography. Interobserver agreement was high. Sensitivity and specificity for grading significant stenosis were 100% and 85%, respectively. CONCLUSION: Contrast-enhanced MR angiography, using +/-0.1 mmol/kg of gadolinium, is an accurate method in the assessment of renal artery stenosis and accessory renal arteries.     

How should we estimate carotid stenosis using magnetic resonance angiography?

Our purpose was to assess the reproducibility of and differences between the most commonly used methods for assessing carotid artery stenosis using magnetic resonance angiography (MRA). We studied 55 patients who underwent axial three-dimensional time-of-flight MRA (1.5 T). Quantitative caliper measurements were performed from maximum intensity projection (MIP) and multiple planar reconstruction (MPR) images, according to the criteria of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST). The measurements were compared to each other and to visual interpretation, using conventional angiography as the reference. The measured percentage stenoses were higher on MRA than on digital subtraction angiography (DSA) using both NASCET (mean difference 1.9–3.0%) and ECST (6.3–6.7%) criteria. The kappa coefficients for the agreement between DSA and MRA were higher using the NAS-CET (0.61–0.76) than the ECST criteria (0.52–0.65). No statistically significant differences were found between measurements from MIP and MPR images. The ECST measurement criteria gave significantly higher percentage stenoses than the NASCET criteria (P<0.001), this difference being more prominent on MRA (mean difference in diameter stenosis percentage 14.3–16.4%) than on DSA (7.6–11.2%) and most important with mild stenoses. The difference between visual interpretation and quantitative measurements on MRA was significant (P=0.01–0.001). There were no statistically significant interobserver differences in the MRA film readings, either in visually estimated degrees of stenosis or stenosis measurements. Thus, the different criteria of the two multicentre trials led to significantly different results, especially in the assessment of mild stenosis, and these differences are more important with MRA than with aging modalities or the reconstruction programs seem less important.     

Recent advances in contrast-enhanced magnetic resonance angiography

Magnetic resonance angiography (MRA) provides a means of visualizing vascular structures noninvasively and is increasingly replacing conventional X-ray angiography in routine use. Contrast-enhanced MRA (CE-MRA), in which gadolinium contrast agents are used to shorten the T1 relaxation, offers increased resolution and higher signal-to-noise ratio compared with earlier flow-dependent [time-of-flight (TOF) or phase-contrast (PC)] techniques. Currently available contrast agents differ in their ability to lower T1 values, and hence the choice of contrast agent is an important consideration in the successful use of CE-MRA. Gadofosveset trisodium (Vasovist, Bayer Schering Pharma AG, Berlin, Germany) is the first of a new class of intravascular contrast agents. This agent is extensively (approximately 85%) and reversibly bound to human serum albumin and is retained within the vasculature thus allowing steady-state imaging to be perform-ed. An additional benefit is that gadofosveset offers higher relaxivity compared with other contrast agents, thus giving a lower blood T1 values which also makes it ideal for first-pass imaging. Clinical trials have consistently shown that gadofosveset enhanced MRA is more sensitive, specific and accurate than time-of-flight MRA, gives fewer uninterpretable scans and affords greater diagnostic confidence. Intravascular contrast agents such as gadofosveset, therefore, offer the potential for improved vascular imaging.     

Asymptomatic middle cerebral artery stenosis diagnosed by magnetic resonance angiography

We reviewed 1440 MRA studies to identify patients with middle cerebral artery stenosis (MCAS). We identified 99 cases, and after reviewing the clinical records, classified 28 as asymptomatic MCAS (AMCAS), a prevalence of 2%. Suspected stroke was the most frequent indication for MRA. Follow-up was available for 21, mean 46.7 months (range 2.4–75.6 months). One stroke occurred in the AMCAS territory (5%), other strokes in five patients (24%). There were five deaths in patients with MCAS; age >69 ( P =0.045) was the only associated risk factor. This study suggests that patients in whom MRA is performed and shows AMCAS may be at increased risk of strokes in any vascular distribution or of death.Presented in part as an abstract at the 27 ^th International Stroke Meeting, San Antonio, Texas, February 2002 and the 54 ^th American Academy of Neurology Meeting, Denver, Colorado, April, 2002     

Assessment of renal artery stenosis by phase-contrast magnetic resonance angiography

Three-dimensional (3D) phase-contrast magnetic resonance angiography (MRA) and velocity-encoded cine magnetic resonance (VEC-MR) imaging were performed in 23 subjects to assess the severity of renal artery stenosis. MRA was used for detection of stenosis, demonstrating a sensitivity of 100% and a specificity of 80%; the severity of stenosis was overestimated in 33%. VEC-MR was used to quantify the renal flow oattern and was successful in 11 subjects. Mean blood flow of normal renal arteries (420 +- 107 ml/min) was significantly higher (P < 0.01) than mean blood flow of stenotic arteries (131 +- 46ml/min). The flow profile displayed both systolic and diastolic peaks in 75% of the normal arteries, while the flow in stenotic arteries showed only a single systolic peak in all cases. The systolic peak in stenotic arteries occurred significantly later (32 +- 3% of the period of one cardiac cycle) than in normal subjects (21 +- 7%) (P < 0.05). Phase-contrast MR is likely to gain considerable importance in the noninvasive aetection and quantification of renal artery stenosis. Correspondence to: C. S. Richter     

三维增强磁共振血管成像和数字减影血管造影在颈部动脉狭窄闭塞性病变中的对比分析

目的 评价三维增强磁共振血管成像(3D-CE-MRA)诊断颈部动脉狭窄闭塞性病变的准确性及应用价值.方法 对43例可疑颈部动脉狭窄或闭塞的患者分别先后进行3D-CE-MRA和数字减影血管造影(DSA)检查,对成像结果进行对比研究.结果 与DSA相比,3D-CE-MRA 对颈部动脉狭窄闭塞性病变诊断的敏感度为83.0%,特异度为94.1%.结论 3D-CE-MRA对颈部动脉狭窄闭塞性病变的显示具有独特的优势,是一种无创、安全、快速、准确性高的检查方法,可以作为首选的检查方法.     

Effects of doubling and tripling the spatial resolution in standard 3D contrast-enhanced magnetic resonance angiography of carotid artery disease

PURPOSE: To determine whether three-dimensional (3D) contrast-enhanced MR angiography (CE-MRA) of carotid artery disease may be more effective when performed at double or triple the spatial resolution of the present common clinical standard at 1.5T. MATERIALS AND METHODS: A total of 110 consecutive patients with suspected carotid artery disease were imaged with elliptical centric 3D CE-MRA. The total acquisition time was increased from the standard clinical protocol of 21 seconds up to 60 seconds in 10-second steps, with corresponding voxel volume reductions from 0.95 mm(3) down to 0.35 mm(3). Quantitative and blinded qualitative measurements were then performed to determine the preferred imaging time. RESULTS: In patients with significant stenosis, the 40-second acquisition with 0.53-mm(3) voxels produced significantly sharper images of the carotid bifurcation than the 21-second standard using 0.95-mm(3) voxels, but did not have a significant effect in patients without disease. CONCLUSION: In patients with carotid artery stenosis, decreasing the voxel volume to 0.5 mm(3) by increasing the scan time from 21 to 40 seconds resulted in sharper depiction of the carotid stenosis. Further decreases in voxel volume, by extending the acquisition time further, did not improve the vessel depiction due to both signal-to-noise ratio (SNR) and sharpness losses.     

Atherosclerosis of the carotid artery: Evaluation by magnetic resonance angiography

Carotid artery atherosclerotic plaques (APs) can lead to brain ischemia, an event shown to correlate with both the degree of stenosis and the composition of the AP. Currently, accurate estimates of stenosis can be obtained by either x-ray angiography or three-dimensional time of-flight (TOF) magnetic resonance angiography (MRA). Our purpose was to determine whether three-dimensional TOF MRA images could also provide information on plaque location, morphology, and composition. Seven pre-endarterectomy patients underwent three-dimensional TOF MRA. After endarterectomy, plaque histology was evaluated. Three-dimensional TOF MRA images contained sufficient soft tissue contrast to differentiate the plaques from the surrounding tissues in all cases. Estimation of plaque morphology had 80% correlation with histology. Finally, intraplaque hemorrhage and calcification were depicted as regions of moderately high and very low intensity, respectively. These preliminary results suggest that three-dimensional TOF MRA may be useful in studying the development and progression of carotid atherosclerosis.     

Improvement in visualization of carotid artery uniformity using silent magnetic resonance angiography

Three-dimensional time-of-flight magnetic resonance angiography (TOF MRA) has been widely used in clinics. TOF MRA can cause dephasing artifacts, which lead to an intraluminal signal decrease. Silent MRA is a novel imaging technique that uses arterial spin labeling to achieve an ultrashort echo time (uTE), which is expected to decrease these effects and allow for accurate assessment of the flow in blood vessels. This study quantified the accuracy of Silent MRA images for visualizing the turbulent flow in flow-phantom and in vivo studies. The vessel contrast and coefficients of variation (CVs) for Silent MRA and TOF MRA were compared using normal and stenosis phantoms. Then, we performed both types of MRA on seven healthy volunteers. In the phantom study, although the contrast in the TOF MRA images was low distal to the stenosis region and at a high flow velocity, the contrast in the Silent MRA images did not change under these conditions. Furthermore, the mean CV for Silent MRA was smaller than that for TOF MRA under stenosis conditions. In the in vivo study, the mean contrast and vessel uniformity were significantly higher for Silent MRA than for TOF MRA. Although Silent MRA has limited spatial resolution and requires additional imaging time, this method may have the potential to improve the image quality of the carotid artery.     

Initial experience with balanced turbo field echo in depicting carotid artery stenosis: comparison with multiple overlapping thin slab acquisition and 3D contrast-enhanced magnetic resonance angiography

PURPOSE: To compare balanced turbo field echo (bTFE) with multiple overlapping thin slice acquisition (MOTSA) and contrast-enhanced MR angiography (CE-MRA) in depicting carotid artery stenosis. MATERIALS AND METHODS: In this study 86 patients with cerebrovascular disease, who had been referred for a carotid examination, were imaged. All of the patients underwent MOTSA and one of four bTFE sequences followed by CE-MRA. Formatted maximum intensity projections (MIPs) and source images were read in a blinded fashion by a radiologist. Inter- and intrasequence statistical analyses were performed. RESULTS: We first compared image quality (IQ) and fat, background, and venous suppression using four distinct bTFE protocols in 118 carotid arteries, and found that bTFE4 performed the best. We then compared IQ, grades of stenosis, and background and venous suppression among bTFE4, MOTSA, and CE-MRA. bTFE produced significantly better IQ and venous suppression (P < 0.001), and higher SNR and CNR (P < 0.05) when compared to MOTSA. CONCLUSION: The bTFE sequence is robust and provides high-quality images in patients with mild to moderate carotid artery stenosis. Even though there is a tendency to overestimate stenosis with bTFE compared to CE-MRA, the shorter scan time of bTFE coupled with enhanced SNR and CNR measurements validates it as a clinically useful adjunct to MOTSA, if not a replacement.     

Coronary artery magnetic resonance angiography

Coronary magnetic resonance angiography (coronary MRA) continues to advance rapidly from both a technical and clinical perspective. Coronary MRA has benefited directly from improvements in spatial resolution, contrast definition, and advances in motion correction, which have furthered its routine use in evaluating coronary artery bypass grafts and anomalous coronary arteries. Work in refining the techniques for more accurate identification of coronary artery disease (CAD) continues, with advances in navigator-gated and breath-hold motion correction techniques, novel k-space strategies (e.g., spiral and radial k-space filling), development and application of intravascular contrast agents, and imaging at higher field strengths. Ultimately, these developments may lead to the routine application of coronary MRA as a screening tool for CAD. This article reviews the development of coronary MRA, discusses the requirements and tools necessary for optimal visualization of the coronary arteries, and describes the application of coronary MRA to acquired and congenital CAD.     

Prospective evaluation of carotid artery stenosis: elliptic centric contrast-enhanced MR angiography and spiral CT angiography compared with digital subtraction angiography

BACKGROUND AND PURPOSE: Although digital subtraction angiography (DSA) is the reference standard for assessing carotid arteries, it is uncomfortable for patients and has a small risk of disabling stroke and death. These problems have fueled the use of spiral CT angiography and MR angiography. We prospectively compared elliptic centric contrast-enhanced MR angiography and spiral CT angiography with conventional DSA for detecting carotid artery stenosis. METHODS: Eighty carotid arteries (in 40 symptomatic patients) were assessed. Elliptic centric MR and spiral CT angiographic data were reconstructed with maximum intensity projection and multiplanar reconstruction techniques. All patients had been referred for DSA evaluation on the basis of findings at Doppler sonography, which served as a screening method (degree of stenosis > or = 70% or inconclusive results). Degree of carotid stenosis estimated by using the three modalities was compared. RESULTS: Significant correlation with DSA was found for stenosis degree for both elliptic centric MR and spiral CT angiography; however, the correlation coefficient was higher for MR than for CT angiography (r = 0.98 vs r = 0.86). Underestimation of stenoses of 70-99% occurred in one case with elliptic centric MR angiography (a 70% stenosis was underestimated as 65%) and in nine cases with spiral CT angiography, in comparison to DSA findings. Overestimation occurred in two cases with MR angiography (stenoses of 65-67% were overestimated as 70-75%). With CT, overestimation occurred in seven cases; a stenosis of 60% in one case was overestimated as 70%. Both techniques confirmed the three cases of carotid occlusion. With elliptic centric MR angiography, carotid stenoses of 70% or greater were detected with high sensitivity, 97.1%; specificity, 95.2%; likelihood ratio (LR) for a positive test result, 20.4; and ratio of LR(+) to LR(-), -0.3. With spiral CT angiography, sensitivity, specificity, LR(+), and LR(+):LR(-) were 74.3%, 97.6%, 31.2, and 0.3, respectively. CONCLUSION: Elliptic centric contrast-enhanced MR angiography is more accurate than spiral CT angiography to adequately evaluate carotid stenosis. Furthermore, elliptic centric contrast-enhanced MR angiography appears to be adequate to replace conventional DSA in most patients examined.     

Preoperative evaluation of carotid artery stenosis: comparison of contrast-enhanced MR angiography and duplex sonography with digital subtraction angiography

BACKGROUND AND PURPOSE: Contrast-enhanced MR angiography and extracranial color-coded duplex sonography are noninvasive, preoperative imaging modalities for evaluation of carotid artery stenosis. Innovative techniques and improvements in image quality require frequent reassessment of accuracy, reliability, and diagnostic value compared with those of digital subtraction angiography (DSA). We evaluated contrast-enhanced MR angiography and duplex sonography compared with DSA for detection of high-grade carotid artery stenoses. METHODS: Four readers, blinded to clinical symptoms and the outcome of other studies, independently evaluated stenoses on contrast-enhanced MR angiograms in 71 vessels of 39 symptomatic patients. Duplex sonography was also performed in all vessels. The severity of stenosis was defined according to North American Symptomatic Carotid Endarterectomy Trial criteria (0-29%, 30-69%, 70-99%, 100%). Results of both modalities were compared with the corresponding DSA findings. RESULTS: Contrast-enhanced MR angiography had a sensitivity and specificity of 94.9% and 79.1%, respectively, for the identification of carotid artery stenoses of 70% or greater. Sensitivity and specificity of duplex sonography were 92.9% and 81.9%, respectively. Combining data from both tests revealed a sensitivity and specificity of 100% and 81.4%, respectively, for concordant results (80% of vessels). CONCLUSION: Concordant results of contrast-enhanced MR angiography and duplex sonography increase the diagnostic sensitivity to 100%. The reliability of MR angiography is comparable to that of DSA. The combination of contrast-enhanced MR angiography and duplex sonography might be preferable over DSA for preoperative evaluation in most patients, thus reducing the risk of perioperative morbidity and improving the overall outcome.