Relationship between vascular enhancement, cerebral hemodynamics, and MR angiography in cases of acute stroke

BACKGROUND AND PURPOSE: The use of MR angiography and contrast-enhanced T1-weighted MR imaging in cases of acute cerebral ischemia may be helpful in the evaluation of middle cerebral artery (MCA) occlusion and leptomeningeal collaterals, respectively. The aim of our work was to investigate the relationship between MCA occlusion, T1-weighted vascular contrast enhancement, hemodynamic alterations, and tissue damage in cases of acute ischemic stroke. METHODS: We studied the MCA territory in 15 patients with acute ischemic stroke within 8 hr of symptom onset. The first MR imaging study (<8 hr after onset) comprised diffusion-weighted imaging, MR angiography, perfusion-weighted imaging, and contrast-enhanced T1-weighted MR imaging sequences. Follow-up MR imaging, performed 1 week later, consisted of MR angiography and T2-weighted fluid-attenuated inversion recovery MR imaging. RESULTS: Early MR angiography showed MCA stem occlusion in nine of 15 patients. Patients with MCA occlusion had significantly larger areas of abnormality on early diffusion-weighted images, significantly larger areas of altered hemodynamics, larger final lesion volumes, and poorer clinical outcome. Among the nine patients with MCA stem occlusion, vascular enhancement was marked in seven and absent in two who had complete MCA infarcts and poor clinical outcome. Among patients with MCA patency, vascular enhancement was marked in only one, mild in four, and absent in one. Patients with marked vascular enhancement had significantly larger regions of altered hemodynamics and significantly higher asymmetries in both regional cerebral blood volume and mean transit time because of increased values in the affected hemisphere. CONCLUSION: Among patients with stroke with MCA occlusion, marked vascular enhancement and increased blood volume indicate efficient leptomeningeal collaterals and compensatory hemodynamic mechanisms.     

Microplasmin and tissue plasminogen activator: comparison of therapeutic effects in rat stroke model at multiparametric MR imaging

PURPOSE: To prospectively compare therapeutic and hemorrhagic effects of microplasmin and tissue plasminogen activator (tPA) in stroke therapy by using multiparametric magnetic resonance (MR) imaging in a photothrombotic rat stroke model. MATERIALS AND METHODS: The animal experiment complied with institutional regulations for laboratory animals. Stroke was induced in rats with photothrombotic occlusion of middle cerebral artery (MCA). T2-weighted, perfusion-weighted (PW), and diffusion-weighted (DW) MR imaging was performed 1 hour and 24 hours after occlusion. On the basis of PW and DW images at 1 hour, 49 rats with cortex and subcortex involvement and with perfusion-diffusion mismatch were randomly assigned into one of four groups: control group, group treated with 7.5 mg microplasmin, group treated with 10 mg/kg microplasmin, or group treated with 10 mg/kg tPA. Agents were intravenously injected 1.5 hours after occlusion. Infarct size and hemorrhagic transformation were assessed with MR imaging and histomorphologic findings. Neurologic deficit was scored. Measurements were statistically analyzed. RESULTS: There were 13 rats in the control group, 13 in the 7.5 mg/kg microplasmin group, nine in the 10 mg/kg microplasmin group, and 14 in the 10 mg/kg tPA group. Despite similar baseline perfusion-diffusion mismatch, histochemically defined total infarct volume was reduced from 25% +/- 5 (standard deviation) in control group to 21% +/- 2, 20% +/- 4, and 20% +/- 5 in 7.5 mg/kg microplasmin, 10 mg/kg microplasmin, and tPA groups, respectively, as similarly shown on T2-weighted, DW, and PW images at 24 hours (P < .05). Cerebral hemorrhage rate at 24 hours was higher in tPA group than in the other three groups. Bederson score of neurologic deficits was significantly reduced in treated groups compared with that in control group. CONCLUSION: Perfusion-diffusion mismatch appeared useful in selecting candidates for thrombolytic therapy. Multiparametric MR imaging allowed noninvasive assessment of effects of microplasmin and tPA in rats; microplasmin had a significantly lower hemorrhagic rate.     

Echoplanar MR imaging for ultrafast detection of brain lesions.

OBJECTIVE: We retrospectively evaluated the use of echo-planar imaging for ultrafast detection of brain lesions. MATERIALS AND METHODS: In our retrospective study, 61 patients were imaged with the following echo-planar sequences: single-shot proton density-weighted, single-shot T2-weighted, single-shot T2-weighted high-resolution, multishot proton density-weighted, and multishot T2-weighted. Lesions revealed in these patients ranged from 0.5 to 12.0 cm (mean, 3.7 cm) and were the result of tumor (n = 16), stroke (n = 21), demyelination (n = 18), and toxoplasmosis (n = 2). Four patients had scans with normal findings. Two neuroradiologists who were unaware of pertinent clinical data reviewed the images. The images were retrospectively compared with conventional spin-echo images for diagnosis, sensitivity of lesion detection, and qualitative criteria: subjective image quality, gray and white matter differentiation, lesion conspicuity, delineation of lesion borders, and artifacts. (Artifacts included those caused by motion, susceptibility, pulsation, and ghosting.) Quantitative criteria, including signal-to-noise and signal difference-to-noise measurements, were also evaluated in 40 lesions. RESULTS: Sensitivity for lesion detection was 97% for single-shot echo-planar T2-weighted MR images and 100% for multishot echo-planar T2-weighted MR images. Single-shot echo-planar proton density-weighted MR images had the highest signal-to-noise ratio (91.2+/-19.3). Echo-planar T2-weighted MR images had the highest signal difference-to-noise (33.8+/-22.9). Echo-planar sequences were superior to spin-echo sequences regarding motion and pulsation artifacts. Spin-echo sequences lacked susceptibility and ghosting artifacts, and were superior in lesion conspicuity and delineation of lesion borders. CONCLUSION: In this study, echo-planar sequences were as sensitive as conventional spin-echo imaging for the diagnostic assessment of lesions. Echo-planar sequences had a strikingly shorter acquisition time and substantially reduced motion and pulsation artifacts. Echo-planar sequences may be a useful diagnostic tool for use in claustrophobic and unstable patients.     

Hepatic metastases: diffusion-weighted sensitivity-encoding versus SPIO-enhanced MR imaging

PURPOSE: To retrospectively compare accuracy of diffusion-weighted (DW) single-shot echo-planar imaging with sensitivity encoding (SENSE) with that of superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging in the evaluation of hepatic metastases due to extrahepatic malignancies. MATERIALS AND METHODS: Patients provided informed consent; ethics committee approval was not required. The data of 24 patients (16 men, eight women; age range, 41-68 years; mean age, 61.9 years) with 40 resected hepatic metastases were retrospectively reviewed. Before SPIO administration, DW SENSE imaging and T2-weighted fast spin-echo (SE) and T1-weighted dual-echo fast field-echo (FFE) MR imaging were performed. After SPIO administration, T2-weighted fast SE, T1-weighted dual-echo, and T2*-weighted FFE MR examinations were performed. Images were divided into two sets: The SPIO-enhanced MR image set consisted of pre- and postcontrast T2-weighted fast SE and dual-echo T1-weighted FFE images and postcontrast T2*-weighted FFE images. The DW SENSE image set included DW SENSE images and precontrast T2-weighted fast SE and dual-echo T1-weighted FFE images. Three radiologists individually interpreted these images and sorted the confidence levels for presence of hepatic metastasis in each section into five grades. Area under the receiver operating characteristic (ROC) curve (A(z)) was calculated for each image set. RESULTS: Hepatic metastases showed higher signal intensity on DW SENSE images than on T2-weighted fast SE images. Conversely, signals from vessels and cysts were suppressed with DW SENSE imaging. ROC analysis showed higher A(z) values when the DW SENSE image set was interpreted (0.90) than when the SPIO-enhanced MR image set was interpreted (0.81). The sensitivity and specificity, respectively, of total cases were 0.66 and 0.90, for the SPIO-enhanced MR image set and 0.82 and 0.94 for the DW SENSE image set. During SPIO-enhanced MR image interpretation, lesions 1 cm in diameter or smaller showed significantly lower sensitivity than lesions larger than 1 cm in diameter. During both interpretation sessions, left lobe lesions showed significantly lower sensitivity than right lobe lesions. CONCLUSION: Combined reading of DW SENSE images and T2-weighted fast SE and dual-echo T1-weighted FFE MR images showed higher accuracy in the detection of hepatic metastases than did reading of SPIO-enhanced MR images.     

Long-term follow-up of asymptomatic patients with major artery occlusion: rate of symptomatic change and evaluation of cerebral hemodynamics

BACKGROUND AND PURPOSE: The natural history of asymptomatic major cerebral artery occlusive disease is unclear. Rate of symptomatic change, appearance of new lesions on MR images, and cerebral hemodynamics were analyzed for patients with asymptomatic major cerebral artery occlusion. METHODS: This prospective study included asymptomatic patients who had occlusive disease between 1992 and 1995. MR imaging and MR angiography were used to detect internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion in 3965 neurologically asymptomatic patients and for follow-up of affected patients for 67 to 105 months (mean, 79 months). Regional cerebral blood flow and cerebrovascular reserve capacity were examined by xenon-enhanced CT at rest and after the administration of acetazolamide, respectively. RESULTS: Eighteen patients had MCA occlusion and 17 had ICA occlusion. During the follow-up period, five patients became symptomatic (four with MCA occlusion and one with ICA occlusion), with no significant difference (P = .332) in the rate of symptomatic change. Among these five patients, new infarction occurred on the ipsilateral side in three patients, contralateral side in one, and bilateral sides in one. New stenotic or occlusive changes occurred in three patients. The patients were divided into groups: group A, without new lesions on MR images (n = 23), and group B, with new lesions (n = 12). There was no significant difference in regional cerebral blood flow value between groups A and B in the whole hemisphere, anterior cerebral artery territory, or MCA territory. There was a significant difference in cerebrovascular reserve capacity between groups A and B between the affected side (P = .00051 and P = .00068, respectively) and the contralateral side (P = .00101 and P = .00115, respectively) for the whole hemisphere and MCA territory, and the difference was more severe on the affected side in both regions. CONCLUSION: These pilot data suggest that asymptomatic MCA occlusion has a worse prognosis than does ICA occlusion. Silent events are common bilaterally. This may be because of hemodynamic factors or perhaps MCA occlusion is a marker for a more progressive type of atherosclerosis. A prospective study involving assessment of hemodynamics and baseline stroke risk factors in patients with MCA occlusion is indicated.     

Time course of cerebral infarction in the middle cerebral arterial territory: deep watershed versus territorial subtypes on diffusion-weighted MR images

PURPOSE: To examine possible differences between the evolution of cerebral watershed infarction (WI) and that of territorial thromboembolic infarction (TI) by using diffusion-weighted (DW) and T2-weighted magnetic resonance (MR) images and apparent diffusion coefficient (ADC) maps. MATERIALS AND METHODS: Fourteen patients with TI and nine with WI underwent MR imaging from the acute to chronic infarction stages. ADC maps were derived from DW images. Lesion-to-normal tissue signal intensity ratios on ADC maps (rADC), echo-planar T2-weighted images, and DW images were calculated. Lesion volumes at acute or early subacute infarction stages were measured on DW images, and final lesion volumes were estimated on fluid-attenuated inversion-recovery images. RESULTS: Analysis of variance revealed a significant difference in temporal evolution patterns of rADC between WI and TI (P <.001). rADC pseudonormalization following TI began about 10 days after symptom onset, but that following WI did not occur until about 1 month after symptom onset. The Pearson correlation coefficient between final and initial infarct volumes was 0.9899 for both infarction subtypes, indicating that the initial ischemic injury volume measured at the acute or early subacute stage predicted the final lesion volume fairly well. CONCLUSION: The evolution time of ADC is faster for TI than for WI. This difference, which likely originates from the different pathophysiologic and hemodynamic features of the two infarction types, might account for the relatively large range of ADC values reported for the time course of ischemic strokes.     

Sensitivity and interrater agreement of CT and diffusion-weighted MR imaging in hyperacute stroke

BACKGROUND AND PURPOSE: Previous acute stroke studies found diffusion-weighted (DW) imaging superior to CT for detection of early ischemic signs (EIS). However, these findings were confounded by a large time interval in favor of DW imaging. We compared DW images and CT scans obtained with a short time delay in patients with acute stroke to define the sensitivity and interrater agreement of both imaging techniques. METHODS: CT scans and DW images were obtained within 6 hours of symptom onset in 46 patients with acute stroke. Three neuroradiologists and three neurologists reviewed the images for EIS in five regions of the middle cerebral artery (MCA) territory and estimated the extent of EIS (< or > one-third of the MCA territory). RESULTS: The mean delay between imaging with both modalities was 24.5 minutes (range, 10-41 minutes). Forty-five of 46 patients had an ischemic stroke. EIS were seen on 33 of 45 CT scans (73% sensitivity; 95% confidence interval [CI]: 58-85%) and on 42 of 45 DW images (93% sensitivity; 94% CI: 82-99%). Interrater agreement was moderate (kappa = 0.57) for CT and excellent (kappa = 0.85) for DW imaging. CT studies had a moderate interrater agreement for estimation of EIS greater than one-third of the MCA territory (kappa = 0.40), whereas DW imaging showed good results (kappa = 0.68). Sensitivity for detection of greater than one-third of the MCA territory was equally poor (57%, 95% CI: 29-82%) for both CT and DW imaging. CONCLUSION: DW imaging helped identify EIS with higher sensitivity than that of CT. The interrater variability of the one-third rule was high for CT, and thus the clinical applicability of CT is limited. Our results support the application of stroke MR imaging for the treatment of patients with acute stroke.     

Acute ischemic stroke: predictive value of 2D phase-contrast MR angiography--serial study with combined diffusion and perfusion MR imaging

PURPOSE: To evaluate phase-contrast magnetic resonance (MR) angiography and diffusion- and perfusion-weighted imaging in predicting evolution of infarction and clinical outcome. MATERIALS AND METHODS: Phase-contrast angiographic and diffusion-weighted images obtained 1 and 2 days after acute middle cerebral artery (MCA) stroke were assessed in 43 patients; 39 underwent perfusion-weighted imaging on day 1. Follow-up phase-contrast angiographic and T2-weighted images (n = 38) were obtained on day 8. Clinical outcome was assessed at 3 months. Patients were assigned to three groups according to angiographic findings on day 1: group 1, absence of flow in proximal MCA (M1 segment); group 2, internal carotid artery (ICA) occlusion with collateral M1 flow; group 3, flow in ICA and M1. Differences in lesion volumes on diffusion- and perfusion-weighted maps among groups were compared with one-way analysis of variance with Tukey post hoc multiple comparisons. RESULTS: Patients in group 1 had significantly larger infarct growth, volumes of hypoperfusion on relative cerebral blood volume (rCBV) and relative cerebral blood flow maps, and initial and final infarct volumes than did other patients (P <.05). Initial perfusion deficits on mean transit time maps were significantly (P =.002) larger in group 2 than in group 3, but there were no significant differences in infarct growth (P =.977), final infarct volume on day 8 (P =.947), and clinical outcome (P =.969). Absence of M1 flow on day 1 was significantly associated with unfavorable clinical outcome (modified Rankin score > or = 3) at 3 months (P =.010, chi(2) test). Discriminant analysis revealed that rCBV maps alone and combination of diffusion-weighted imaging and MR angiography yielded the highest accuracy in predicting an unfavorable clinical outcome. CONCLUSION: Phase-contrast MR angiography can provide complementary information to that with diffusion- and perfusion- weighted imaging in predicting the outcome of patients with acute stroke.     

Diffusion/perfusion MR imaging of acute cerebral ischemia

In vivo echo-planar MR imaging was used to measure apparent diffusion coefficients (ADC) of cerebral tissues in a comprehensive noninvasive evaluation of early ischemic brain damage induced by occlusion of the middle cerebral artery (MCA) in a cat model of acute regional stroke. Within 10 min after arterial occlusion, ADC was significantly lower in tissues within the vascular territory of the occluded MCA than in normally perfused tissues in the contralateral hemisphere. Sequential echo-planar imaging was then used in conjunction with bolus injections of the magnetic susceptibility contrast agent, dysprosium DTPA-BMA, to characterize the underlying cerebrovascular perfusion deficits. Normally perfused regions of brain were identified by a dose-dependent 35-70% loss of signal intensity within 6-8 s of contrast administration, whereas ischemic regions appeared relatively hyperintense. These data indicate that sequential diffusion/perfusion imaging may be useful in differentiating permanently damaged from reversibly ischemic brain tissue.     

MR detection of secondary changes remote from ischemia: preliminary observations after occlusion of the middle cerebral artery in rats.

PURPOSETo determine whether secondary MR changes occur in the thalamus or the substantia nigra after middle cerebral artery (MCA) occlusion in rats.METHODSSprague-Dawley rats were subjected to MCA occlusion. At varying intervals, proton density-, T1-, and T2-weighted images were obtained with a 4.7-T superconductive MR unit.RESULTST2-weighted images revealed an area of high signal intensity in the ipsilateral substantia nigra 4 days after occlusion. A lesion of low signal intensity appeared in the ipsilateral thalamus 7 days after surgery on proton density- and/or T2-weighted images.CONCLUSIONMR showed secondary changes in the thalamus and the substantia nigra after MCA occlusion in rats. MR imaging should provide more information on the neuropathology of the delayed neuronal degeneration after cerebral ischemia.     

Vascular occlusion sites determine differences in lesion growth from early apparent diffusion coefficient lesion to final infarct

BACKGROUND AND PURPOSE: Occlusion of major cerebral arteries is the primary source of tissue damage in ischemic stroke and the target of thrombolytic therapy. We hypothesized that large infarcts in more proximal vascular occlusions correspond with substantially increased ischemic lesions shown on initial apparent diffusion coefficient (ADC) maps. METHODS: Initial ADC lesions in 120 patients with acute ischemic stroke were analyzed within 6 hours of stroke onset. Patients were categorized on the basis of vascular occlusion, as shown on MR angiography. Lesion volumes were determined by using manual delineation (ADC(man)) and a threshold method for ADC values (<550 x 10(-9) mm(2)/s(-1), ADC(<550)). Infarct volumes were analyzed by using T2-weighted (n = 109) or CT (n = 11) images obtained on days 5-8. RESULTS: Median lesion volumes for ADC(<550), ADC(man), and infarcts, respectively, were as follows: proximal internal carotid artery (ICA)/middle cerebral artery (MCA) occlusions, 10, 23, and 32 cm(3); carotid-T occlusions, 11, 37, and 138 cm(3); MCA trunk occlusions, 11, 27, and 44 cm(3)); and MCA branch occlusions 8, 27, and 21 cm(3). Initial ADC lesion volumes were different only between the carotid T and the MCA branch (P < .05). On days 5-8, infarct volumes decreased from proximal to distal sites (P < .05), with the exception of MCA trunk versus proximal ICA/MCA occlusions. Recanalization rate in carotid-T occlusion was significantly lower than those of all other occlusion types. CONCLUSION: Initial ADC lesions can be small, even in patients with proximal vascular occlusions. These patients develop considerably large infarctions, suggesting a high potential for infarct growth. This growth might be averted with improved early recanalization of proximal vascular occlusions.     

Iron-induced susceptibility effect at the globus pallidus causes underestimation of flow and volume on dynamic susceptibility contrast-enhanced MR perfusion images

BACKGROUND AND PURPOSE: Age-related iron accumulation in extrapyramidal nuclei causes T2 shortening, which may result in decreased signal intensity in these areas on MR images. Because the dynamic susceptibility contrast-enhanced technique uses heavily T2*- or T2-weighted images, the iron-induced susceptibility may have direct impact on perfusion imaging. The purpose of this study was to assess the effect of iron-induced susceptibility on the calculated perfusion parameters. The difference of this effect between gradient-echo and spin-echo sequences was also assessed. METHODS: Dynamic susceptibility contrast-enhanced MR perfusion imaging data of 12 patients were used for this study. Perfusion images were obtained using a single shot spin-echo echo-planar imaging sequence in seven patients and a gradient-echo echo-planar imaging sequence in five patients. Region of interest measurements of relative cerebral blood flow, relative cerebral blood volume, and mean transit time were obtained at various parts of the gray matter, including the globus pallidus, putamen, caudate nucleus, thalamus, and cerebral cortex of temporal, frontal, and occipital lobes. The baseline signal intensity on the source images and the magnitude of signal change (DeltaR2* or DeltaR2) were also assessed. RESULTS: The globus pallidus had statistically significantly lower values of relative cerebral blood flow, relative cerebral blood volume, baseline signal intensity, and magnitude of signal change compared with other parts of the gray matter for both gradient-echo and spin-echo sequences (P <.05). Underestimations of these values were more prominent for the gradient-echo than for the spin-echo sequence. Little variance in the measured mean transit time was noted. CONCLUSION: Iron-induced susceptibility effect may lead to underestimation of relative cerebral blood flow and relative cerebral blood volume in the basal ganglia.     

Endovascular recanalization of internal carotid artery occlusion in acute ischemic stroke

BACKGROUND: Endovascular therapy (ET) of internal carotid artery (ICA) stenosis is equivalent to carotid endarterectomy for stroke prevention; however, patients with ICA occlusion and acute symptoms are traditionally not candidates for ET. We report our experience in endovascular recanalization of acute stroke patients with ICA occlusion. PATIENTS AND TECHNIQUES: We reviewed our registry for acute stroke patients treated with ET who had (1) ICA occlusion by digital subtraction angiography (thrombolysis in myocardial ischemia=0) with location of type II (above ophthalmic artery involving M1 or A1 but not both) or type III (proximal to the ophthalmic artery but distal to the bifurcation); (2) acute stroke symptoms from the index lesion presenting 3 hours after onset of symptoms; (3) minimal ischemic changes on brain CT scan (less than one third of the MCA territory); (4) attempted ET. Neuroradiologists reviewed angiograms for thrombolysis in cerebral infarction. A blinded vascular neurologist reviewed post-procedural brain imaging for Alberta Stroke Program Early CT (ASPECT) scoring. Outcome scales were assessed. RESULTS: We identified 14 patients, 10 of whom were men (mean age, 58 +/- 14 years; median age, 54 years; age range, 40-74 years). There were 8 left ICA occlusions, 3 type II; and 6 right ICA occlusions, one type II. Median baseline National Institutes of Health Stroke Scale score was 17 (range, 11-25; mean, 18 +/- 4.9). Mean time to ET was 389 +/- 103 minutes (median, 306 minutes; range, 197-1290 minutes). Immediate recanalization occurred in 64%. Decrease in expected stroke volume by brain imaging occurred in 50% with mean ASPECT score of 4 +/- 2.9 (median, 3; range, 0-8; 21% > or = 8). Two hemorrhages occurred, one symptomatic; 3 patients died. Good outcome was achieved in 64% of cases. CONCLUSION: Endovascular therapy of carotid occlusion in hyperacute stroke patients is feasible and may help to reduce stroke volume and increase good outcome in some patients.     

MR imaging of renal cell carcinoma: its role in determining cell type

Chemical shift gradient-echo MR imaging (CSI) can detect a small amount of fat as signal loss on opposed-phase images as compared with in-phase images. Cytoplasmic fat in clear cell renal cell carcinoma (RCC) or interstitial histiocytic fat in papillary cell RCC can be successfully demonstrated by this technique. T2*-weighted gradient-echo or echo-planar MR imaging can detect local susceptibility, for example, due to cytoplasmic or interstitial histiocytic hemosiderin deposition in papillary cell RCC. CSI can also show this focal susceptibility as excessive signal loss on in-phase images as compared with opposed-phase images. MR imaging can thus help predict the cell types (clear cell and papillary cell) of RCC. These findings may be important in the decision-making process in the management of patients with suspected RCC, particularly those who are not indicated for radical surgery.     

Salivary glands and lesions: evaluation of apparent diffusion coefficients with split-echo diffusion-weighted MR imaging--initial results.

The authors investigated the feasibility of performing diffusion-weighted (DW) magnetic resonance (MR) imaging with split acquisition of fast spin-echo signals (hereafter, split echo) for the assessment of salivary glands and salivary lesions. Eighteen patients without salivary disease and 10 patients with Sj?gren syndrome, chronic parotitis, or focal salivary masses underwent split-echo and echo-planar DW MR imaging. DW MR images and apparent diffusion coefficient maps of the salivary gland had higher quality with split-echo rather than with echo-planar DW MR imaging.     

Fast magnetic resonance imaging of liver.

Recent magnetic resonance (MR) units with a stronger gradient system have allowed various fast MR imaging techniques to develop. These fast scan techniques have easily realized breath-holding acquisition in the liver and the image quality has been greatly improved without sacrificing spatial resolution. The majority of the fast imaging techniques have been devoted to T2-weighted imaging to obtain useful T2-weighted images in the shortest possible time. Among the fast sequences, fast spin-echo (FSE) sequence is the most promising technique and allows high-quality T2-weighted images with reduced motion artifacts. However, FSE sequences using multiple refocused pulses may essentially realize only poor soft-tissue contrast due to magnetization transfer and T2-filtering effects, and therefore, echo-planar (EP) imaging is expected to provide high image contrast. In addition, single-shot EP imaging allows even diffusion-weighted (DW) and perfusion-weighted (PW) imaging in the liver due to its short scanning time. Recent development of fast gadolinium-enhanced 3D MR angiography has also impacted liver imaging. Combined with such gadolinium-enhanced 3D-MRA sequences and zerofilling image interpolation technique, biphasic gadolinium-enhanced 3D-MRA (whole-liver dynamic MR imaging in the arterial phase and MR portography in the portal phase) can be obtained.     

Predicting cerebral ischemic infarct volume with diffusion and perfusion MR imaging

BACKGROUND AND PURPOSE: Diffusion and perfusion MR imaging have proved useful in the assessment of acute stroke. We evaluated the utility of these techniques in detecting acute ischemic infarction and in predicting final infarct size. METHODS: Diffusion and hemodynamic images were obtained in 134 patients within a mean of 12.3 hours of onset of acute ischemic stroke symptoms. We retrospectively reviewed patient radiology reports to determine the presence or absence of lesion identification on initial diffusion- (DW) and perfusion-weighted (PW) images. Radiologists were not blinded to the initial clinical assessment. For determination of sensitivity and specificity, the final discharge diagnosis was used as the criterion standard. Neurologists were not blinded to the DW or PW imaging findings. In 81 patients, acute lesions were compared with final infarct volumes. RESULTS: Sensitivities of DW imaging and cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) perfusion parameters were 94%, 74%, 84%, and 84%, respectively. Specificities of DW imaging, CBV, CBF, and MTT were 96%, 100%, 96%, and 96%, respectively. Results were similar in 93 patients imaged within 12 hours. In 81 patients with follow-up, regression analysis yielded r(2) = 0.9, slope = 1.24 for DW imaging; r(2) = 0.84, slope = 1.22 for CBV; r(2) = 0.35, slope = 0.44 for CBF; and r(2) = 0.22, slope = 0.32 for MTT, versus follow-up volume. A DW-CBV mismatch predicted additional lesion growth, whereas DW-CBF and DW-MTT mismatches did not. Results were similar in 60 patients imaged within 12 hours. CONCLUSION: Diffusion and hemodynamic images are sensitive and specific for detecting acute infarction. DW imaging and CBV best predict final infarct volume. DW-CBV mismatch predicts lesion growth into the CBV abnormality. CBF and MTT help identify additional tissue with altered perfusion but have lower correlation with final volume.     

Quantitative MR evaluation of intracranial epidermoid tumors by fast fluid-attenuated inversion recovery imaging and echo-planar diffusion-weighted imaging.

BACKGROUND AND PURPOSE: Quantification of MR can provide objective, accurate criteria for evaluation of a given MR sequence. We quantitatively compared conventional MR sequences with fast fluid-attenuated inversion recovery (fast-FLAIR) and echo-planar diffusion-weighted (DW) MR imaging in the examination of intracranial epidermoid tumors. METHODS: Eight patients with surgically confirmed intracranial epidermoid tumors were examined with T1-weighted MR sequences, fast T2- and proton density-weighted dual-echo sequences, fast-FLAIR sequences, and DW echo-planar sequences. We measured the MR signal intensity and apparent diffusion coefficient (ADC) of epidermoid tumors, normal brain tissue, and CSF and calculated the tumor-to-brain and tumor-to-CSF contrast ratios and contrast-to-noise ratios (CNR). Results were compared among the five MR methods. RESULTS: On fast-FLAIR imaging, the mean signal intensity of epidermoid tumors was significantly higher than that of CSF but significantly lower than that of the brain; the contrast ratio and CNR of tumor-to-CSF were 4.71 and 9.17, respectively, significantly greater than the values with conventional MR imaging. On echo-planar DW imaging, epidermoid tumors showed a remarkably hyperintense signal relative to those of the brain and CSF; the mean contrast ratio and CNR of tumor-to-CSF were 13.25 and 19.34, respectively, significantly greater than those on fast-FLAIR or conventional MR imaging. The mean ADC of epidermoid tumors was 1.197 x 10(-3) mm(2)/s, significantly lower than that of CSF but higher than that of brain tissues. CONCLUSION: Fast-FLAIR imaging is superior to conventional MR imaging in depicting intracranial epidermoid tumors. Echo-planar DW imaging provides the best lesion conspicuity among the five MR methods. The hyperintensity of epidermoid tumors on echo-planar DW imaging is not caused by the diffusion restriction but by the T2 shine-through effect.     

Significance of the perfusion-diffusion mismatch in chronic cerebral ischemia

PURPOSE: To determine whether the perfusion deficit could predict brain infarction in patients with chronic cerebral ischemia who experienced recurring episodes of neurological symptoms and showed a perfusion-diffusion mismatch on magnetic resonance (MR) images. MATERIALS AND METHODS: In 53 consecutive patients (38 males and 15 females, 62+/-13 years old) with ischemia in the middle cerebral artery (MCA) territory, lesion volumetry was performed on parametric maps of the time-to-peak, the cerebral blood volume, and diffusion-weighted (DW) images. The infarct lesions were assessed on follow-up T2-weighted (T2W) MR images after eight days. Cerebrovascular changes were determined by time-of-flight (TOF) MR angiography (MRA). Inferential and correlation statistics were used. RESULTS: Patients with chronic ischemic brain disease (N=39) who presented with a severe perfusion-diffusion mismatch in the presence of a normal cerebral blood volume had no or small brain infarctions as found on follow-up T2W images. MRA revealed widespread abnormalities of the basal cerebral arteries compatible with brain perfusion abnormalities. In contrast, in acute stroke patients (N=14) the deficit of cerebral perfusion predicted the infarct lesion in the T2W images. CONCLUSION: Our results suggest that in chronic cerebral ischemia the normal blood volume was maintained despite the depression of cerebral perfusion and recurring minor insults.     

Short-term changes in cerebral microhemodynamics after carotid stenting

BACKGROUND AND PURPOSE: The cerebral hemodynamic sequelae of interventions in patients with severe internal carotid artery (ICA) stenoses are not fully understood. In this study, we sought to determine the immediate changes in cerebral perfusion characteristics, determined by MR imaging in patients who have undergone unilateral transluminal angioplasty and stent placement. METHODS: Eleven patients with symptomatic high-grade ICA stenosis underwent MR imaging within 4 hours before and within 3 hours after carotid stent placement. First-pass gadolinium-enhanced imaging of perfusion was performed by using a gradient-recalled echo-planar technique. Localized relative cerebral blood volume (rCBV) and bolus first-moment transit time (TT(FM)) were calculated for different vascular territories (middle, anterior, and posterior cerebral arteries) in each hemisphere. RESULTS: Significantly longer TT(FM) (P <.005) was observed in the symptomatic territory of the middle cerebral artery before intervention. After intervention, TT(FM) remained significantly longer in this territory (P <.05). However, the magnitude of the interhemispheric asymmetry had declined significantly (50-60% reduction; P <.05). No significant differences or changes in rCBV were identified between hemispheres, between images, or in areas of unilateral leptomeningeal enhancement after intervention. CONCLUSION: MR can demonstrate short-term partial resolution of timing asymmetry in interhemispheric perfusion after angioplasty and stent insertion for severe stenosis of the ICA.