Effect of age and vascular anatomy on blood flow in major cerebral vessels

Blood Flow Lateralization and Collateral Compensatory Mechanisms in Patients With Carotid Artery Stenosis

Background and Purpose- Four-dimensional phase-contrast magnetic resonance imaging enables quantification of blood flow rate (BFR; mL/min) in multiple cerebral arteries simultaneously, making it a promising technique for hemodynamic investigation in patients with stroke. The aim of this study was to quantify the hemodynamic disturbance and the compensatory pattern of collateral flow in patients with symptomatic carotid stenosis. Methods- Thirty-eight patients (mean, 72 years; 27 men) with symptomatic carotid stenosis (≥50%) or occlusion were investigated using 4-dimensional phase-contrast magnetic resonance imaging. For each patient, BFR was measured in 19 arteries/locations. The ipsilateral side to the symptomatic carotid stenosis was compared with the contralateral side. Results- Internal carotid artery BFR was lower on the ipsilateral side (134±87 versus 261±95 mL/min; P<0.001). BFR in anterior cerebral artery (A1 segment) was lower on ipsilateral side (35±58 versus 119±72 mL/min; P<0.001). Anterior cerebral artery territory bilaterally was primarily supplied by contralateral internal carotid artery. The ipsilateral internal carotid artery mainly supplied the ipsilateral middle cerebral artery (MCA) territory. MCA was also supplied by a reversed BFR found in the ophthalmic and the posterior communicating artery routes on the ipsilateral side (-5±28 versus 10±28 mL/min, P=0.001, and -2±12 versus 6±6 mL/min, P=0.03, respectively). Despite these compensations, BFR in MCA was lower on the ipsilateral side, and this laterality was more pronounced in patients with severe carotid stenosis (≥70%). Although comparing ipsilateral MCA BFR between stenosis groups (<70% and ≥70%), there was no difference ( P=0.95). Conclusions- With a novel approach using 4-dimensional phase-contrast magnetic resonance imaging, we could simultaneously quantify and rank the importance of collateral routes in patients with carotid stenosis. An important observation was that contralateral internal carotid artery mainly secured the bilateral anterior cerebral artery territory. Because of the collateral recruitment, compromised BFR in MCA is not necessarily related to the degree of carotid stenosis. These findings highlight the importance of simultaneous investigation of the hemodynamics of the entire cerebral arterial tree.

Contributions of Aging to Cerebral Small Vessel Disease

Cerebral small vessel disease (SVD) is characterized by changes in the pial and parenchymal microcirculations. SVD produces reductions in cerebral blood flow and impaired blood-brain barrier function, which are leading contributors to age-related reductions in brain health. End-organ effects are diverse, resulting in both cognitive and noncognitive deficits. Underlying phenotypes and mechanisms are multifactorial, with no specific treatments at this time. Despite consequences that are already considerable, the impact of SVD is predicted to increase substantially with the growing aging population. In the face of this health challenge, the basic biology, pathogenesis, and determinants of SVD are poorly defined. This review summarizes recent progress and concepts in this area, highlighting key findings and some major unanswered questions. We focus on phenotypes and mechanisms that underlie microvascular aging, the greatest risk factor for cerebrovascular disease and its subsequent effects.

Use of three-dimensional time-of-flight magnetic resonance angiography at 1.5 Tesla to evaluate the intracranial arteries of 39 dogs with idiopathic epilepsy

OBJECTIVE

To assess visualization of the intracranial arteries and internal carotid artery (ICA) on 3-D time-of-flight (TOF) magnetic resonance angiography (MRA) images obtained at 1.5 T and to investigate factors that affect the image quality of those arteries in dogs.

ANIMALS

39 dogs with idiopathic epilepsy.

PROCEDURES

Each dog underwent 3-D TOF MRA, and 5 pairs of intracranial arteries, the basilar artery, and both ICAs were evaluated. Each artery was assigned an image-quality score on a scale of 0 to 3, where 0 = poor and 3 = excellent. Multivariable regression analysis was used to assess whether age, body weight (BW), serum total cholesterol concentration, intracranial volume (ICV), and mean arterial pressure were significantly associated with the image quality of each vessel.

RESULTS

In all dogs, the image-quality score was 2 or 3 for the proximal middle cerebral arteries, basilar artery, and caudal aspect of the caudal communicating arteries. In some dogs, the rostral cerebellar arteries, rostral aspect of the caudal communicating arteries, and middle and rostral aspects of the ICA were poorly visualized. For various arteries, image quality was negatively associated with age and positively associated with BW and ICV.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that 3-D TOF MRA images obtained at 1.5 T did not consistently and clearly delineate the ICA and narrow or peripheral intracranial arteries of dogs; therefore, careful attention is required when such images are assessed. Patient age, BW, and ICV can also affect the image quality of some intracranial arteries on 3-D TOF MRA images. (Am J Vet Res 2019;80:480-489).

Combined native magnetic resonance angiography, flow-quantifying, and perfusion-imaging for impending second-stroke assessment

This special report introduces native flow quantitative imaging for evaluating stroke risk. Moreover, the advantage of combining three imaging techniques [magnetic resonance angiography (MRA), phase-contrast (PC) flow imaging, and arterial spin-labeling imaging] is shown to be beneficial for responding to ischemia and preserving viable neurons. These quantitative imaging techniques provide authoritative information for diagnosing impending stroke and selecting appropriate treatment.

Relationships in Ongoing Structural Maintenances of the Two Cerebral Cortices of an Individual Brain

A human brain has separate left and right cerebral cortices, each of which must be continuously structurally maintained during adulthood. There is no understanding of how ongoing structural maintenances of separate parts of a mature individual brain, including the 2 cortices, are related. To explore this issue, this study used an unconventional N-of-1 magnetic resonance imaging time-series paradigm to identify relationships between maintenances of structural thicknesses of the 2 cortices in an adult human brain over week intervals for 6 months. The results suggest that maintenances of left and right cortical thicknesses were symmetrically related in some, but asymmetrically related in other, respects. For matched times, thickness magnitudes and variations on the 2 sides were positively correlated and appeared to reflect maintenance symmetry. Maintenance relationships also extended from earlier to later times with temporal continuity and apparent “if-then” contingencies which were reflected in symmetry and asymmetry dynamics spanning 1- to 2-week periods. The findings suggest concepts of individual brain cortical maintenance symmetry, asymmetry, and temporal continuity dynamics that have not been previously recognized. They have implications for defining cortical maintenance traits or states and for development of N-of-1 precision medicine paradigms that can contribute to understanding individual brain health.

A review of the diagnosis and management of vertebral basilar (posterior) circulation disease

We have reviewed the English literature published in the last 70 years on Diseases of the Vertebral Basilar Circulation, or Posterior Circulation Disease (PCD). We have found that errors have been made in the conduct and interpretation of these studies that have led to incorrect approaches to the management of PCD. Because of the difficulty in evaluating the PC, the management of PCD has been incorrectly applied from anterior circulation disease (ACD) experience to PCD. PCD is a common form of stroke affecting 20-40% patients with stroke. Yet, the evidence is strong that the Anterior Circulation (AC) and Posterior Circulations (PC) differ in their pathology, in their clinical presentations, in the rapidity of development of symptoms, in optimal imaging methods, and in available treatments. There appears to be two categories of patients who present with PCD. The first, acute basilar artery occlusion has a more rapid onset. The diagnosis must be made quickly and if imaging proves a diagnosis of Basilar Artery Occlusion (BAO), the treatment of choice is Interventional removal of the basilar artery thrombosis or embolus. The second category of PCD and the most commonly seen PCD disease process presents with non-specific symptoms and early warnings of PCD that now can be related to ischemic events in the entire PC vessels. These warning symptoms and signs occur much earlier than those in the AC. IA angiography is still the gold standard of diagnosis and is superior in definition to MR and CT angiography which are commonly used as a convenient screening imaging tool to evaluate PCD but are both inferior to IA angiography in definition for lesions below 3-4 mm. In at least two reported studies 7T MR angiography appears superior to other imaging modalities and will become the gold standard of imaging of PCD in the future. Medical treatments applied to the ACD have not been proven of value in specific forms of PCD. Interventional therapy was promising but of unproven value in Randomized Controlled Trials (RCT) except for the treatment of Basilar Artery Occlusion (BAO). Surgical revascularization has been proved to be highly successful in patients, who are refractory to medical therapy. These studies have been ignored by the scientific community basically because of an incorrect interpretation of the flawed EC-IC Bypass Trial in 1985 as applying to all stroke patients. Moreover, the EC-IC Bypass Study did not include PCD patients in their study population, but the study results were extrapolated to patients with PCD without any scientific basis. This experience led clinicians to an incorrect bias that surgical treatments are of no value in PCD. Thus, incorrectly, surgical treatments of PCD have not been considered among the therapeutic possibilities for PCD. QMRA is a new quantitative MR technique that measures specific blood flow in extra and intracranial vessels. QMRA has been used to select those patients who may benefit from medical, or interventional, or surgical treatment for PCD based on flow determinations with a high success rate. QMRA accurately predicts the flows in many large and small vessels in the PC and AC and clearly indicates that both circulations are intimately related. From medical and surgical studies, the longer one waits for surgical treatment the higher the risk of a poor outcome results. This observation becomes obvious when the rapidity of development of PCD is compared with ACD. Recent advances in endovascular therapy in the treatment of acute basilar thrombosis is a clear sign that early diagnosis and treatment of PCD will reduce the morbidity and mortality of these diseases. In this review it is evident that there are multiple medical and surgical treatments for PCD depending upon the location of the lesion(s) and the collateral circulation demonstrated. It is clear that the AC and PC have significant differences. With the exception of the large population studies from Oxford England, the reported studies on the management of PCD in the literature represent small selected subsets of the universe of PC diseases, the information from which is not generalizable to the universe of PCD patients. At this point in the history of PCD, there are not large enough databases of similar patients to provide a basis for valid randomized studies, with the exception of the surgical studies. Thus, a high index of suspicion of the early warning symptoms of PCD should lead to a rapid individual clinical assessment of patients selecting those with PCD. Medical, interventional, and/or surgical treatments should be chosen based on knowledge presented in this review. Recording the results in a national Registry on a continuing basis will provide the data that may help advance the management of PCD based on larger data bases of well documented patient information to guide the selection of future therapies for PCD treatments. It is also clear that the management of patients within the complex of diseases that comprise PCD should be performed in centers with expertise in the imaging, medical, interventional and surgical approaches to diseases of the PCD.

Quantitative magnetic resonance angiography as a potential predictor for cerebral hyperperfusion syndrome: a preliminary study

OBJECTIVE

Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk.

METHODS

In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors.

RESULTS

Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS.

CONCLUSIONS

Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.

Measurement of blood-brain barrier permeability using dynamic contrast-enhanced magnetic resonance imaging with reduced scan time

PURPOSE

To investigate the feasibility of measuring the subtle disruption of blood-brain barrier (BBB) using DCE-MRI with a scan duration shorter than 10 min.

METHODS

The extended Patlak-model (EPM) was introduced to include the effect of plasma flow (F_p ) in the estimation of vascular permeability-surface area product (PS). Numerical simulation studies were carried out to investigate how the reduction in scan time affects the accuracy in estimating contrast kinetic parameters. DCE-MRI studies of the rat brain were conducted with Fisher rats to confirm the results from the simulation. Intracranial F98 glioblastoma models were used to assess areas with different levels of permeability. In the normal brain tissues, the Patlak model (PM) and EPM were compared, whereas the 2-compartment-exchange-model (TCM) and EPM were assessed in the peri-tumor and the tumor regions.

RESULTS

The simulation study results demonstrated that scan time reduction could lead to larger bias in PS estimated by PM (>2000%) than by EPM (<47%), especially when F_p is low. When F_p was high as in the gray matter, the bias in PM-PS (>900%) were larger than that in EPM-PS (<42%). The animal study also showed similar results, where the PM parameters were more sensitive to the scan duration than the EPM parameters. It was also demonstrated that, in the peri-tumor region, the EPM parameters showed less change by scan duration than the TCM parameters.

CONCLUSION

The results of this study suggest that EPM can be used to measure PS with a scan duration of 10 min or less.

Intracranial contrast transit times on digital subtraction angiography decrease more in patients with delayed intraparenchymal hemorrhage after Pipeline

Background Pipeline embolization devices (PEDs) are used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage (DIPH). Changes in intracranial hemodynamics after PED are poorly understood. Objective Here, we assess hemodynamic changes after PED in patients and compare these changes in patients with and without DIPH (DIPH+ and DIPH-). Methods Records of patients with distal internal carotid artery (ICA) aneurysms treated with PED at our institution between 2012 and 2017 were retrospectively reviewed. Regions of interest were selected proximally to PED over the cavernous ICA and distally over the middle cerebral artery (MCA), and then transit times were determined using syngo iFlow software (Siemens). Ratio of MCA to ICA transit time was compared before, after treatment, and at follow-up. Ratios were also compared between DIPH+ and DIPH- subgroups. Correlations between aneurysm size, age, and ratios were investigated. Results Fifty-three patients were included. The ratio of MCA to ICA transit time decreased significantly after PED deployment (1.13 vs. 1.22, p < 0.01). The ratio in the DIPH + subgroup ( n = 4) was significantly lower (1.00 vs. 1.14, p = 0.01) and decreased significantly more (21% vs. 4.4%, p = 0.02) compared to the DIPH- subgroup ( n = 49). The ratio tended to be higher in larger aneurysms at baseline ( r = 0.25, p = 0.07) but not after PED treatment ( r = 0.11, p = 0.15). Age did not correlate with ratio. Conclusion The ratio of MCA to ICA transit time decreases following PED treatment and decreases more in patients with DIPH. These contrast transit time changes can be detected in real time immediately after PED deployment.

Promoting Neurovascular Recovery in Aged Mice after Ischemic Stroke - Prophylactic Effect of Omega-3 Polyunsaturated Fatty Acids

The aged population is among the highest at risk for ischemic stroke, yet most stroke patients of advanced ages (>80 years) are excluded from access to thrombolytic treatment by tissue plasminogen activator, the only FDA approved pharmacological therapy for stroke victims. Omega-3 polyunsaturated fatty acids (n-3 PUFAs) robustly alleviate ischemic brain injury in young adult rodents, but have not yet been studied in aged animals. This study investigated whether chronic dietary supplementation of n-3 PUFAs protects aging brain against cerebral ischemia and improves long-term neurological outcomes. Aged (18-month-old) mice were administered n-3 PUFA-enriched fish oil in daily chow for 3 months before and up to 8 weeks after 45 minutes of transient middle cerebral artery occlusion (tMCAO). Sensorimotor outcomes were assessed by cylinder test and corner test up to 35 days and brain repair dynamics evaluated immunohistologically up to 56 days after tMCAO. Mice receiving dietary supplementation of n-3 PUFAs for 3 months showed significant increases in brain ratio of n-3/n-6 PUFA contents, and markedly reduced long-term sensorimotor deficits and chronic ischemic brain tissue loss after tMCAO. Mechanistically, n-3 PUFAs robustly promoted post-ischemic angiogenesis and neurogenesis, and enhanced white matter integrity after tMCAO. The Pearson linear regression analysis revealed that the enhancement of neurogenesis and white matter integrity both correlated positively with improved sensorimotor activities after tMCAO. This study demonstrates that prophylactic dietary supplementation of n-3 PUFAs effectively improves long-term stroke outcomes in aged mice, perhaps by promoting post-stroke brain repair processes such as angiogenesis, neurogenesis, and white matter restoration.

A Stereotactic Probabilistic Atlas for the Major Cerebral Arteries

Improved whole brain angiographic and velocity-sensitive MRI is pushing the boundaries of noninvasively obtained cerebral vascular flow information. The complexity of the information contained in such datasets calls for automated algorithms and pipelines, thus reducing the need of manual analyses by trained radiologists. The objective of this work was to lay the foundation for such automated pipelining by constructing and evaluating a probabilistic atlas describing the shape and location of the major cerebral arteries. Specifically, we investigated how the implementation of a non-linear normalization into Montreal Neurological Institute (MNI) space improved the alignment of individual arterial branches. In a population-based cohort of 167 subjects, age 64–68 years, we performed 4D flow MRI with whole brain volumetric coverage, yielding both angiographic and anatomical data. For each subject, sixteen cerebral arteries were manually labeled to construct the atlas. Angiographic data were normalized to MNI space using both rigid-body and non-linear transformations obtained from anatomical images. The alignment of arterial branches was significantly improved by the non-linear normalization (p < 0.001). Validation of the atlas was based on its applicability in automatic arterial labeling. A leave-one-out validation scheme revealed a labeling accuracy of 96 %. Arterial labeling was also performed in a separate clinical sample (n = 10) with an accuracy of 92.5 %. In conclusion, using non-linear spatial normalization we constructed an artery-specific probabilistic atlas, useful for cerebral arterial labeling.

Aneurysm size and the Windkessel effect: An analysis of contrast intensity in digital subtraction angiography

Large cerebral aneurysms are considered more dangerous than their smaller counterparts, with higher risk of subarachnoid hemorrhage. Understanding the hemodynamics of large aneurysms has potential to predict their response to treatment. Digital subtraction angiography images for patients with intracranial aneurysms over a seven-year period were reviewed. Unruptured solitary aneurysms of the internal carotid artery (ICA) proximal to the terminus and posterior communicating artery were included. Contrast intensity over time was analyzed at the center of the M1 segment of the middle cerebral artery distal to the aneurysm and compared to the contralateral side. Analysis included time to peak (TP)10%-100% (time needed for contrast to change from 10% intensity to 100%), washout time (WT)100%-10% (time for 100% intensity to 10%), and quartile time (QT)25%-25% (time for 25% intensity during vessel filling to 25% during emptying). Fifty patients met the inclusion criteria. Analysis over the ipsilateral M1 segment revealed a significant increase in QT25%-25% (8.5 vs 7.6 seconds, p = 0.006) compared to the contralateral side. There was a correlation between TP10%-100% and QT25%-25% with aneurysm size (Pearson's r = 0.37, p = 0.007 and r = 0.43, p = 0.001, respectively). Larger ICA aneurysms were associated with delayed contrast intensity times . A plausible mechanism is that large aneurysms act as a capacitance chamber (Windkessel effect) that slow the arrival of contrast distal to the aneurysm. This may be of significance for large aneurysms after treatment, where the loss of the Windkessel effect places the distal circulation at greater risk for hemorrhage, and warrants further study.

Imaging Brain Collaterals: Quantification, Scoring, and Potential Significance

Leptomeningeal collaterals provide the primary source of perfusion to ischemic brain tissue following the onset of acute ischemic stroke and are becoming an important imaging biomarker for stroke therapy triage. Collateral circulation is predictive of infarct growth, end infarct volume, and response to endovascular therapy. The strength of the collateral circulation varies among patients and is partially dependent on genetic and modifiable risk factors. Collateral circulation may be assessed by standard angiographic techniques, including digital subtraction angiography, computed tomography and magnetic resonance (MR) angiography, as well as a growing array of advanced MR techniques including arterial spin labeling and dynamic MR angiography. Simple scoring systems are used to estimate the relative strength of the collateral circulation for a given patient, although there are some discrepancies in the predictive value of these systems. In this review, we discuss methods and techniques for determining the robustness of the collateral circulation and the role of the collateral circulation in acute ischemic stroke assessment and triage.

Impaired neurovascular coupling in aging and Alzheimer's disease: Contribution of astrocyte dysfunction and endothelial impairment to cognitive decline

The importance of (micro)vascular contributions to cognitive impairment and dementia (VCID) in aging cannot be overemphasized, and the pathogenesis and prevention of age-related cerebromicrovascular pathologies are a subject of intensive research. In particular, aging impairs the increase in cerebral blood flow triggered by neural activation (termed neurovascular coupling or functional hyperemia), a critical mechanism that matches oxygen and nutrient delivery with the increased demands in active brain regions. From epidemiological, clinical and experimental studies the picture emerges of a complex functional impairment of cerebral microvessels and astrocytes, which likely contribute to neurovascular dysfunction and cognitive decline in aging and in age-related neurodegenerative diseases. This overview discusses age-related alterations in neurovascular coupling responses responsible for impaired functional hyperemia. The mechanisms and consequences of astrocyte dysfunction (including potential alteration of astrocytic endfeet calcium signaling, dysregulation of eicosanoid gliotransmitters and astrocyte energetics) and functional impairment of the microvascular endothelium are explored. Age-related mechanisms (cellular oxidative stress, senescence, circulating IGF-1 deficiency) impairing the function of cells of the neurovascular unit are discussed and the evidence for the causal role of neurovascular uncoupling in cognitive decline is critically examined.

Factors Affecting Choroidal Vascular Density in Normal Eyes: Quantification Using En Face Swept-Source Optical Coherence Tomography

PURPOSE

To quantify the vascular density of the choroid of normal eyes and to identify the influencing factors using en face images obtained with swept-source optical coherence tomography (SS OCT).

DESIGN

Prospective cross-sectional study.

METHODS

One hundred and sixty-three eyes of 163 healthy volunteers (83 female; mean age 42.2 ± 22.6 years) with a corrected visual acuity of ≥1.0 were investigated. En face SS OCT images of the choroid were used for quantitative assessment of the vascular density in the large choroid vessel layer. Relationships between vascular density of the choroid and age, sex, refractive error (RE), axial length (AL), and subfoveal choroidal thickness (SCT) were also investigated.

RESULTS

There was a significant negative relationship between vascular density of the choroid and subject age (P < .001). Analysis according to age showed a significant correlation in the group aged >30 years (P < .001), but not in the group aged ≤30 years (P = .225). SCT had a significant positive relationship with vascular density of the choroid (P < .001). However, a significant correlation was not observed between sex, RE, or AL and vascular density of the choroid (P = .981, P = .292, and P = .216, respectively). Multivariable regression analysis with vascular density of the choroid as the dependent variable and age, sex, RE, AL, and SCT as independent variables showed that age and SCT are important determinants of vascular density of the choroid (P < .001).

CONCLUSION

Age and SCT affect vascular density of the choroid.

Unilateral fetal-type circle of Willis anatomy causes right-left asymmetry in cerebral blood flow with pseudo-continuous arterial spin labeling: A limitation of arterial spin labeling-based cerebral blood flow measurements?

The accuracy of cerebral blood flow measurements using pseudo-continuous arterial spin labeling can be affected by vascular factors other than cerebral blood flow, such as flow velocity and arterial transit time. We aimed to elucidate the effects of common variations in vascular anatomy of the circle of Willis on pseudo-continuous arterial spin labeling signal. In addition, we investigated whether possible differences in pseudo-continuous arterial spin labeling signal could be mediated by differences in flow velocities. Two hundred and three elderly participants underwent magnetic resonance angiography of the circle of Willis and pseudo-continuous arterial spin labeling scans. Mean pseudo-continuous arterial spin labeling-cerebral blood flow signal was calculated for the gray matter of the main cerebral flow territories. Mean cerebellar gray matter pseudo-continuous arterial spin labeling-cerebral blood flow was significantly lower in subjects having a posterior fetal circle of Willis variant with an absent P1 segment. The posterior fetal circle of Willis variants also showed a significantly higher pseudo-continuous arterial spin labeling-cerebral blood flow signal in the ipsilateral flow territory of the posterior cerebral artery. Flow velocity in the basilar artery was significantly lower in these posterior fetal circle of Willis variants. This study indicates that pseudo-continuous arterial spin labeling measurements underestimate cerebral blood flow in the posterior flow territories and cerebellum of subjects with a highly prevalent variation in circle of Willis morphology. Additionally, our data suggest that this effect is mediated by concomitant differences in flow velocity between the supplying arteries.

Complex Alterations of Intracranial 4-Dimensional Hemodynamics in Vein of Galen Aneurysmal Malformations During Staged Endovascular Embolization

BACKGROUND

Vein of Galen aneurysmal malformations (VGAMs) are rare congenital cerebral arteriovenous shunts often treated by staged endovascular embolization early in life. Treatment-induced changes in intracranial hemodynamics and their impact on the clinical management of VGAM patients remain unclear.

OBJECTIVE

To evaluate hemodynamic alterations in the cerebral arterial and venous network in pediatric patients with VGAMs during staged embolizations.

METHODS

Serial 4-dimensional flow magnetic resonance imaging (21 scans) was performed in 6 VGAM patients (3 female; mean age, 2.1 ± 4.0 years) undergoing staged embolization. Time-integrated pathlines were used to visualize 3-dimensional blood flow changes in intracranial arterial and venous systems. Total cerebral arterial inflow (flow in bilateral internal carotid arteries plus basilar artery), arteriovenous shunt flow, and blood flow in other major cerebral arteries (middle cerebral artery; posterior cerebral artery) were quantified for all patients.

RESULTS

Intracranial 3-dimensional blood flow visualization demonstrated marked reduction of arteriovenous shunting and distinct hemodynamic alterations after embolization. From baseline to endpoint embolization, total cerebral arterial inflow dropped by 40.2% (from 22.70 ± 6.54 mL/s to 13.57 ± 4.87 mL/s), corresponding to arteriovenous shunt flow reduction of 73.5% (from 9.69 ± 6.16 mL/s to 2.57 ± 3.79 mL/s). In addition, the ipsilateral posterior cerebral artery/middle cerebral artery flow ratio decreased by 86.9% (from 4.20 ± 6.28 to 0.55 ± 0.23).

CONCLUSION

Hemodynamic alterations in VGAMs after embolization can be visualized and quantified using 4-dimensional flow magnetic resonance imaging. Cerebral arterial inflow and arteriovenous shunt flow reduction and complex flow redistribution after embolization illustrate the potential of 4-dimensional flow magnetic resonance imaging to better evaluate the efficacy of interventions and monitor treatment effects.

Age-Related Changes of Normal Cerebral and Cardiac Blood Flow in Children and Adults Aged 7 Months to 61 Years

BACKGROUND

Cerebral and cardiac blood flow are important to the pathophysiology and development of cerebro- and cardiovascular diseases. The purpose of this study was to investigate the age dependence of normal cerebral and cardiac hemodynamics in children and adults over a broad range of ages.

METHODS AND RESULTS

Overall, 52 children (aged 0.6-17.2 years) and 30 adults (aged 19.2-60.7 years) without cerebro- and cardiovascular diseases were included in this study. Intracranial 4-dimensional flow and cardiac 2-dimensional phase-contrast magnetic resonance imaging were performed for all participants to measure flow parameters in the major intracranial vessels and aorta. Total cerebral blood flow (TCBF), cardiac and cerebral indexes, brain volume, and global cerebral perfusion (TCBF/brain volume) were evaluated. Flow analysis revealed that TCBF increased significantly from age 7 months to 6 years (P<0.001) and declined thereafter (P<0.001). Both cardiac and cerebral indices declined with age (P<0.001). The ratio of TCBF to ascending aortic flow declined rapidly until age 18 years (P<0.001) and remained relatively stable thereafter. Age-related changes of cerebral vascular peak velocities exhibited a trend similar to TCBF. By comparison, aortic peak velocities maintained relatively high levels in children and declined with age in adults (P<0.001). TCBF significantly correlated with brain volume in adults (P=0.005) and in 2 pediatric subgroups, aged <7 years (P<0.001) and 7 to 18 years (P=0.039).

CONCLUSIONS

Cerebral and cardiac flow parameters are highly associated with age. The findings collectively highlight the importance of age-matched control data for the characterization of intracranial and cardiac hemodynamics.

Automatic labeling of cerebral arteries in magnetic resonance angiography

OBJECTIVES

In order to introduce 4D flow magnetic resonance imaging (MRI) as a standard clinical instrument for studying the cerebrovascular system, new and faster postprocessing tools are necessary. The objective of this study was to construct and evaluate a method for automatic identification of individual cerebral arteries in a 4D flow MRI angiogram.

MATERIALS AND METHODS

Forty-six elderly individuals were investigated with 4D flow MRI. Fourteen main cerebral arteries were manually labeled and used to create a probabilistic atlas. An automatic atlas-based artery identification method (AAIM) was developed based on vascular-branch extraction and the atlas was used for identification. The method was evaluated by comparing automatic with manual identification in 4D flow MRI angiograms from 67 additional elderly individuals.

RESULTS

Overall accuracy was 93%, and internal carotid artery and middle cerebral artery labeling was 100% accurate. Smaller and more distal arteries had lower accuracy; for posterior communicating arteries and vertebral arteries, accuracy was 70 and 89%, respectively.

CONCLUSION

The AAIM enabled fast and fully automatic labeling of the main cerebral arteries. AAIM functionality provides the basis for creating an automatic and powerful method to analyze arterial cerebral blood flow in clinical routine.

Relationships and redundancies of selected hemodynamic and structural parameters for characterizing virtual treatment of cerebral aneurysms with flow diverter devices

BACKGROUND AND PURPOSE

To quantify the relationship and to demonstrate redundancies between hemodynamic and structural parameters before and after virtual treatment with a flow diverter device (FDD) in cerebral aneurysms.

METHODS

Steady computational fluid dynamics (CFD) simulations were performed for 10 cerebral aneurysms where FDD treatment with the SILK device was simulated by virtually reducing the porosity at the aneurysm ostium. Velocity and pressure values proximal and distal to and at the aneurysm ostium as well as inside the aneurysm were quantified. In addition, dome-to-neck ratios and size ratios were determined. Multiple correlation analysis (MCA) and hierarchical cluster analysis (HCA) were conducted to demonstrate dependencies between both structural and hemodynamic parameters.

RESULTS

Velocities in the aneurysm were reduced by 0.14m/s on average and correlated significantly (p<0.05) with velocity values in the parent artery (average correlation coefficient: 0.70). Pressure changes in the aneurysm correlated significantly with pressure values in the parent artery and aneurysm (average correlation coefficient: 0.87). MCA found statistically significant correlations between velocity values and between pressure values, respectively. HCA sorted velocity parameters, pressure parameters and structural parameters into different hierarchical clusters. HCA of aneurysms based on the parameter values yielded similar results by either including all (n=22) or only non-redundant parameters (n=2, 3 and 4).

CONCLUSION

Hemodynamic and structural parameters before and after virtual FDD treatment show strong inter-correlations. Redundancy of parameters was demonstrated with hierarchical cluster analysis.

Cerebral Blood Flow Alterations in Acute Sport-Related Concussion

Sport-related concussion (SRC) is a major health problem, affecting millions of athletes each year. While the clinical effects of SRC (e.g., symptoms and functional impairments) typically resolve within several days, increasing evidence suggests persistent neurophysiological abnormalities beyond the point of clinical recovery after injury. This study aimed to evaluate cerebral blood flow (CBF) changes in acute SRC, as measured using advanced arterial spin labeling (ASL) magnetic resonance imaging (MRI). We compared CBF maps assessed in 18 concussed football players (age, 17.8 ± 1.5 years) obtained within 24 h and at 8 days after injury with a control group of 19 matched non-concussed football players. While the control group did not show any changes in CBF between the two time-points, concussed athletes demonstrated a significant decrease in CBF at 8 days relative to within 24 h. Scores on the clinical symptom (Sport Concussion Assessment Tool 3, SCAT3) and cognitive measures (Standardized Assessment of Concussion [SAC]) demonstrated significant impairment (vs. pre-season baseline levels) at 24 h (SCAT, p < 0.0001; SAC, p < 0.01) but returned to baseline levels at 8 days. Two additional computerized neurocognitive tests, the Automated Neuropsychological Assessment Metrics and Immediate Post-Concussion and Cognitive Testing, showed a similar pattern of changes. These data support the hypothesis that physiological changes persist beyond the point of clinical recovery after SRC. Our results also indicate that advanced ASL MRI methods might be useful for detecting and tracking the longitudinal course of underlying neurophysiological recovery from concussion.

Cerebrovascular and ventilatory responses to acute isocapnic hypoxia in healthy aging and lung disease: effect of vitamin C

Acute hypoxia increases cerebral blood flow (CBF) and ventilation (V̇e). It is unknown if these responses are impacted with normal aging, or in patients with enhanced oxidative stress, such as (COPD). The purpose of the study was to 1) investigate the effects of aging and COPD on the cerebrovascular and ventilatory responses to acute hypoxia, and 2) to assess the effect of vitamin C on these responses during hypoxia. In 12 Younger, 14 Older, and 12 COPD, we measured peak cerebral blood flow velocity (V̄p; index of CBF), and V̇e during two 5-min periods of acute isocapnic hypoxia, under conditions of 1) saline-sham; and 2) intravenous vitamin C. Antioxidants [vitamin C, superoxide dismutase (SOD), glutathione peroxidase, and catalase], oxidative stress [malondialdehyde (MDA) and advanced protein oxidation product], and nitric oxide metabolism end products (NOx) were measured in plasma. Following the administration of vitamin C, vitamin C, SOD, catalase, and MDA increased, while NOx decreased. V̄p and V̇e sensitivity to hypoxia was reduced in Older by ∼60% ( P < 0.02). COPD patients exhibited similar V̄p and V̇e responses to Older ( P > 0.05). Vitamin C did not have an effect on the hypoxic V̇e response but selectively decreased the V̄p sensitivity in Younger only. These findings suggest a reduced integrative reflex (i.e., cerebrovascular and ventilatory) during acute hypoxemia in healthy older adults. Vitamin C does not appear to have a large influence on the cerebrovascular or ventilatory responses during acute hypoxia.

Scaling of cerebral blood perfusion in primates and marsupials

The evolution of primates involved increasing body size, brain size and presumably cognitive ability. Cognition is related to neural activity, metabolic rate and rate of blood flow to the cerebral cortex. These parameters are difficult to quantify in living animals. This study shows that it is possible to determine the rate of cortical brain perfusion from the size of the internal carotid artery foramina in skulls of certain mammals, including haplorrhine primates and diprotodont marsupials. We quantify combined blood flow rate in both internal carotid arteries as a proxy of brain metabolism in 34 species of haplorrhine primates (0.116-145 kg body mass) and compare it to the same analysis for 19 species of diprotodont marsupials (0.014-46 kg). Brain volume is related to body mass by essentially the same exponent of 0.70 in both groups. Flow rate increases with haplorrhine brain volume to the 0.95 power, which is significantly higher than the exponent (0.75) expected for most organs according to 'Kleiber's Law'. By comparison, the exponent is 0.73 in marsupials. Thus, the brain perfusion rate increases with body size and brain size much faster in primates than in marsupials. The trajectory of cerebral perfusion in primates is set by the phylogenetically older groups (New and Old World monkeys, lesser apes) and the phylogenetically younger groups (great apes, including humans) fall near the line, with the highest perfusion. This may be associated with disproportionate increases in cortical surface area and mental capacity in the highly social, larger primates.

Hemodynamic Features of Symptomatic Vertebrobasilar Disease

BACKGROUND AND PURPOSE

Atherosclerotic vertebrobasilar disease is an important cause of posterior circulation stroke. To examine the role of hemodynamic compromise, a prospective multicenter study, Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS), was conducted. Here, we report clinical features and vessel flow measurements from the study cohort.

METHODS

Patients with recent vertebrobasilar transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral or basilar arteries (BA) were enrolled. Large-vessel flow in the vertebrobasilar territory was assessed using quantitative MRA.

RESULTS

The cohort (n=72; 44% women) had a mean age of 65.6 years; 72% presented with ischemic stroke. Hypertension (93%) and hyperlipidemia (81%) were the most prevalent vascular risk factors. BA flows correlated negatively with percentage stenosis in the affected vessel and positively to the minimal diameter at the stenosis site (P<0.01). A relative threshold effect was evident, with flows dropping most significantly with ≥80% stenosis/occlusion (P<0.05). Tandem disease involving the BA and either/both vertebral arteries had the greatest negative impact on immediate downstream flow in the BA (43 mL/min versus 71 mL/min; P=0.01). Distal flow status assessment, based on an algorithm incorporating collateral flow by examining distal vessels (BA and posterior cerebral arteries), correlated neither with multifocality of disease nor with severity of the maximal stenosis.

CONCLUSIONS

Flow in stenotic posterior circulation vessels correlates with residual diameter and drops significantly with tandem disease. However, distal flow status, incorporating collateral capacity, is not well predicted by the severity or location of the disease.