Dedicated coil for carotid MR angiography

Imaging of acute stroke: state of the art

The high incidence of stroke, plus its fatal or debilitating outcome, has prompted tremendous advances over the last two decades on both diagnostic and therapeutic fronts. Multiple randomized trials have proven the utility of thrombolytic agents with rejuvenation of the role of diagnostic imaging. State of the art imaging (mainly computed tomography and magnetic resonance imaging) is crucial for patient selection (eg, excluding intracranial hemorrhage), diagnosis of stroke and prediction of prognosis. Here, we discuss the anatomic and physiologic changes due to an ischemic insult as manifested by modern imaging techniques, including diffusion and perfusion imaging, as well as demonstration of vascular disease by cross sectional angiography supplemented by three dimensional postprocessing. The main target of management is "Penumbra", or salvageable tissue, which is primarily dependent upon the expediency of the whole process, better expressed by the phrase "Time is Brain".

Magnetic resonance angiographic and clinical features of extracranial vertebral artery dissection

OBJECTIVES

Clinical data and neuroradiological findings of 19 patients with 20 vertebral artery dissections were analysed to describe the features of time of flight magnetic resonance angiography (MRA) for the diagnosis and follow up of this vascular disorder.

METHODS

All patients underwent a combined MRI and MRA protocol with 1.5 T scanners, using a three dimensional flow compensated gradient echo sequence for MRA. Duplex sonography was performed on all patients and selective angiography was available from 17 vertebral artery dissections.

RESULTS

MRI showed ischaemic lesions of the brain in 18 of 19 patients (95%). In the acute and subacute stage, MRA detected signal abnormalities within the dissected vertebral artery in 94% (16/17) and MRI was specific for a dissection in 29% (5/17). Sensitivity of selective angiography was 100% and specificity was 35% (6/17). Combination of the results of both methods increased the specificity to 50%. Duplex sonography was sensitive in 79% (15/19), but lacked specific results. Follow up magnetic resonance in 16 patients showed recanalisation of the dissected vessel in 10 (63%), persistent occlusion in five (31%), and a dissecting aneurysm in one (6%) patient.

CONCLUSIONS

Magnetic resonance improves the triage for selective angiography and discloses complementary information for the diagnosis of vertebral artery dissection. If magnetic resonance identifies a double lumen or a mural haematoma with a stenosis or aneurysmal dilatation, invasive procedures can be omitted.

Magnetic resonance angiography

Magnetic resonance angiography (MRA) permits the non-invasive visualization of blood flow through the effects of moving spins on the magnetic resonance signal. MRA techniques can be divided into two main classifications depending upon the primary effect responsible for contrast in the image. Angiograms can be produced using either the time-of-flight (TOF) or phase contrast (PC) methods. Each method has particular advantages and limitations as an angiographic imaging technique and these are reflected in their respective applications. This review article is intended to outline the scientific and technical development of MRA from its basis in the earliest in vitro nuclear magnetic resonance (NMR) experiments, through the implementation of in vivo angiographic techniques on whole body MRI systems, to the recent rapid expansion in MRA acquisition and processing techniques.

Assessment of carotid artery stenosis by ultrasonography, conventional angiography, and magnetic resonance angiography: correlation with ex vivo measurement of plaque stenosis

PURPOSE

Several studies have investigated the correlation between Doppler ultrasonography (DUS), angiography (CA), and magnetic resonance angiography (MRA) in the evaluation of stenosis of the carotid bifurcation. However, these studies suffer from the lack of a true control-the lesion itself-and therefore conclusions about the diagnostic accuracy of each method remain relative. To determine the absolute accuracy of these modalities, we have prospectively studied lesion size with DUS, MRA, and CA in 28 patients undergoing 31 elective carotid endarterectomies and compared the percent of carotid stenosis determined by each technique to the carotid atheroma resected en bloc.

METHODS

All patients were evaluated by each modality within 1 month before the thromboendarterectomy. With DUS, stenosis size was determined by standard flow criteria. For angiography and MRA, stenosis was defined as residual lumenal diameter/estimated normal arterial diameter (European Carotid Surgery Trial criteria). At surgery the carotid atheroma was removed en bloc in all patients. Patients in whom the lesion could not be removed successfully without damage were excluded from the study. Stenosis of the atheroma was determined ex vivo with high-resolution (0.03 mm3) magnetic resonance and confirmed by acrylic injection of the specimen under pressure and measurement of the atheroma wall and lumen.

RESULTS

The measurements of the ex vivo stenosis by high-resolution magnetic resonance imaging correlated closely with the size of stenosis determined by the acrylic specimen casts (r = 0.92). By ex vivo measurement, the lesions were placed in the following size categories: 40% to 59% stenosis (n = 2), 60% to 79% stenosis (n = 6), 80% to 89% stenosis (n = 7), and 90% to 99% stenosis (n = 16).

CONCLUSIONS

In general, the correlation of measurements of ex vivo stenosis with all modalities was good in these severely diseased arteries, although it was better for DUS (r = 0.80; p < 0.001) and MRA (r = 0.76; p < 0.001) than for CA (r = 0.56; p < 0.05).

Thyroid cyst mistaken for carotid pseudoaneurysm by MR angiography. Case report

A normal volunteer for magnetic resonance angiography of the carotid arteries had an abnormal examination that suggested a common carotid pseudoaneurysm. High resolution sonography identified a normal carotid artery immediately adjacent to a thyroid lesion, part of which was cystic and which mimicked carotid aneurysmal disease.

Instrumentation for magnetic resonance angiography

Magnetic resonance angiography (MRA) places high demands on instrumentation capabilities. Magnetic gradient strength capabilities, main magnetic field strength and homogeneity, and eddy current compensation all play a role in determining the quality of the flow studies. In addition, radiofrequency coil design and use is governed by the specific vascular territories of interest. Once the instrumentational and pulse sequence considerations have been optimized, the postprocessing and display of the acquired three-dimensional data sets is of key importance. Great strides have been made in addressing instrumentation needs for MRA, but further improvements are anticipated.

Magnetic resonance angiography of extracranial carotid and vertebral arteries, including their origins: comparison with digital subtraction angiography

Although carotid bifurcation stenoses are not the only lesions of the extracranial cerebral arteries, magnetic resonance angiographic (MRA) studies to date have concentrated on the carotid bifurcation. We compared digital subtraction angiography of the extracranial portions of the cerebral arteries with MRA using an ordinary body coil, the time-of-flight method, and multiple transverse slabs which covered the arteries down to the aortic arch. Twenty-two patients (15 with arteriosclerotic diseases, 4 with aortitis, and 3 with tumours) had MRA using a 1.5 T magnet system with a three-dimensional fast imaging with steady state precession (FISP) technique. Thirty-nine carotid and 39 vertebral arteries were assessed by three radiologists with regard to stenoses or occlusions, graded as normal, mild (< 30%), moderate (30-60%) or severe (> 60%) stenosis, or occluded. Grading corresponded well in 81%; stenoses appeared more marked on MRA in 14% and were seen less clearly on MRA in 5%. When 26 carotid bifurcations were assessed separately, grading corresponded well in 95%. MRA is the only method which can display the whole course of the extracranial carotid and vertebral arteries non-invasively and satisfactorily.

Application of a connected-voxel algorithm to MR angiographic data

A connected-voxel algorithm (CVA) that improves the contrast and conspicuity of blood vessels in maximum-intensity-projection (MIP) magnetic resonance (MR) angiography is described. Images from a variety of anatomic regions in healthy volunteers were calculated with either an MIP procedure alone or with data that had first been processed with the CVA. A low-signal-intensity threshold is first applied to separate groups of voxels associated with different vessels from one another and to eliminate the contribution from low-intensity stationary material. The remaining voxels are grouped by a connectivity criterion into discrete "objects." Vessels are represented by extended objects, and small objects are discarded. The CVA, therefore, reduces the full three-dimensional data set into a small number of discrete objects. It is a powerful technique that can be used to remove signal from vessels overlying the vessel of interest, to separate objects representing arterial flow from those representing venous flow, to eliminate flow artifact from projection images, and to more completely retain signal within the vascular lumen. This technique has been successfully demonstrated with MR angiography in healthy volunteers.