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Degollado-García J, Casas-Martínez MR, Mejia BRF, Balcázar-Padrón JC, Rodríguez-Rubio HA, Nathal E. Internal maxillary artery (IMax) - middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report. J Cerebrovasc Endovasc Neurosurg 2024; 26:51-57. [PMID: 37997040 PMCID: PMC10995475 DOI: 10.7461/jcen.2023.e2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/21/2023] [Accepted: 05/12/2023] [Indexed: 12/06/2023] Open
Abstract
Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft's free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.
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Affiliation(s)
- Javier Degollado-García
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Martin R. Casas-Martínez
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Bill Roy Ferrufino Mejia
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Juan C. Balcázar-Padrón
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Héctor A. Rodríguez-Rubio
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Edgar Nathal
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
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2
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Bhandari A, Feridooni T, Pikula A, Styra R, Mikulis DJ, Howe KL. Evaluating the influence of altered cerebral hemodynamics on cognitive performance in asymptomatic carotid artery stenosis: A systematic review. J Vasc Surg 2024; 79:436-447. [PMID: 37619916 DOI: 10.1016/j.jvs.2023.08.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Substantial controversy exists regarding asymptomatic carotid stenosis (ACS) and its potential role in the pathophysiology of cognitive impairment. If proven, this hypothesis may suggest an additional definition for symptomatic carotid disease that would alter current management. This study aimed to synthesize the literature evaluating the relationship between impaired cerebral hemodynamics and cognition in patients with ACS. METHODS A literature search was performed using MEDLINE, Embase, and EBM Reviews through May 2022. We included prospective case-control studies that used validated, objective measure(s) of either global cognition or one or more domains of cognitive function and assessed cerebrovascular reserve (CVR). RESULTS Five studies were included, comprising a total of 782 patients with moderate (50%-69%) to severe (70%-99%) ACS. Patients with ACS and impaired ipsilateral CVR demonstrated significant cognitive impairment compared with controls. Patients with unilateral or bilateral ACS and normal CVR had cognitive scores similar to controls. Those with bilateral CVR impairment demonstrated the lowest cognitive scores. CONCLUSIONS This review lends support to the claim that cognitive impairment, likely the result of impaired cerebral hemodynamics, is an under-recognized morbidity in patients with ACS. CVR may serve as an additional tool to determine whether patients are in fact symptomatic from their carotid stenosis and warrant consideration for intervention.
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Affiliation(s)
- Apoorva Bhandari
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tiam Feridooni
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Aleksandra Pikula
- Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Rima Styra
- Department of Psychiatry, University of Toronto, University Health Network, Toronto, ON, Canada
| | - David J Mikulis
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada.
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3
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Wu YF, Sun J, Chen M, Lin Q, Jin KY, Su SH, Hai J. Combined VEGF and bFGF loaded nanofiber membrane protects against neuronal injury and hypomyelination in a rat model of chronic cerebral hypoperfusion. Int Immunopharmacol 2023; 125:111108. [PMID: 37890380 DOI: 10.1016/j.intimp.2023.111108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Currently, there are no effective therapeutic targets for the treatment of chronic cerebral hypoperfusion(CCH)-induced cerebral ischemic injury. Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) are discovered as the inducers of neurogenesis and angiogenesis. We previously made a nanofiber membrane (NFM), maintaining a long-term release of VEGF and bFGF up to 35 days, which might make VEGF and bFGF NFM as the potential protective agents against cerebral ischemic insult. In this study, the effects of VEGF and bFGF delivered by NFM into brain were investigated as well as their underlying mechanismsin a rat model of CCH. VEGF + bFGF NFM application increased the expressions of tight junction proteins, maintained BBB integrity, and alleviated vasogenic cerebral edema. Furthermore, VEGF + bFGF NFM sticking enhanced angiogenesis and elevated CBF. Besides, VEGF + bFGF NFM treatment inhibited neuronal apoptosis and decreased neuronal loss. Moreover, roofing of VEGF + bFGF NFM attenuated microglial activation and blocked the launch of NLRP3/caspase-1/IL-1β pathway. In addition, VEGF + bFGF NFM administration prevented disruption to the pre/postsynaptic membranes and loss of myelin sheath, relieving synaptic injury and demyelination. Oligodendrogenesis, neurogenesis and PI3K/AKT/mTOR pathway were involved in the treatment of VEGF + bFGF NFM against CCH-induced neuronal injury and hypomyelination. These findings supported that VEGF + bFGF NFM application constitutes a neuroprotective strategy for the treatment of CCH, which may be worth further clinical translational research as a novel neuroprotective approach, benifiting indirect surgical revascularization.
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Affiliation(s)
- Yi-Fang Wu
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Jun Sun
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Ming Chen
- Department of Neurosurgery, Xinhua hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
| | - Qi Lin
- Department of Pharmacy, Institutes of Medical Sciences, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Kai-Yan Jin
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Shao-Hua Su
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China.
| | - Jian Hai
- Department of Neurosurgery, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China.
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4
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Zvolanek KM, Moia S, Dean JN, Stickland RC, Caballero-Gaudes C, Bright MG. Comparing end-tidal CO 2, respiration volume per time (RVT), and average gray matter signal for mapping cerebrovascular reactivity amplitude and delay with breath-hold task BOLD fMRI. Neuroimage 2023; 272:120038. [PMID: 36958618 DOI: 10.1016/j.neuroimage.2023.120038] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/27/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023] Open
Abstract
Cerebrovascular reactivity (CVR), defined as the cerebral blood flow response to a vasoactive stimulus, is an imaging biomarker with demonstrated utility in a range of diseases and in typical development and aging processes. A robust and widely implemented method to map CVR involves using a breath-hold task during a BOLD fMRI scan. Recording end-tidal CO2 (PETCO2) changes during the breath-hold task is recommended to be used as a reference signal for modeling CVR amplitude in standard units (%BOLD/mmHg) and CVR delay in seconds. However, obtaining reliable PETCO2 recordings requires equipment and task compliance that may not be achievable in all settings. To address this challenge, we investigated two alternative reference signals to map CVR amplitude and delay in a lagged general linear model (lagged-GLM) framework: respiration volume per time (RVT) and average gray matter BOLD response (GM-BOLD). In 8 healthy adults with multiple scan sessions, we compare spatial agreement of CVR maps from RVT and GM-BOLD to those generated with PETCO2. We define a threshold to determine whether a PETCO2 recording has "sufficient" quality for CVR mapping and perform these comparisons in 16 datasets with sufficient PETCO2 and 6 datasets with insufficient PETCO2. When PETCO2 quality is sufficient, both RVT and GM-BOLD produce CVR amplitude maps that are nearly identical to those from PETCO2 (after accounting for differences in scale), with the caveat they are not in standard units to facilitate between-group comparisons. CVR delays are comparable to PETCO2 with an RVT regressor but may be underestimated with the average GM-BOLD regressor. Importantly, when PETCO2 quality is insufficient, RVT and GM-BOLD CVR recover reasonable CVR amplitude and delay maps, provided the participant attempted the breath-hold task. Therefore, our framework offers a solution for achieving high quality CVR maps in both retrospective and prospective studies where sufficient PETCO2 recordings are not available and especially in populations where obtaining reliable measurements is a known challenge (e.g., children). Our results have the potential to improve the accessibility of CVR mapping and to increase the prevalence of this promising metric of vascular health.
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Affiliation(s)
- Kristina M Zvolanek
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Biomedical Engineering, McCormick School of Engineering and Applied Sciences, Northwestern University, Evanston, IL, USA.
| | - Stefano Moia
- Basque Center on Cognition, Brain and Language, Donostia, Gipuzkoa, Spain; Medical Imaging Processing Lab (MIP:Lab), Neuro-X institute, EPFL, Geneva, Switzerland
| | - Joshua N Dean
- Department of Biomedical Engineering, McCormick School of Engineering and Applied Sciences, Northwestern University, Evanston, IL, USA
| | - Rachael C Stickland
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Molly G Bright
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Biomedical Engineering, McCormick School of Engineering and Applied Sciences, Northwestern University, Evanston, IL, USA
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5
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Wang C, Reid G, Mackay CE, Hayes G, Bulte DP, Suri S. A Systematic Review of the Association Between Dementia Risk Factors and Cerebrovascular Reactivity. Neurosci Biobehav Rev 2023; 148:105140. [PMID: 36944391 DOI: 10.1016/j.neubiorev.2023.105140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/15/2023] [Accepted: 03/15/2023] [Indexed: 03/23/2023]
Abstract
Cumulative evidence suggests that impaired cerebrovascular reactivity (CVR), a regulatory response critical for maintaining neuronal health, is amongst the earliest pathological changes in dementia. However, we know little about how CVR is affected by dementia risk, prior to disease onset. Understanding this relationship would improve our knowledge of disease pathways and help inform preventative interventions. This systematic review investigates 59 studies examining how CVR (measured by magnetic resonance imaging) is affected by modifiable, non-modifiable, and clinical risk factors for dementia. We report that non-modifiable risk (older age and apolipoprotein ε4), some modifiable factors (diabetes, traumatic brain injury, hypertension) and some clinical factors (stroke, carotid artery occlusion, stenosis) were consistently associated with reduced CVR. We also note a lack of conclusive evidence on how other behavioural factors such as physical inactivity, obesity, or depression, affect CVR. This review explores the biological mechanisms underpinning these brain- behaviour associations, highlights evident gaps in the literature, and identifies the risk factors that could be managed to preserve CVR in an effort to prevent dementia.
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Affiliation(s)
- Congxiyu Wang
- Department of Psychiatry, University of Oxford, UK; Wellcome Centre for Integrative Neuroimaging, University of Oxford, UK
| | - Graham Reid
- Department of Psychiatry, University of Oxford, UK; Department of Experimental Psychology, University of Oxford, UK
| | - Clare E Mackay
- Department of Psychiatry, University of Oxford, UK; Wellcome Centre for Integrative Neuroimaging, University of Oxford, UK
| | - Genevieve Hayes
- Institute of Biomedical Engineering, University of Oxford, UK
| | - Daniel P Bulte
- Institute of Biomedical Engineering, University of Oxford, UK
| | - Sana Suri
- Department of Psychiatry, University of Oxford, UK; Wellcome Centre for Integrative Neuroimaging, University of Oxford, UK.
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6
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Tsunoda S, Inoue T, Takeuchi N, Shinkai T, Segawa M, Akabane A. Two adult patients with moyamoya disease presenting with alexia with agraphia limited to kanji: can revascularization improve characteristic symptoms? Acta Neurochir (Wien) 2023; 165:625-30. [PMID: 36562875 DOI: 10.1007/s00701-022-05460-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
Patients with moyamoya disease (MMD) may exhibit higher brain dysfunction due to hypoperfusion, which may be ameliorated by revascularization. However, few studies have examined the relationship between cerebral perfusion and language function or the ameliorating effect of revascularization on language dysfunction. We present two cases with MMD who presented with alexia with agraphia, specifically for Japanese kanji. The patients had impaired perfusion in the left inferior temporal and lateral occipital lobes. Following superficial temporal artery-middle cerebral artery bypass, the symptoms improved dramatically. Thus, correction of hypoperfusion may be effective even in adult patients with MMD presenting with language dysfunction.
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7
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Lee MJ, Park BY, Cho S, Kim S, Park H, Kim ST, Chung CS. Cerebrovascular reactivity and deep white matter hyperintensities in migraine: A prospective CO 2 targeting study. J Cereb Blood Flow Metab 2022; 42:1879-1889. [PMID: 35607990 PMCID: PMC9536123 DOI: 10.1177/0271678x221103006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Several studies suggested the association of migraine with deep white matter hyperintensities (WMHs). We aimed to explore the cerebrovascular reactivity (CVR), deep WMH burden, and their association in patients with migraine using a state-of-the-art methodology. A total of 31 patients with migraine without aura and 31 age/sex-matched controls underwent 3T MRI with prospective end-tidal carbon dioxide (CO2) targeting. We quantified deep WMH clusters using an automated segmentation tool and measured voxel-wise CVR by changes in blood oxygen level-dependent signal fitted to subjects' end-tidal CO2. The association of migraine and CVR with the presence of WMH in each voxel and interaction of migraine and CVR on WMH were analysed. Patients had a higher number of deep WMHs than controls (p = 0.015). Migraine and reduced CVR were associated with increased probability of having WMHs in each voxel (adjusted OR 30.78 [95% CI 1.89-500.53], p = 0.016 and adjusted OR 0.30 [0.29-0.32], p < 0.001, respectively). Migraine had an effect modification on CVR on deep WMHs (p for interaction <0.001): i.e. the association between CVR and WMH was greater in patients than in controls. We suggest that the migraine-WMH association can be explained by the effect modification on the CVR.
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Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Seoul National University College of Medicine, Seoul, South Korea
| | - Bo-Yong Park
- Department of Data Science, Inha University, Incheon, South Korea
| | - Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, South Korea
| | - Seonwoo Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Hyunjin Park
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, South Korea.,School of Electronic and Electrical Engineering, Sungkyunkwan University, Suwon, South Korea
| | - Sung Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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8
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Papassin J, Heck O, Condamine E, Pietras J, Detante O, Krainik A. Impaired cerebrovascular reactivity is associated with recurrent stroke in patients with severe intracranial arterial stenosis: A C02 BOLD fMRI study. J Neuroradiol 2021; 48:339-45. [DOI: 10.1016/j.neurad.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 11/20/2022]
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9
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Vlisides PE, Moore LE, Whalin MK, Robicsek SA, Gelb AW, Lele AV, Mashour GA. Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol. 2020;32:210-226. [PMID: 32433102 DOI: 10.1097/ana.0000000000000686] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.
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10
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Raper DMS, Rutledge WC, Winkler EA, Meisel K, Callen AL, Cooke DL, Abla AA. Controversies and Advances in Adult Intracranial Bypass Surgery in 2020. Oper Neurosurg (Hagerstown) 2021; 20:1-7. [PMID: 32895706 DOI: 10.1093/ons/opaa276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/11/2020] [Indexed: 02/02/2023] Open
Abstract
Cerebral revascularization utilizing a variety of bypass techniques can provide either flow augmentation or flow replacement in the treatment of a range of intracranial pathologies, including moyamoya disease, intracranial atherosclerotic disease, and complex aneurysms that are not amenable to endovascular or simple surgical techniques. Though once routine, the publication of high-quality prospective evidence, along with the development of flow-diverting stents, has limited the indications for extracranial-to-intracranial (EC-IC) bypass. Nevertheless, advances in imaging, assessment of cerebral hemodynamics, and surgical technique have changed the risk-benefit calculus for EC-IC bypass. New variations of revascularization surgery involving multiple anastomoses, flow preserving solutions, IC-IC constructs, and posterior circulation bypasses have been pioneered for otherwise difficult to treat pathology including giant aneurysms, dolichoectasia, and medically refractory intracranial atherosclerosis. This review provides a practical update on recent advances in adult intracranial bypass surgery.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Karl Meisel
- Department of Neurology, University of California, San Francisco, California
| | - Andrew L Callen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
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11
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Sebök M, van Niftrik CHB, Winklhofer S, Wegener S, Esposito G, Stippich C, Luft A, Regli L, Fierstra J. Mapping Cerebrovascular Reactivity Impairment in Patients With Symptomatic Unilateral Carotid Artery Disease. J Am Heart Assoc 2021; 10:e020792. [PMID: 34102856 PMCID: PMC8477889 DOI: 10.1161/jaha.121.020792] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Comprehensive hemodynamic impairment mapping using blood oxygenation‐level dependent (BOLD) cerebrovascular reactivity (CVR) can be used to identify hemodynamically relevant symptomatic unilateral carotid artery disease. Methods and Results This prospective cohort study was conducted between February 2015 and July 2020 at the Clinical Neuroscience Center of the University Hospital Zurich, Zurich, Switzerland. One hundred two patients with newly diagnosed symptomatic unilateral internal carotid artery (ICA) occlusion or with 70% to 99% ICA stenosis were included. An age‐matched healthy cohort of 12 subjects underwent an identical BOLD functional magnetic resonance imaging examination. Using BOLD functional magnetic resonance imaging with a standardized CO2 stimulus, CVR impairment was evaluated. Moreover, embolic versus hemodynamic ischemic patterns were evaluated on diffusion‐weighted imaging. Sixty‐seven patients had unilateral ICA occlusion and 35 patients unilateral 70% to 99% ICA stenosis. Patients with ICA occlusion exhibited lower whole‐brain and ipsilateral hemisphere mean BOLD‐CVR values as compared with healthy subjects (0.12±0.08 versus 0.19±0.04, P=0.004 and 0.09±0.09 versus 0.18±0.04, P<0.001) and ICA stenosis cohort (0.12±0.08 versus 0.16±0.05, P=0.01 and 0.09±0.09 versus 0.15±0.05, P=0.01); however, only 40 (58%) patients of the cohort showed significant BOLD‐CVR impairment. Conversely, there was no difference in mean BOLD‐CVR values between healthy patients and patients with ICA stenosis, although 5 (14%) patients with ICA stenosis showed a significant BOLD‐CVR impairment. No significant BOLD‐CVR difference was discernible between patients with hemodynamic ischemic infarcts versus those with embolic infarct distribution (0.11±0.08 versus 0.13±0.06, P=0.12). Conclusions Comprehensive BOLD‐CVR mapping allows for identification of hemodynamically relevant symptomatic unilateral carotid artery stenosis or occlusion.
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Affiliation(s)
- Martina Sebök
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Sebastian Winklhofer
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neuroradiology University Hospital ZurichUniversity of Zurich Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neurology University Hospital ZurichUniversity of Zurich Switzerland
| | - Giuseppe Esposito
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Christoph Stippich
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Neuroradiology and Radiology Schmieder Clinic Allensbach Germany
| | - Andreas Luft
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neurology University Hospital ZurichUniversity of Zurich Switzerland.,Cereneo Center for Neurology and Rehabilitation Vitznau Switzerland
| | - Luca Regli
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
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12
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Kim JH, Ha SK, Jin SW, Lee HB, Kim SD, Kim SH, Lim DJ. Color Doppler ultrasonography for predicting the patency of anastomosis after superficial temporal to middle cerebral artery bypass surgery. Acta Neurochir (Wien) 2021; 163:1503-13. [PMID: 33404878 DOI: 10.1007/s00701-020-04669-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Color Doppler ultrasonography (CDUS) is used to evaluate the surgical success and postoperative hemodynamic changes of patients who receive superficial temporal to middle cerebral artery (STA-MCA) bypass surgery. Previous studies enrolled small populations, and difficulties interpreting the results have limited their use in clinical settings. OBJECTIVE We attempted to determine the feasibility of using CDUS to evaluate STA hemodynamics and identify the most reliable parameter as a new clinical implication for determining bypass patency. METHOD Twenty-six patients who underwent STA-MCA bypass surgery were prospectively enrolled. Four times CDUS and two times digital subtraction angiography (DSA) were performed. The CDUS parameters were compensated using the ratio of the operated to the non-operated sides (R1) and compared before and after surgery (R2). The CDUS parameters are then compared with the patency on DSA by statistical analyses. RESULTS Increased CDUS parameters of the mean flow rate (MFR) and cross-sectional diameter (CSD) showed significant correlations with good patency on DSA. The R2 at 1 month was identified as the most reliable parameter for predicting the patency in both MFR and CSD. Their cutoff values were 1.475 and 1.15, respectively. CONCLUSION CDUS can be utilized for predicting the patency after STA-MCA bypass surgery; if the postoperative (compensated and compared) CDUS parameters increased by more than 47.5% in the MFR or 15% in the CSD, the patency of the anastomosis on DSA would be good.
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13
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Deckers PT, van Hoek W, Kronenburg A, Yaqub M, Siero JCW, Bhogal AA, van Berckel BNM, van der Zwan A, Braun KPJ. Contralateral improvement of cerebrovascular reactivity and TIA frequency after unilateral revascularization surgery in moyamoya vasculopathy. Neuroimage Clin 2021; 30:102684. [PMID: 34215154 PMCID: PMC8102652 DOI: 10.1016/j.nicl.2021.102684] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/24/2021] [Accepted: 04/18/2021] [Indexed: 11/17/2022]
Abstract
Contralateral cerebrovascular reactivity may improve after unilateral surgery in moyamoya. TIA frequency from the contralateral hemisphere can decrease after unilateral moyamoya surgery. These findings support staged rather than direct bilateral surgery in moyamoya.
Objective Moyamoya vasculopathy is a rare, often bilateral disease characterized by progressive stenosis and occlusion of the distal internal carotid artery, leading to a progressive deterioration of cerebrovascular reactivity (CVR) and increased risk of transient ischemic attacks (TIAs), infarction and hemorrhage. Surgical revascularization is a widely accepted symptomatic treatment, often performed bilaterally in one or two stages. To possibly further optimize treatment strategy, we investigated the effect of unilateral revascularization surgery on the CVR of, and TIA frequency originating from, the contralateral hemisphere. Methods From our database of 143 moyamoya vasculopathy patients we selected those with bilateral disease, who underwent hemodynamic imaging ([15O]H2O positron emission tomography (PET)-CT with acetazolamide challenge) before and 14 months (median) after unilateral revascularization. We evaluated CVR in three regions per hemisphere, and averaged these per hemisphere for statistical comparison. Conservatively treated patients were showed as a comparison group. To examine TIA frequency, we selected patients who presented with TIAs that (also) originated from the contralateral – not to be operated – hemisphere. We scored changes in CVR and TIA frequency of the ipsilateral and contralateral hemisphere over time. Results Seven surgical and seven conservative patients were included for CVR comparison. Of the 20 scored contralateral regions in the surgical group, 15 showed improved CVR after unilateral revascularization, while 5 remained stable. The averaged scores improved significantly for both hemispheres. In conservatively treated patients, however, only 3 of the 20 scored regions improved in the least-affected (contralateral) hemispheres, and 9 deteriorated. From the 6 patients with contralateral TIAs at presentation, 4 had a decreased TIA frequency originating from the contralateral hemisphere after unilateral surgery, while 2 patients remained stable. Conclusion Both CVR and TIA frequency in the contralateral hemisphere can improve after unilateral revascularization surgery in bilateral MMV.
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Affiliation(s)
- Pieter T Deckers
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands.
| | - Wytse van Hoek
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Annick Kronenburg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Maqsood Yaqub
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Jeroen C W Siero
- Imaging Division, Department of Radiology, Utrecht Center for Image Sciences, University Medical Center Utrecht, Utrecht the Netherlands; Spinoza Centre for Neuroimaging, Amsterdam, the Netherlands
| | - Alex A Bhogal
- Imaging Division, Department of Radiology, Utrecht Center for Image Sciences, University Medical Center Utrecht, Utrecht the Netherlands
| | - Bart N M van Berckel
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Albert van der Zwan
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Kees P J Braun
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
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Abstract
Stroke is associated with substantial morbidity and mortality. The aim of this review is to provide an evidence-based synthesis of the literature related to perioperative stroke, including its etiology, common risk factors, and potential risk reduction strategies. In addition, the authors will discuss screening methods for the detection of postoperative cerebral ischemia and how multidisciplinary collaborations, including endovascular interventions, should be considered to improve patient outcomes. Lastly, the authors will discuss the clinical and scientific knowledge gaps that need to be addressed to reduce the incidence and improve outcomes after perioperative stroke.
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15
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Roder C, Klose U, Hurth H, Brendle C, Tatagiba M, Ernemann U, Khan N, Hauser TK. Longitudinal Reproducibility of CO2-Triggered BOLD MRI for the Hemodynamic Evaluation of Adult Patients with Moyamoya Angiopathy. Cerebrovasc Dis 2021; 50:332-338. [PMID: 33556937 DOI: 10.1159/000513301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Hemodynamic evaluation of moyamoya patients is crucial to decide the treatment strategy. Recently, CO2-triggered BOLD MRI has been shown to be a promising tool for the hemodynamic evaluation of moyamoya patients. However, the longitudinal reliability of this technique in follow-up examinations is unknown. This study aims to analyze longitudinal follow-up data of CO2-triggered BOLD MRI to prove the reliability of this technique for long-term control examinations in moyamoya patients. METHODS Longitudinal CO2 BOLD MRI follow-up examinations of moyamoya patients with and without surgical revascularization have been analyzed for all 6 vascular territories retrospectively. If revascularization was performed, any directly (by the disease or the bypass) or indirectly (due to change of collateral flow after revascularization) affected territory was excluded based on angiography findings (group 1). In patients without surgical revascularization between the MRI examinations, all territories were analyzed (group 2). RESULTS Eighteen moyamoya patients with 39 CO2 BOLD MRI examinations fulfilled the inclusion criteria. The median follow-up between the 2 examinations was 12 months (range 4-29 months). For 106 vascular territories analyzed in group 1, the intraclass correlation coefficient was 0.784, p < 0.001, and for group 2 (84 territories), it was 0.899, p < 0.001. Within the total follow-up duration of 140 patient months, none of the patients experienced a new stroke. CONCLUSIONS CO2 BOLD MRI is a promising tool for mid- and long-term follow-up examinations of cerebral hemodynamics in moyamoya patients. Systematic prospective evaluation is required prior to making it a routine examination.
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Affiliation(s)
- Constantin Roder
- Center for Moyamoya and Cerebral Revascularization, Department of Neurosurgery, Eberhard Karls University Tübingen, Tübingen, Germany.,Interdisciplinary Center for Neurovascular Diseases Tübingen (ZNET), Tübingen, Germany
| | - Uwe Klose
- Department of Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Helene Hurth
- Center for Moyamoya and Cerebral Revascularization, Department of Neurosurgery, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Cornelia Brendle
- Department of Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Center for Moyamoya and Cerebral Revascularization, Department of Neurosurgery, Eberhard Karls University Tübingen, Tübingen, Germany.,Interdisciplinary Center for Neurovascular Diseases Tübingen (ZNET), Tübingen, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany.,Interdisciplinary Center for Neurovascular Diseases Tübingen (ZNET), Tübingen, Germany
| | - Nadia Khan
- Center for Moyamoya and Cerebral Revascularization, Department of Neurosurgery, Eberhard Karls University Tübingen, Tübingen, Germany, .,Moyamoya Center, University Children's Hospital Zürich, Zürich, Switzerland,
| | - Till-Karsten Hauser
- Department of Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
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16
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Kim JH, Yoon W, Kim CK, Roh H, Bae HJ, Kwon TH, Suh SI, Oh K, Chong K. Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis. Cerebrovasc Dis 2021; 50:34-45. [PMID: 33423028 DOI: 10.1159/000512106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/03/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. AIMS We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. METHODS Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. RESULTS In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0-2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. CONCLUSIONS Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.
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Affiliation(s)
- Jang Hun Kim
- Trauma Center, Armed Forces Capital Hospital, Gyeonggi-do, Republic of Korea
| | - Wonki Yoon
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea,
| | - Chi Kyung Kim
- Department of Neurology, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Haewon Roh
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hee Jin Bae
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Taek-Hyun Kwon
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang-Il Suh
- Department of Radiology, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyungmi Oh
- Department of Neurology, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyuha Chong
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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17
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Callen AL, Caton MT, Rutledge C, Raper D, Narvid J, Villanueva-Meyer JE, Abla A. The Effect of Extracranial-to-Intracranial Bypass on Cerebral Vasoreactivity: A 4D Flow MRI Pilot Study. J Neuroimaging 2020; 30:587-592. [PMID: 32862480 DOI: 10.1111/jon.12776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Extracranial-to-intracranial (EC-IC) surgical bypass improves cerebral blood flow (CBF) and cerebrovascular vasoreactivity (CVR) for patients with carotid occlusion. Bypass graft patency and contribution of the graft to the postoperative increase in CVR are challenging to assess. To assess the effectiveness of 4D flow magnetic resonance imaging (MRI) to evaluate bypass graft patency and flow augmentation through the superficial temporal artery (STA) before and after EC-IC bypass. METHODS Three consecutive patients undergoing EC-IC bypass for carotid occlusion were evaluated pre- and postoperatively using CVR testing with pre- and poststimulus 4D flow-MRI for assessment of the bypass graft and intracranial vasculature. RESULTS Preoperatively, 2 patients (patients 1 and 3) did not augment flow through either native STA. The third, who had evidence of extensive native EC-IC collateralization on digital subtraction angiography (DSA), did augment flow through the STA preoperatively (CVR = 1). Postoperatively, all patients demonstrated CVR > 1 on the side of bypass. The patient who had CVR > 1 preoperatively demonstrated the greatest increase in resting postoperative graft flow (from 40 to 130 mL/minute), but the smallest CVR, with a poststimulus graft flow of 160 mL/minute (CVR = 1.2). The 2 patients who did not demonstrate augmentation of graft flow preoperatively augmented postoperatively from 10 to 20 mL/minute (CVR = 2.0) and 10-80 mL/minute (CVR = 8.0), respectively. Intracranial flow was simultaneously interrogated. Two patients demonstrated mild reductions in resting flow velocities in all interrogated vessels immediately following bypass. The patient who underwent CVR testing on postoperative day 48 demonstrated a stable or increased flow rate in most intracranial vessels. CONCLUSION Four-dimensional flow MRI allows for noninvasive, simultaneous interrogation of the intra- and extracranial arterial vasculature during CVR testing, and reveals unique paradigms in cerebrovascular physiology. Observing these flow patterns may aid in improved patient selection and more detailed postoperative evaluation for patients undergoing EC-IC bypass.
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Affiliation(s)
- Andrew L Callen
- Department of Radiology, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Michael T Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Daniel Raper
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Adib Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
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18
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Yu Y, Yan LF, Sun Q, Hu B, Zhang J, Yang Y, Dai YJ, Cui WX, Xiu SJ, Hu YC, Heng CN, Liu QQ, Hou JF, Pan YY, Zhai LH, Han TH, Cui GB, Wang W. Neurovascular decoupling in type 2 diabetes mellitus without mild cognitive impairment: Potential biomarker for early cognitive impairment. Neuroimage 2019; 200:644-658. [PMID: 31252056 DOI: 10.1016/j.neuroimage.2019.06.058] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 12/15/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a significant risk factor for mild cognitive impairment (MCI) and the acceleration of MCI to dementia. The high glucose level induce disturbance of neurovascular (NV) coupling is suggested to be one potential mechanism, however, the neuroimaging evidence is still lacking. To assess the NV decoupling pattern in early diabetic status, 33 T2DM without MCI patients and 33 healthy control subjects were prospectively enrolled. Then, they underwent resting state functional MRI and arterial spin labeling imaging to explore the hub-based networks and to estimate the coupling of voxel-wise cerebral blood flow (CBF)-degree centrality (DC), CBF-mean amplitude of low-frequency fluctuation (mALFF) and CBF- mean regional homogeneity (mReHo). We further evaluated the relationship between NV coupling pattern and cognitive performance (false discovery rate corrected). T2DM without MCI patients displayed significant decrease in the absolute CBF-mALFF, CBF-mReHo coupling of CBFnetwork and in the CBF-DC coupling of DCnetwork. Besides, networks which involved CBF and DC hubs mainly located in the default mode network (DMN). Furthermore, less severe disease and better cognitive performance in T2DM patients were significantly correlated with higher coupling of CBF-DC, CBF-mALFF or CBF-mReHo, especially for the cognitive dimensions of general function and executive function. Thus, coupling of CBF-DC, CBF-mALFF and CBF-mReHo may serve as promising indicators to reflect NV coupling state and to explain the T2DM related early cognitive impairment.
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Affiliation(s)
- Ying Yu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Lin-Feng Yan
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Qian Sun
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Bo Hu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Jin Zhang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Yang Yang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Yu-Jie Dai
- Department of Clinical Nutrition, Xijing Hospital, Fourth Military Medical University (Air Force Medical University), 15 West Changle Road, Xi'an, 710032, Shaanxi, China.
| | - Wu-Xun Cui
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Si-Jie Xiu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Yu-Chuan Hu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Chun-Ni Heng
- Department of Endocrinology, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Qing-Quan Liu
- Department of Endocrinology, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Jun-Feng Hou
- Department of Endocrinology, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Yu-Yun Pan
- Student Brigade, Fourth Military Medical University (Air Force Medical University), 169 Changle Road, Xi'an, 710032, Shaanxi, China.
| | - Liang-Hao Zhai
- Student Brigade, Fourth Military Medical University (Air Force Medical University), 169 Changle Road, Xi'an, 710032, Shaanxi, China.
| | - Teng-Hui Han
- Student Brigade, Fourth Military Medical University (Air Force Medical University), 169 Changle Road, Xi'an, 710032, Shaanxi, China.
| | - Guang-Bin Cui
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
| | - Wen Wang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, Fourth Military Medical University (Air Force Medical University), 569 Xinsi Road, Xi'an, 710038, Shaanxi, China.
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