Cine Phase-contrast Magnetic Resonance Research Articles

Spontaneous Third Ventriculostomy in Cases of Aqueductal Stenosis: A Retrospective Case Series

Spontaneous third ventriculostomy (STV) is a rare occurrence in cases of obstructive hydrocephalus where the walls of the third ventricle rupture, communicating the ventricular system and the subarachnoid space leading to arrest of active hydrocephalus. We aim to review our series of STVs while reviewing previous reports. A retrospective review of cases undergoing Cine phase-contrast magnetic resonance imaging PC-MRI from 2015 to 2022 of any age with imaging evidence of arrested obstructive hydrocephalus was performed. Patients in which aqueductal stenosis was radiologically evident and the presence of third ventriculostomy through which CSF flow was detectable were included. Patients who previously underwent endoscopic third ventriculostomy were excluded. Data on patient demographics, presentation, and imaging details of STV and aqueductal stenosis were collected. We searched the PubMed database using the following keyword combination: ((("spontaneous ventriculostomy") OR ("spontaneous third ventriculostomy")) OR ("spontaneous ventriculocisternostomy")) including English reports of STV published between 2010 and 2022. Fourteen cases were included (7 adults, 7 pediatrics), all with history of hydrocephalus. STV occurred in the floor of the third ventricle in 57.1% of the cases, at the lamina terminalis in 35.7%, and at both sites in one case. 11 publications reporting 38 cases of STV were identified from 2009 to date. Minimum follow up period was 10 months and maximum follow up is 77 months. In cases of chronic obstructive hydrocephalus, neurosurgeons should be minded with the possibility of the presence of an STV on PC-MRI leading to arrested hydrocephalus. The delayed flow at the aqueduct of Sylvius might not be the only determinant of the necessity of CSF diversion and the presence of an STV should be factored into the neurosurgeon's decision considering the patient's clinical picture.

Influence of the area of the aqueduct and region of interest on quantification of stroke volume in healthy volunteers using phase-contrast cine magnetic resonance imaging.

Phase-contrast cine magnetic resonance imaging (PC-MRI) has been used to measure cerebrospinal fluid (CSF) flow dynamics, but the influence of the area of the aqueduct and region of interest (ROI) on quantification of stroke volume (SV) has not been assessed. To assess the influence of the area of the ROI in quantifying the aqueductal SV measured with PC-MRI within the cerebral aqueduct. Nine healthy volunteers (mean age = 29.6 years) were enrolled in the study, and brain MRI examinations were performed on a 3.0-T system. Quantitative analysis of the aqueductal CSF flow was performed using manual ROI placement. ROIs were separately drawn for each of the 12 phases of the cardiac cycle, and changes in aqueduct size during the cardiac cycle were determined. The SV was calculated using 12 different aqueductal ROIs and compared with the SV calculated using a fixed ROI size. There was variation in the size of the aqueduct during the cardiac cycle. In addition, the measured SV increased with a greater area of the ROI. A significant difference in the calculated SVs with the 12 variable ROIs was observed compared with that using a fixed ROI throughout the cardiac cycle. To establish reliable reference values for the SV in future studies, a variable ROI should be considered.

Surgical Management of Chiari Malformation Type I Associated with Syringomyelia: Outcome of Surgeries Based on the New Classification and Study of Cerebrospinal Fluid Dynamics.

Introduction: The mainstay of treatment of syringomyelia associated with Chiari malformation type I (CM-I) is the management of CM-I to normalize the cerebrospinal fluid (CSF) flow at the foramen magnum. CM-I is classified into three independent types. Surgical treatment was selected based on the mechanism of hindbrain ptosis in each CM-I type. Materials and Methods: Foramen magnum decompression (FMD: 213 cases), expansive suboccipital cranioplasty (ESCP: 87 cases), and craniocervical fixation (CCF: 30 cases) were performed. CSF flow dynamics were assessed pre- and post-surgery using cine phase contrast magnetic resonance imaging. During surgery, CSF flow dynamics were examined using color Doppler ultrasonography (CDU). Results: ESCP and FMD demonstrated high rates of improvement in neurological symptoms and signs (82.7%), whereas CCF demonstrated a high rate of improvement in neurological symptoms (89%). The pre-operative maximum flow velocity (cm/s) was significantly lower in patients than in controls and increased post-operatively. During surgery, CDU indicated that the volume of the major cistern was 8 mL, and the maximum flow velocity was >3 mL/s. Conclusions: An appropriate surgical treatment should be selected for CM-I to correct hindbrain ptosis. In addition, it is necessary to confirm the normalization of CSF flow at the foramen of Magendie.

Deep Learning-based Automated Aortic Area and Distensibility Assessment: the Multi-Ethnic Study of Atherosclerosis (MESA).

This study details application of deep learning for automatic segmentation of the ascending and descending aorta from 2D phase-contrast cine magnetic resonance imaging for automatic aortic analysis on the large MESA cohort with assessment on an external cohort of thoracic aortic aneurysm (TAA) patients. This study includes images and corresponding analysis of the ascending and descending aorta at the pulmonary artery bifurcation from the MESA study. Train, validation, and internal test sets consisted of 1123 studies (24,282 images), 374 studies (8067 images), and 375 studies (8069 images), respectively. The external test set of TAAs consisted of 37 studies (3224 images). CNN performance was evaluated utilizing a dice coefficient and concordance correlation coefficients (CCC) of geometric parameters. Dice coefficients were as high as 97.55% (CI: 97.47-97.62%) and 93.56% (CI: 84.63-96.68%) on the internal and external test of TAAs, respectively. CCC for maximum and minimum and ascending aortic area were 0.969 and 0.950, respectively, on the internal test set and 0.997 and 0.995, respectively, for the external test. The absolute differences between manual and deep learning segmentations for ascending and descending aortic distensibility were 0.0194 × 10-4 ± 9.67 × 10-4 and 0.002 ± 0.001mmHg-1, respectively, on the internal test set and 0.44 × 10-4 ± 20.4 × 10-4 and 0.002 ± 0.001mmHg-1, respectively, on the external test set. We successfully developed a U-Net-based aortic segmentation and analysis algorithm in both MESA and in external cases of TAA.

Cine phase-contrast magnetic resonance imaging evaluation of cerebrospinal fluid flow dynamics in healthy pediatric subjects.

ObjectiveTo evaluate cerebrospinal fluid dynamics, using cine phase-contrast magnetic resonance imaging (cine-PC MRI), in healthy pediatric subjects, determining the normal flow values in this population, as well as identifying differences related to age, sex, and body surface area.Materials and MethodsThis was a descriptive cross-sectional study involving 32 healthy children and adolescents, in whom the flow of cerebrospinal fluid through the cerebral aqueduct was evaluated quantitatively with cine-PC MRI. We used specialized software to analyze the images obtained with cine-PC MRI, drawing a region of interest on the aqueduct. A flow-time curve was obtained, as were automated measurements of the various parameters.ResultsThe following normal (mean) values were obtained: net flow, 1.10 ± 0.99 mL/m; stroke volume, 12.2 ± 10.1 µL/cycle; mean velocity, 0.72 ± 1.00 cm/s; peak systolic velocity, 5.28 ± 2.30 cm/s; peak diastolic velocity, 4.51 ± 1.77 cm/s. These values were not affected by age or sex. In addition, body surface area was not found to correlate significantly with mean velocity or stroke volume.ConclusionIn children and adolescents, the basic cerebrospinal fluid flow parameters, as determined by cine-PC MRI, appear to be independent of age and sex.

Intra-Left Ventricular Hemodynamics Assessed with 4D Flow Magnetic Resonance Imaging in Patients with Left Ventricular Thrombus.

Left ventricular thrombus (LVT) has been identified to be crucial in patients with reduced ejection fraction (EF). Three-dimensional cine phase-contrast magnetic resonance imaging (4D flow MRI) can visualize the intra-LV vortex during diastole and quantify the maximum flow velocity (Vmax) at the apex. In this study, we investigated whether the change in the intra-LV vortex was associated with the presence of LVT in patients with cardiac disease.In total, 36 patients (63.5 ± 11.9 years, 28 men, 12/24 with/without LVT) with diffuse LV dysfunction underwent 4D flow MRI. The relative vortex area using streamline images and Vmax of blood flow toward the apex at the apical left ventricle were evaluated. The correlation between the relative vortex area and Vmax was assessed using Pearson's correlation coefficient. The ability to detect LVT was evaluated using the area under the curve (AUC) of the receiver operating characteristic.The relative vortex area was found to be smaller (27 ± 10% versus 45 ± 11%, P = 0.000026), whereas Vmax at the apical left ventricle was lower (19.1 ± 4.4 cm/second versus 27.4 ± 8.9 cm/second, P = 0.0006) in patients with LVT. Vmax at the apical left ventricle demonstrated significant correlations with the relative vortex area (r = 0.43, P = 0.01) and relative transverse length of the vortex (r = 0.45, P = 0.007). The AUC was 0.91 for the relative vortex area, whereas it was 0.80 for Vmax in the apical left ventricle.A smaller LV vortex and lower flow velocity at the LV apex were associated with LVT in patients with reduced EF.

Physiological significance of pericoronary inflammation in epicardial functional stenosis and global coronary flow reserve

Both fractional flow reserve (FFR) and global coronary flow reserve (g-CFR) provide prognostic information in patients with stable coronary artery disease (CAD). Inflammation plays a vital role in impaired endothelial dysfunction and atherosclerotic progression, potentially predicting cardiovascular mortality. This study aimed to evaluate the physiological significance of pericoronary adipose tissue inflammation assessed by CT attenuation (PCATA) in epicardial functional stenosis severity and g-CFR in patients with CAD. A total of 131 CAD patients with a single de novo epicardial coronary stenosis who underwent coronary CT-angiography (CCTA), phase-contrast cine-magnetic resonance imaging (PC-CMR) and FFR measurement were studied. PCATA was assessed using the mean CT attenuation value. G-CFR was obtained by quantifying absolute coronary sinus flow (ml/min/g) by PC-CMR at rest and during maximum hyperemia. Median FFR, g-CFR, and PCATA values were 0.75, 2.59, and − 71.3, respectively. Serum creatinine, NT-proBNP, left ventricular end-diastolic volume, and PCATA were independently associated with g-CFR. PCATA showed a significant incremental predictive efficacy for impaired g-CFR (< 2.0) when added to the clinical risk model. PCATA was significantly associated with g-CFR, independent of FFR. Our results suggest the pathophysiological mechanisms linking perivascular inflammation with g-CFR in CAD patients.

Evaluation of CSF flow dynamics in patients with schizophrenia using phase-contrast cine MRI

Patients with schizophrenia show progressive clinical deterioration. Brain abnormalities have been suggested in these patients, including enlargement of the lateral ventricles, increased cerebrospinal fluid (CSF) volume and reductions in the frontal and temporal lobes. CSF flow pathology is a central factor in the development of many neurological disorders, but much less is known about the role of CSF flow dynamics in schizophrenia. In this study, parameters of CSF flow dynamics at the aqueduct level of 50 schizophrenic patients were compared to those of 50 controls using phase-contrast cine magnetic resonance imaging. Patients had lower peak velocity, lower net forward volume, and lower average flow over the range studied than controls. The average velocity was significantly lower in patients exhibiting violent behavior compared to non-violent patients. The aqueduct tendedto be larger in schizophrenic patients with earlier age of onset of the disorder. Furthermore, as the number of hospitalizations increased, the average velocity and flow over the range studied decreased commensurately. This study demonstrated that CSF flow dynamics are altered in patients with schizophrenia. The results indicated that additional studies of CSF flow dynamics in schizophrenia are needed, along with volumetric examinations of the brain, to elucidate the pathophysiology of the disease.

Head-nodding: a driving force for the circulation of cerebrospinal fluid

The myodural bridge (MDB) is a dense connective tissue bridge connecting the suboccipital muscles to the spinal dura mater, and it has been proven to be a normal common existing structure in humans and mammals. Some scholars believe that the suboccipital muscles can serve as a dynamic cerebrospinal fluid (CSF) pump via the MDB, and they found head rotations promote the CSF flow in human body, which provided evidence for this hypothesis. Head movement is a complex motion, but the effects of other forms of head movement on CSF circulation are less known. The present study explored the effects of head-nodding on CSF circulation. The CSF flow of 60 healthy volunteers was analyzed via cine phase-contrast magnetic resonance imaging at the level of the occipitocervical junction before and after one-minute-head-nodding period. Furthermore, the CSF pressures of 100 volunteers were measured via lumbar puncture before and after 5 times head-nodding during their anesthetizing for surgical preparation. As a result, it was found that the maximum and average CSF flow rates at the level of the upper border of atlas during ventricular diastole were significantly decreased from 1.965 ± 0.531 to 1.839 ± 0.460 ml/s and from 0.702 ± 0.253 to 0.606 ± 0.228 ml/s respectively. In the meantime, the changes in the ratio of cranial and caudal orientation of the net flow volume were found differed significantly after the one-minute-head-nodding period (p = 0.017). And on the other hand, the CSF pressures at the L3–L4 level were markedly increased 116.03 ± 26.13 to 124.64 ± 26.18 mmH2O. In conclusion, the head-nodding has obvious effects on CSF circulation and head movement is one of the important drivers of cerebrospinal fluid circulation. We propose that the suboccipital muscles, participating in various head movements, might pull the dura sac via the myodural bridge, and thus, head movement provides power for the CSF circulation.

Cerebrospinal Fluid Flow Dynamics during Handgrip Exercise in Young Healthy Adults: An MRI Study

Cerebral blood flow (CBF) increases during exercise, but its impact on cerebrospinal fluid (CSF) flow remains unknown. This study investigated CBF and CSF flow dynamics during moderate-intensity rhythmic handgrip (RHG) exercise in young healthy men and women. Twenty-six participants (12 women) underwent the RHG and resting control conditions in random order. Participants performed 3 sets of RHG, during which CINE phase-contrast magnetic resonance imaging (PC-MRI) was performed to measure blood stroke volume (SV) and flow rate in the internal carotid (ICA) and vertebral (VA) arteries, the internal jugular vein (IJV), the superior sagittal (SSS) and straight sinuses (SRS), and CSF SV and flow rate in the cerebral aqueduct of Sylvius. Blood pressure, end-tidal CO2 (EtCO2), heart rate (HR), and respiratory rate were simultaneously measured during CINE PC-MRI scans. Compared with control conditions, RHG showed significant elevations of HR, mean arterial pressure, and respiratory rate with a mild reduction of EtCO2 (all P<0.05). RHG decreased blood SV in the measured arteries, veins, and sinuses and CSF SV in the aqueduct (all P<0.05). Conversely, RHG increased blood flow in the ICA, VA, and IJV (all P<0.05). At the aqueduct, RHG decreased the absolute CSF flow rate (P=0.031), which was calculated as a sum of the caudal and cranial CSF flow rates. Change in the ICA SV was positively correlated with changes in the IJV, SSS, SRS, and aqueductal SV during RHG (all P<0.05). These findings demonstrate a close coupling between the CBF and CSF flow dynamics during moderate-intensity RHG exercise in young healthy adults.

Brain blood and cerebrospinal fluid flow dynamics during rhythmic handgrip exercise in young healthy men and women.

The cerebral fluid response to exercise, including the arterial and venous cerebral blood flow (CBF) and cerebrospinal fluid (CSF), currently remains unknown. We used time-resolved phase-contrast magnetic resonance imaging to assess changes in CBF and CSF flow dynamics during moderate-intensity rhythmic handgrip (RHG) exercise in young healthy men and women. Our data demonstrated that RHG increases the cerebral arterial inflow and venous outflow while decreasing the pulsatile CSF flow during RHG. Furthermore, changes in blood stroke volume at the measured arteries, veins, and sinuses and CSF stroke volume at the cerebral aqueduct were positively correlated with each other during RHG. Male and female participants exhibited distinct blood pressure responses to RHG, but their cerebral fluid responses were similar. These results collectively suggest that RHG influences both CBF and CSF flow dynamics in a way that is consistent with the Monro-Kellie hypothesis to maintain intracranial volume-pressure homeostasis in young healthy adults. Cerebral blood flow (CBF) increases during exercise, but its impact on cerebrospinal fluid (CSF) flow remains unknown. This study investigated CBF and CSF flow dynamics during moderate-intensity rhythmic handgrip (RHG) exercise in young healthy men and women. Twenty-six participants (12 women) underwent the RHG and resting control conditions in random order. Participants performed 3 sets of RHG, during which cine phase-contrast magnetic resonance imaging (PC-MRI) was performed to measure blood stroke volume (SV) and flow rate in the internal carotid (ICA) and vertebral (VA) arteries, the internal jugular vein (IJV), the superior sagittal (SSS) and straight sinuses (SRS), and CSF SV and flow rate in the cerebral aqueduct of Sylvius. Blood pressure, end-tidal CO2 (EtCO2 ), heart rate (HR), and respiratory rate were simultaneously measured during cine PC-MRI scans. Compared with control conditions, RHG showed significant elevations of HR, mean arterial pressure, and respiratory rate with a mild reduction of EtCO2 (all P < 0.05). RHG decreased blood SV in the measured arteries, veins, and sinuses and CSF SV in the aqueduct (all P < 0.05). Conversely, RHG increased blood flow in the ICA, VA, and IJV (all P < 0.05). At the aqueduct, RHG decreased the absolute CSF flow rate (P = 0.0307), which was calculated as a sum of the caudal and cranial CSF flow rates. Change in the ICA SV was positively correlated with changes in the IJV, SSS, SRS, and aqueductal SV during RHG (all P < 0.05). These findings demonstrate a close coupling between the CBF and CSF flow dynamics during RHG in young healthy adults.

Impaired coronary flow reserve evaluated by phase-contrast cine magnetic resonance imaging in patients with atrial fibrillations.

Myocardial perfusion and perfusion reserve are diminished in patients with atrial fibrillation (AF). Phase-contrast (PC) cine magnetic resonance imaging (MRI) of the coronary sinus serves as a non-invasive means of quantifying coronary flow reserve (CFR) without any radioactive tracer. The present study aimed to evaluate the utility of PC cine MRI of the coronary sinus for assessing decreased CFR in patients with AF. We studied 362 patients with known or suspected coronary artery disease (CAD) [age 72 ± 9years; 267 (74%) male; 90 (25%) had AF] and 20 age- and gender-matched control subjects [age 72 ± 9years, 14 (70%) male]. Using a 1.5-T MR scanner and cardiac coils, blood flow of the coronary sinus (CBF) was quantified by PC cine MRI. CFR was calculated as CBF during adenosine triphosphate infusion divided by CBF at rest. CFR was significantly lower in patients with AF than in those without AF among all patients (n = 362) (2.45 ± 0.42 vs. 2.71 ± 0.58, p < 0.001), in patients with known CAD (n = 155) (2.40 ± 0.46 vs. 2.72 ± 0.58, p = 0.002), and in those with suspected CAD (n = 207) (2.49 ± 0.40 vs. 2.72 ± 0.59, p = 0.007). Significant differences in CFR were found between controls and patients without AF (3.12 ± 0.52 vs. 2.71 ± 0.58, p < 0.001). AF was independently associated with CFR in both known CAD patients [β = - 0.248, 95% confidence interval (CI): - 0.561 to - 0.119, p = 0.003) and suspected CAD patients (β = - 0.154, 95% CI - 0.353 to - 0.034, p = 0.018). The presence of AF was related to impaired CFR in both known and suspected CAD patients. PC cine MRI of the coronary sinus can be useful for detecting impaired CFR in patients with AF.

Pulsatile cerebrospinal fluid dynamics in Chiari I malformation syringomyelia: Predictive value in posterior fossa decompression and insights into the syringogenesis.

Background:Pathophysiological mechanisms underlying the syringomyelia associated with Chiari I malformation (CM-1) are still not completely understood, and reliable predictors of the outcome of posterior fossa decompression (PFD) are lacking accordingly. The reported prospective case-series study aimed to prove the existence of a pulsatile, biphasic systolic–diastolic cerebrospinal fluid (CSF) dynamics inside the syrinx associated with CM-1 and to assess its predictive value of patients' outcome after PFD. Insights into the syringogenesis are also reported.Methods:Fourteen patients with symptomatic CM-1 syringomyelia underwent to a preoperative neuroimaging study protocol involving conventional T1/T2 and cardiac-gated cine phase-contrast magnetic resonance imaging sequences. Peak systolic and diastolic velocities were acquired at four regions of interest (ROIs): syrinx, ventral, and dorsal cervical subarachnoid space and foramen magnum region. Data were reported as mean ± standard deviation. After PFD, the patients underwent a scheduled follow-up lasting 3 years. One-way analysis of variance with Bonferroni Post hoc test of multiple comparisons was performed P was <0.001.Results:All symptoms but atrophy and spasticity improved. PFD caused a significant velocity changing of each ROI. Syrinx and premedullary cistern velocities were found to be decreased within the 1st month after PFD (<0.001). A caudad and cephalad CSF jet flow was found inside the syrinx during systole and diastole, respectively.Conclusion:Syrinx and premedullary cistern velocities are related to an early improvement of symptoms in patients with CM-1 syringomyelia who underwent PFD. The existence of a biphasic pulsatile systolic–diastolic CSF pattern inside the syrinx validates the “transmedullary” theory about the syringogenesis.

Endoscopic Third Ventriculostomy - A Review.

Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus. This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV. A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience. ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve. ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.

Prognostic value of unrecognized myocardial infarction and hyperemic coronary sinus flow in patients undergoing elective percutaneous coronary intervention

Abstract Background Cardiac magnetic resonance (CMR) imaging is a useful instrument for the assessment of pathological and functional conditions without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Both unrecognized myocardial infarction (UMI) and impaired global myocardial blood flow (g-MBF) have been reported to be strongly associated with worse outcome in patients with cardiovascular disease. However, their combined efficacy remains undetermined. Purpose We sought to assess the prognostic value of the presence of UMI and pre-procedural hyperemic g-MBF evaluated by phase-contrast cine magnetic resonance imaging (PC-CMR) in patients with chronic coronary syndrome who underwent elective percutaneous coronary intervention (PCI). Methods A total of 177 patients with de novo functionally significant stenosis who underwent pre-PCI CMR and PCI between September, 2016 and March, 2019 were retrospectively studied. UMI was defined as a scar detected by late gadolinium enhancement (LGE) without previously diagnosed MI. g-MBF was assessed by quantifying coronary sinus flow using PC-CMR at rest and hyperemic state. The predictors of major adverse cardiac events (MACE; cardiac death, nonfatal myocardial infarction, clinically driven unplanned revascularization, or hospitalization for congestive heart failure) during follow-up were investigated. Results UMI was detected in 40 (27.7%) patients and rest and maximal hyperemic g-MBF evaluated by the coronary sinus flow obtained by PC-CMR were 0.95 ml/min/g and 2.26 ml/min/g, respectively. During the median follow-up of 26 months, cardiovascular death occurred in 1 patient (0.6%), nonfatal myocardial infarction occurred in 4 patients (2.3%), and clinically driven revascularization and hospitalization due to congestive heart failure occurred in 25 patients (14.1%) and 3 patients (1.7%) patients, respectively. In patients with MACE, hyperemic g-MBF was significantly lower and the prevalence of UMI were significantly higher compared with those without MACE (1.94 ml/min/g vs 2.36 ml/min/g P=0.014; 48.3% vs 23.6%, P=0.011). Cox proportional hazards model indicated that impaired hyperemic g-MBF (&amp;lt;2.00 ml/min/g) and the presence of UMI were significant predictors of MACE (HR 2.22, 95% CI 1.060–4.640, P=0.034; HR 2.660, 95% CI 1.290–5.470, P=0.008). During follow-up, cardiac event-free survival was significantly worse in patients with impaired hyperemic g-MBF (&amp;lt;2.00 ml/min/g) and UMI (log-rank χ2=11.0, P=0.010). Conclusion In patients with chronic coronary syndrome undergoing elective PCI, the combined assessment of UMI and hyperemic g-MBF obtained by preprocedural noninvasive CMR may provide significant prognostic information. Funding Acknowledgement Type of funding source: None

Prognostic value of coronary flow capacity assessed by coronary sinus flow obtained by phase contrast cine-magnetic resonance imaging in patients with acute coronary syndrome

Abstract Background The concept of coronary flow capacity (CFC) originated from positron emission tomography has been reported to provide prognostic information. Phase contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying global coronary sinus flow (CSF) and global coronary flow reserve (g-CFR) without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Purpose We evaluated the prognostic value of postprocedural CFC by quantifying CSF using PC-CMR in patients with acute coronary syndrome (ACS) treated with primary or urgent percutaneous coronary intervention (PCI). Methods This study prospectively but nonconsecutively enrolled 569 ACS patients who underwent uncomplicated primary (for ST-segment elevation myocardial infarction (STEMI)) or urgent PCI within 48 hours of symptom onset (for non-ST elevation acute coronary syndrome (NSTE-ACS)). Breath-hold PC-CMR images of CS were acquired to assess absolute CSF at rest and during maximum hyperemia within 30 days after culprit lesion PCI and revascularization of functionally significant non-culprit lesions. The entire cohort was stratified by the CFC according to the thresholds of hyperemic CSF and g-CFR. Impaired CFC was defined as a severely-reduced CFC in the present study. The association of CFC and baseline clinical characteristics with major adverse cardiac events (all-cause death, nonfatal myocardial infarction, hospitalization for congestive heart failure or stroke) was investigated. Results In the final analysis of 502 patients (Male 417 (83.1%), mean age was 67 [58, 73]) and 310 patients (82.3%) with STEMI and 192 patients (38.2%) with NSTE-ACS were studied. In a total cohort, rest and maximal hyperemic CSF and corrected G-CFR were 0.93 [0.68, 1.24] ml/min/g, 2.08 [1.44, 2.77] ml/min/g, and 2.21 [1.58, 3.05], respectively. During a median follow-up of 28 months, MACE occurred in 53 patients (all-cause death: 19, nonfatal myocardial infarction: 16, late revascularization: 59, hospitalization for congestive heart failure: 9, stroke: 9). Cox proportional hazards analysis showed that corrected G-CFR and impaired CFC were both independent predictors of MACE. (hazard ratio (HR), 0.61, 95% confidence interval (CI): 0.45–0.82, p=0.001; HR, 3.51, 95% CI: 1.79–6.86, p≤0.001, respectively). Cardiac event-free survival was significantly worse in patients with impaired CFC (log-rank χ2=22.9, P&amp;lt;0.001). Net reclassification index (NRI) and integrated discrimination improvement (IDI) were both significantly improved when impaired CFC was added to the clinical risk model for predicting MACE. Conclusions In ACS patients successfully revascularized with primary or urgent PCI, CFC categorization stratified by noninvasive PC-CMR provided significant prognostic information independent of infarction size, conventional risk factors and g-CFR. Funding Acknowledgement Type of funding source: None

Repeat endoscopic third ventriculostomy success rate according to ventriculostoma closure patterns in children.

This study aimed to examine the success rate of repeat endoscopic third ventriculostomy (redo-ETV) according to pattern of ventriculostoma closure based on observations in 97 paediatric redo-ETV patients. Clinical data and intraoperative video recordings of 97 paediatric hydrocephalus patients who underwent redo-ETV due to ventriculostoma closure at two institutions were retrospectively analysed. We excluded patients with a history of intraventricular haemorrhage, cerebrospinal fluid (CSF) infection or CSF shunt surgery and those with incompletely penetrated membranes during the initial ETV. Verification of ventriculostoma closure was confirmed with cine phase-contrast magnetic resonance imaging and classified into 3 types: type 1, total closure of the ventriculostoma by gliosis or scar tissue that results in a non-translucent/opaque third ventricle floor; type 2, narrowing/closure of the ventriculostoma by newly formed translucent/semi-transparent membranes; and type 3, presence of a patent ventriculostoma orifice with CSF flow blockage by newly formed reactive membranes or arachnoidal webs in the basal cisterns. The overall success rate of redo-ETV was 37.1%. The success rates of redo-ETV according to closure type were 25% for type 1, 43.6% for type 2 and 38.2% for type 3. The frequency of type 1 ventriculostoma closure was significantly higher in patients with myelomeningocele-related hydrocephalus. For patients with ventriculostoma closure after ETV, reopening of the stoma can be performed. Our findings regarding the frequencies of ventriculostoma closure types and the success rate of redo-ETV in paediatric patients according to ventriculostoma closure type are preliminary and should be verified by future studies.

Proximal Aortic Compliance in Young Male Endurance Athletes: An MRI Study.

High-intensity endurance training can elicit profound cardiac adaptations; however, the current evidence as to its impact on the proximal aorta is limited. The purpose of this study was to investigate the morphological and functional characteristics of the proximal aorta in endurance athletes. Fifteen young male middle- and long-distance runners were compared with 19 age- and sex-matched sedentary control participants. CINE phase-contrast magnetic resonance imaging was used to measure blood flow velocities and cross-sectional areas of the ascending and proximal descending aorta. Aortic blood pressure was measured simultaneously during the phase-contrast magnetic resonance imaging scan using a generalized transfer function. Maximal oxygen uptake (V˙O2max) was measured in the athletes. Left ventricular morphology was assessed in a subgroup of participants (n = 16) with cardiac magnetic resonance imaging. The athlete group exhibited an average V˙O2max of 69.5 ± 3.1 mL·kg-1⋅min-1, which is above the 90th percentile of men with similar age according to the American College of Sports Medicine guideline. The athletes had significantly higher stroke volume and slower heart rate at rest and greater left ventricular end-diastolic volume and mass than the sedentary participants. Significantly larger cross-sectional areas and higher compliance of the ascending and proximal descending aorta were also found in the athletes, independently of body surface area. Moreover, higher compliance of the ascending aorta was associated with greater stroke volume (r = 0.382, P = 0.026) and slower heart rate (r = -0.442, P = 0.009) across all participants. The proximal aorta of young male endurance athletes undergoes morphological and functional adaptations that may be resulting from the significant hemodynamic alterations associated with their cardiac function.

The Ascending Aortic Function In Elite Endurance Athletes: An Mri Study

High-intensity chronic endurance training has chronotropic and inotropic effects on the heart; however, adaptations of the ascending aorta which is directly exposed to cardiac pulsations remain unclear. PURPOSE: We investigated the functional and structural properties of the thoracic aorta, including the ascending and descending locations, in elite endurance athletes. METHODS: Fourteen young endurance-trained men (21±1 years, peak oxygen uptake=69.6±3.1 ml/kg/min) were compared with 19 sedentary control men (21±2 years). The ascending and descending aortic cross-sectional areas were measured by 2D CINE phase-contrast magnetic resonance imaging (MRI), and the aortic strain, compliance, and distensibility were calculated. Aortic blood pressure was measured during MRI using the general transfer function method. Two-way mixed analysis of variance was used to determine the effects of exercise status and aortic locations. RESULTS: Endurance athletes had similar body mass index and aortic blood pressures to sedentary control subjects. At rest, heart rate was slower (58±9 vs. 48±5 bpm, P=0.001) and stroke volume was greater in athletes (82.1±10.8 vs. 95.8±18.5 ml/beat, P=0.012) while cardiac output was similar between the groups. The systolic aortic cross-sectional areas were increased in athletes compared with sedentary subjects (ascending: 6.32±0.99 vs. 6.95±1.00 cm2, descending: 4.08±0.64 vs. 4.85±0.83 cm2, P=0.012). The diastolic aortic areas (P=0.062) and the aortic compliances (P=0.069) showed a trend of elevations in athletes. The greater ascending aortic strain and compliance were associated with slower heart rate (r=-0.56 and -0.43 respectively) and higher stroke volume (r=0.44 and 0.35 respectively) across all participants (all P<0.05). CONCLUSIONS: Our findings suggest that endurance athletes have dilated thoracic aorta and better recoiling function of the ascending aorta due to increased systolic expansion and a longer time of relaxation with slower heart rate. This study was supported by the JSPS (19K19970, TT) and the ARIHHP Cooperative Grant (University of Tsukuba, TT)

Influences of mitral annuloplasty on left ventricular flow dynamics assessed with 3-dimensional cine phase-contrast flow magnetic resonance imaging

ObjectivesWe assessed the influence of annuloplasty procedures in mitral repair on left ventricular (LV) vortex flow patterns and aortic outflow patterns, and flow energy loss (EL). MethodsTwenty healthy volunteers and 14 patients who had undergone mitral valve repair were examined using 3-dimensional cine phase-contrast magnetic resonance imaging. A band group included 7 patients with semi-rigid and 2 with flexible partial bands. The ring group included 5 patients with semi-rigid complete rings. LV vortex flow patterns, aortic outflow patterns, EL, and aortic annulus changes during one cardiac cycle were evaluated. ResultsMitral repair induced different vortex flow patterns compared with that of healthy volunteers. The vortex beneath the anterior mitral leaflet with semi-rigid devices was double-stranded in early diastole, and it was single-stranded with flexible bands with a large shift toward the apex during diastole. LVEL in patients who underwent mitral repair (0.84 ± 0.42 mW) was greater than that in healthy volunteers (0.47 ± 0.10 mW). Complete rings disturbed aortic outflow patterns, with EL distribution changes. Smaller devices relative to patient body size disturbed LV flow patterns and caused high EL. No significant relationship was found between indexed ring orifice area and transmitral mean pressure gradient (r = −0.25, P = .414), but a negative relationship exists between indexed ring orifice area and LVEL (r = −0.84, P < .001). ConclusionsMitral repair, especially with relatively small annuloplasty rings, induced abnormal LV flow patterns and EL elevation, which have the potential to be a novel hemodynamic evaluation method after mitral repair.