Magnetic Resonance Imaging Angiography Research Articles

Age‐ and Sex‐Related Morphological Changes in Cerebral Blood Vessels: a 7T TOF MRA Study

AbstractBackgroundIn this study we evaluated age‐ and sex‐associated morphological changes of cerebral blood vessels using 7T Time‐of‐flight (TOF) magnetic resonance angiography (MRA).MethodOur study consisted of 25 cognitively normal older adults (20 female, mean age 68.2 years). Whole‐Brain TOF MRA images were collected on a 7T Siemens scanner at the University of Pittsburgh (slice number = 354, voxel size = 0.38*0.38*0.38 mm, 12 mins). An iterative vessel segmentation algorithm, VesselMapper, was used to segment blood vessels on TOF MRA images (Li et al., 2023). For each subject, vessels are further divided into large and small vessels by median split based on vessel diameters. Mean tortuosity of large vessels, small vessels and overall vessels was computed. Linear regression analyses were performed to evaluate the main effects of age and sex, and the age*sex interaction on vessel tortuosity and diameter.ResultAs shown in Figure 1, we found age‐related increase in mean vessel tortuosity (greater age is associated with greater tortuosity, p<0.02). This age‐related difference is driven by small vessels (p = 0.002) rather than large vessels (p = 0.7). We also found that age is positively associated with mean voxel tortuosity (p<0.001, black line in Figure 2). Furthermore, women showed greater age‐related increase in mean arterial tortuosity, compared to men (age*sex interaction p = 0.04, Figure 2).ConclusionOur findings validated that morphological markers of cerebral blood vessels are sensitive to aging. Small vessels in the brain are particularly vulnerable. Further, compared to men, older women are at a higher risk for cerebral small vessel disease, which may contribute to elevated SVD‐related AD risk in women.Limitation: The study has an unbalanced sample (more women than men) and a relatively modest sample size (N = 25). A cross‐sectional instead of longitudinal design was used in this analysis. Future study with a large balanced sample and a longitudinal design are required to confirm our findings.Reference: Li, Jiatai, et al. “VesselMapper ‐ A Robust Vessel Segmentation Algorithm for 3D Images.” Annual Meeting of the Organization for Human Brain Mapping. 2023

Age‐ and Sex‐Related Morphological Changes in Cerebral Blood Vessels: a 7T TOF MRA Study

AbstractBackgroundIn this study we evaluated age‐ and sex‐associated morphological changes of cerebral blood vessels using 7T Time‐of‐flight (TOF) magnetic resonance angiography (MRA).MethodOur study consisted of 25 cognitively normal older adults (20 female, mean age 68.2 years). Whole‐Brain TOF MRA images were collected on a 7T Siemens scanner at the University of Pittsburgh (slice number = 354, voxel size = 0.38*0.38*0.38 mm, 12 mins). An iterative vessel segmentation algorithm, VesselMapper, was used to segment blood vessels on TOF MRA images (Li et al., 2023). For each subject, vessels are further divided into large and small vessels by median split based on vessel diameters. Mean tortuosity of large vessels, small vessels and overall vessels was computed. Linear regression analyses were performed to evaluate the main effects of age and sex, and the age*sex interaction on vessel tortuosity and diameter.ResultAs shown in Figure 1, we found age‐related increase in mean vessel tortuosity (greater age is associated with greater tortuosity, p<0.02). This age‐related difference is driven by small vessels (p = 0.002) rather than large vessels (p = 0.7). We also found that age is positively associated with mean voxel tortuosity (p<0.001, black line in Figure 2). Furthermore, women showed greater age‐related increase in mean arterial tortuosity, compared to men (age*sex interaction p = 0.04, Figure 2).ConclusionOur findings validated that morphological markers of cerebral blood vessels are sensitive to aging. Small vessels in the brain are particularly vulnerable. Further, compared to men, older women are at a higher risk for cerebral small vessel disease, which may contribute to elevated SVD‐related AD risk in women. Limitation: The study has an unbalanced sample (more women than men) and a relatively modest sample size (N = 25). A cross‐sectional instead of longitudinal design was used in this analysis. Future study with a large balanced sample and a longitudinal design are required to confirm our findings. Reference: Li, Jiatai, et al. “VesselMapper ‐ A Robust Vessel Segmentation Algorithm for 3D Images.” Annual Meeting of the Organization for Human Brain Mapping. 2023

Brain MRA 3D Skeleton Extraction Based on Normal Plane Centroid Algorithm

INTRODUCTION: Analysis of magnetic resonance angiography image data is crucial for early detection and prevention of stroke patients. Extracting the 3D Skeleton of cerebral vessels is the focus and difficulty of analysis.
 OBJECTIVES: The objective is to remove other tissue components from the vascular tissue portion of the image with minimal loss by reading MRA image data and performing processing processes such as grayscale normalization, interpolation, breakpoint detection and repair, and image segmentation to facilitate 3D reconstruction of cerebral blood vessels and the reconstructed vascular tissues make extraction of the Skeleton easier.
 METHODS: Considering that most of the existing techniques for extracting the 3D vascular Skeleton are corrosion algorithms, machine learning algorithms require high hardware resources, a large number of learning and test cases, and the accuracy needs to be confirmed, an average plane center of mass computation method is proposed, which improves the average plane algorithm by combining the standard plane algorithm and the center of mass algorithm.
 RESULTS: Intersection points and skeleton breakpoints on the Skeleton are selected as critical points and manually labeled for experimental verification, and the algorithm has higher efficiency and accuracy than other algorithms in directly extracting the 3D Skeleton of blood vessels.
 CONCLUSION: The method has low hardware requirements, accurate and reliable image data, can be automatically modeled and calculated by Python program, and meets the needs of clinical applications under information technology conditions.

Vascular synthesis based on hemodynamic efficiency principle recapitulates measured cerebral circulation properties in the human brain

Quantifying anatomical and hemodynamical properties of the brain vasculature in vivo is difficult due to limited spatiotemporal resolution neuroimaging, variability between subjects, and bias between acquisition techniques. This work introduces a metabolically inspired vascular synthesis algorithm for creating a digital representation of the cortical blood supply in humans. Spatial organization and segment resistances of a cortical vascular network were generated. Cortical folding and macroscale arterial and venous vessels were reconstructed from anatomical MRI and MR angiography. The remaining network, including ensembles representing the parenchymal capillary bed, were synthesized following a mechanistic principle based on hydrodynamic efficiency of the cortical blood supply. We evaluated the digital model by comparing its simulated values with in vivo healthy human brain measurements of macrovessel blood velocity from phase contrast MRI and capillary bed transit times and bolus arrival times from dynamic susceptibility contrast. We find that measured and simulated values reasonably agree and that relevant neuroimaging observables can be recapitulated in silico. This work provides a basis for describing and testing quantitative aspects of the cerebrovascular circulation that are not directly observable. Future applications of such digital brains include the investigation of the organ-wide effects of simulated vascular and metabolic pathologies.

Central arterial stiffening and intracranial atherosclerosis: the atherosclerosis risk in communities neurocognitive study (ARIC-NCS): Aortic stiffness & intracranial atherosclerosis

ObjectivesPrevious studies suggest an association between central arterial stiffness (CAS) and intracranial atherosclerotic disease (ICAD) among Asian participants with stroke or hypertension; this association has not been evaluated in United States populations. We assessed the cross-sectional association of CAS with ICAD presence and burden in late-life, and differences in association by age, sex, and race. Materials and methodsWe conducted a cross-sectional analysis of 1,285 Atherosclerosis Risk in Communities Study participants [mean age 75 (standard deviation: 5) years, 38 % male, 20 % Black] at Visit 5 (2011-2013). CAS was measured as carotid-femoral pulse wave velocity (cfPWV) using the Omron VP-1000 Plus. ICAD was assessed using high-resolution vessel wall MRI and MR angiography. We evaluated associations of a 1 standard deviation (SD) cfPWV (3.02 m/s) and high vs. non-high cfPWV (≥ 13.57 m/s vs. < 13.57 m/s) with presence of plaques (yes/no) and plaque number (0, 1-2, and >2) using multivariable logistic and ordinal logistic regression models adjusted for covariates. ResultsEach one SD greater cfPWV was associated with higher odds of plaque presence (odds ratio (OR)=1.32, 95 % confidence interval (CI): 1.22, 1.43), and an incrementally higher odds of number of plaques (OR 1-2 vs. 0 plaques = 1.21, 95 % CI: 1.10, 1.33; OR >2 vs. 0 plaques = 1.51, 95 % CI: 1.33,1.71). Results suggested differences by race, with greater magnitude associations among Black participants. ConclusionsCAS was positively associated with ICAD presence and burden; cfPWV may be a useful subclinical vascular measure for identification of individuals who are at high risk for cerebrovascular disease.

Imaging investigation of cervicocranial artery dissection by using high resolution magnetic resonance VWI and MRA: qualitative and quantitative analysis at different stages

BackgroundTo explore the value of magnetic resonance angiography (MRA) and high resolution magnetic resonance vessel wall imaging (HRMR-VWI) in cervicocranial artery dissection (CCAD) for the disease diagnosis, course staging and treatment. On the basis of qualitative evaluation, this study also extract the changes of different stages in vessel wall in different vessel segments to identify imaging indicators for the quantitative evaluation of CCAD.MethodsWe retrospectively enrolled 34 patients with CCAD (38branches) with conventional MRA and HRMR-VWI examinations. Two radiologists independently analyzed imaging features of vessel wall and lumen in the different stages, and the typical sign detection of artery dissection were compared between MRA and HRMR-VWI. Then the parameters of vessel wall was quantitatively evaluated by the post-processing software (Vesselmass, Leiden University Medical Center, Leiden, The Netherlands.ResultsHRMR-VWI revealed typical sign detection of artery dissection in all patients in the acute and subacute stage. Among them, the intimal flap/double lumen sign ditection were more common than the MRA, there was significant difference (P = 0.012). MRA revealed typical sign detection of artery dissection in more than half the patients, and the detection was no significant difference at the chronic stage between MRA and HRMR-VWI (P = 1.000/1.000/0.761). In the acute and subacute stage, the typical sign detection of intramural hematoma and Grade II enhancement revealed by HR-MRI was higher than the observations in the chronic stage (P = 0.000/0.000/0.016), while there was no significant difference by MRA (P = 0.902). The values of wall thickness, relative signal intensity of vessel wall enhancement, relative signal intensity of intramural hematoma (IMH), and percentage of stenosis in CCAD decreased from acute to subacute and then to chronic stages. Each quantitative parameter in patients with CCAD in the early stages (i.e., acute and subacute stages) was significantly different from that in patients with CCAD in the recovered group at chronic stage (P < 0.05). Wall thickness and relative signal intensity of vessel wall enhancement in patients with CCAD in the early stages were not significantly different from those in patients with CCAD in the incompletely recovered group at chronic stage (P > 0.05).ConclusionsAs the only noninvasive imaging technology, HRMR-VWI displays the structure of the vessel wall in vivo, showing not only excellent performance in the early diagnosis of CCAD, but also describing the changes of different stages in the qualitative and quantitative characteristics of vessel wall. It also helps to guide the diseasediagnosis, course staging and treatment of CCAD. Although the diagnostic efficacy of MRA was not as good as HRMR-VWI, it should be the first choice of method for routine examination in evaluating CCAD, especially at the chronic stage of CCAD.

Alagille syndrome and liver: an adult case report

BackgroundAlagille syndrome is a rare autosomal-dominant disorder, representing 10 to 15% of the causes of neonatal cholestasis with no gender predominance. The diagnosis is based on the association of liver, heart, eye, skeleton abnormalities, and characteristic facial appearance.Case presentationAn 18-year-old male patient, with a family history of benign recurrent intrahepatic cholestasis in a brother, was diagnosed at birth with bile duct paucity. He consulted in adulthood for cholestatic jaundice and pruritus. Physical exam found cutaneous jaundice, particular face, skeletal abnormality of fingers, posterior embryotoxon, and splenomegaly. An echocardiogram found cardiovascular abnormalities. The diagnosis of Alagille syndrome was made in front of five major criteria. A liver biopsy revealed a cirrhosis liver. Upper gastrointestinal endoscopy revealed grade II esophageal varices of portal hypertension. Laboratory tests revealed bicytopenia related to hypersplenism, hypoferritinemia, cytolysis with cholestasis, high bilirubin levels, low prothrombin time, hypoalbuminemia, decreased factor V activity, and hypocholesterolemia. The patient had vitamin K supplementation and was put on ursodeoxycholic acid, propranolol for the liver disease, a high protein hypercaloric diet for malnutrition, vitamin D supplementation and bisphosphonate for the osteoporosis, therapeutic abstention with monitoring for the asymptomatic cardiac disease. After a year of treatment, the patient had an overall health status improvement. Abdominal ultrasound found liver nodules. A biliary MRI showed a multinodular liver. The complement by CT hepatic angiography did not show any nodules while the MRI angiography revealed multiple dysplastic nodules. A liver biopsy was performed and found regenerative nodules.ConclusionThe treatment of Alagille syndrome is based on managing the cholestasis and its complications, especially pruritus because it can have a significant impact on quality of life. Due to the complexity of presentation and multi-organ involvement, management of cases with Alagille syndrome should be done by a multidisciplinary team. Liver disease is responsible for morbidity while cardiac disease is a mortality risk factor in this population.

Imaging signs of vulnerability, neurological events and cognitive impairment in asymptomatic carotid artery stenosis: results from the Carotid Artery Multi-modality imaging Prognostic (CAMP) study

Abstract Background Carotid artery plaques with imaging signs of vulnerability, such as ulceration, intraplaque haemorrhage (IPH) or a lipid-rich necrotic core (LRNC), are associated with a high risk of ischemic stroke, and are reported to be considered for invasive treatment if % diameter stenoses ≥60. Little is known about their fate in patients with &amp;lt;60% stenoses. Purpose To evaluate the prevalence of ulceration, IPH and LRNC and their characteristics in patients with asymptomatic, non-significant (&amp;lt;60%) carotid artery stenoses. Methods One hundred and twenty-one patients with asymptomatic, unilateral, mild/moderate (40-60%) carotid artery stenoses at Doppler ultrasound (DUS), were prospectively evaluated with computed tomography angiography (CTA), magnetic resonance angiography (MRA) and brain magnetic resonance imaging (MRI). IPH and LRNC were defined at MRA, while ulceration was defined at CTA. Verbal and memory skills were tested by the Fifteen Reye’s Words and other standardized tests. Results At least one sign of vulnerability (IPH, LRNC or ulceration) was detected in 51.6% patients. Signs of vulnerability were more frequent in patients with ≥50% stenoses compared with those with &amp;lt;50% at DUS (62.5% vs 27.6%, p=0.002). No difference in the prevalence of cardiovascular risk factors was present in those with and without signs of vulnerability (Table). An ulceration at CTA was significantly associated with presence of IPH or LRNC even after adjustment for the degree of stenosis (OR 4.2, 95% CI 1.3-13.2; OR 4.0, 95% CI 1.4-11.2). Subclinical embolic brain infarctions were found in 10% of patients. A higher prevalence of LRNC was found in patients with brain infarctions (50% vs 17%, p&amp;lt;0.05). Patients with either IPH or LRNC performed worse at standardized tests of cognitive impairment (score 1.6±1.1 vs 2.2±1.4, p&amp;lt;0.05). Conclusions Imaging signs of vulnerability are highly prevalent in patients with asymptomatic intermediate carotid artery stenosis, and can be detected in more than one fourth of patients with a non-significant plaque in terms of degree of stenosis. Plaque ulceration at CTA is independently associated with LRNC and IPH at MRA, independent of the degree of stenosis. Plaques with LRNC are associated with subclinical embolic brain infarcts and a worse cognitive performance.TableFigure

Simultaneous, free-breathing, non-contrast 3D whole-heart coronary magnetic resonance angiography and vulnerable plaque imaging in patients with suspected acute coronary syndrome

Abstract Background Coronary artery high-risk plaque identified on cardiovascular magnetic resonance (CMR) is associated with future coronary events, independent of coronary artery luminal stenosis. We have recently developed a 3-dimensional whole-heart free-breathing non-contrast CMR sequence that allows for simultaneous high-resolution visualisation of the coronary arteries and vulnerable plaque on co-registered bright and black blood images (iT2prep-BOOST) with 100% respiratory scan efficiency. Objectives To validate iT2prep-BOOST in patients with non-ST-segment elevation myocardial infarction (NSTEMI) against the reference standard imaging modalities of invasive X-ray coronary angiography and intravascular imaging [optical coherence tomography (OCT)/intravascular ultrasound (IVUS)]. Methods 41 consecutive patients with suspected NSTEMI, based upon clinical history, electrocardiographic changes and positive high-sensitivity troponin assays, were recruited into the study. Invasive coronary angiography ± intravascular imaging was used to classify coronary segments into the following categories: normal, non-culprit and culprit segments; stenosed segments as well as segments with vulnerable plaque features (lipid, calcium, fibroatheroma, thin cap fibroatheroma (TCFA), plaque rupture and thrombus). The highest plaque/myocardial signal intensity ratio (PMR) in each coronary segment was analysed on iT2prep-BOOST. Results The mean iT2prep-BOOST acquisition time was 10.8 ± 1.3 minutes. The mean ± standard error of mean (SEM) PMR of culprit segments was significantly higher than non-culprit segments, which was significantly higher than normal segments (1.01 ± 0.05 vs. 0.67 ± 0.01 vs. 0.35 ± 0.01, P&amp;lt;0.001). Coronary segments with lipid, calcium and fibroatheroma had a significantly higher PMR compared to normal coronary segments (P&amp;lt;0.001) but lower than segments with TCFA, plaque rupture and thrombus (P&amp;lt;0.001). There was a progressive increase in PMR with increasing degree of coronary stenosis (P&amp;lt;0.001). Patients with type 2 diabetes, hypertension, hyperlipidaemia and family history of coronary artery disease had a significantly higher PMR on iT2prep-BOOST (P&amp;lt;0.001, P=0.02, P=0.04 and P=0.02 respectively). Finally, PMR was positively correlated with HbA1c, total cholesterol, non-HDL cholesterol, LDL cholesterol and triglyceride levels (P&amp;lt;0.001, P=0.02, P=0.02, P=0.05 and P=0.05 respectively). Conclusions In summary, the proposed iT2prep-BOOST framework has the potential to simultaneously acquire coronary artery angiography and to differentiate normal segments from non-culprit and culprit plaque segments. Furthermore, PMR is associated with both biochemical and patient related risk factors for coronary artery disease (CAD). The long-term prognostic value of PMR needs to be investigated in a longitudinal multi-centre study of patients with suspected CAD.Figure 1Figures 2 and 3

Abstract 17738: Cardiac MRI vs Coronary Angiography in Stable Coronary Artery Disease: A Head-to-Head Comparison

Introduction: Coronary angiography has been the gold standard invasive procedure for diagnosing and treating coronary artery disease (CAD). However, it poses risks and complications. In contrast, cardiac MRI offers non-invasive tools for early detection and diagnosis of CAD, presenting an alternative to angiography with fewer associated risks. Hypothesis: Our study aims to investigate if MRI can replace invasive procedures in stable CAD, reducing the need for such procedures while maintaining comparable diagnostic outcomes to coronary angiography. Methods: An extensive literature search was conducted, involving PubMed and Google Scholar databases up to February 2023. After careful evaluation, four clinical trials (CARMENTA, CE-MARC, MR INFORM, and MR Impact 2) comparing MRI and angiography in stable coronary artery disease were included in our study. Animal studies, expert opinions, literature reviews, and studies without reported MRI outcomes were excluded. Results: In the MR INFORM trial, among 221 patients with significant CMR-detected ischemia, 184 had confirmed angiographic lesions, while 35 did not. There were no significant differences in major adverse cardiovascular events or angina-free status at 1 year between the CMR and angiogram groups. The CE MARC 2 trial involving 752 patients reported a sensitivity of 86.5% and a specificity of 83.4% for multiparametric CMR, with a positive predictive value (PPV) of 77.2% and a negative predictive value (NPV) of 90.5%. The CARMENTA trial demonstrated a significant reduction in invasive coronary angiograms with CMR as the initial evaluation (87% vs. 100%), without significant differences in outcomes or the detection of obstructive coronary artery disease compared to computed tomography angiography. In the MR Impact 2 trial, CMR exhibited a sensitivity of 75% (±7%) and a specificity of 59% (±8%). The PPV, NPV, and accuracy for CMR were 70% (±5%), 65% (±5%), and 68% (±5%), respectively. Conclusions: CMR shows promise in diagnosing coronary artery disease, correlating well with angiography and reducing invasive procedures without significant outcome differences. Further research is needed to assess its clinical utility, highlighting its potential role in practice.

Recurrent Stroke in Young Adult as a Manifestation of Moyamoya Disease: Case Report

Background: Moyamoya disease is a chronic cerebrovascular disorder characterized by progressive narrowing of the intracranial portions of the distal internal carotid artery, the initial proximal components of the middle cerebral artery, anterior cerebral artery, and posterior cerebral artery. Moyamoya disease can manifest as a stroke in young adult. Methods: This report presents a young female patient with Moyamoya disease in Siloam Hospital Denpasar, Bali, Indonesia, diagnosed using MRI and Digital Subtraction Angiography. Case Report: A 29-year-old woman with recurrent stroke, presented with right-side hemiparesis, urinary incontinence, disinhibition syndrome, hypertension, and a history of left hemiparesis from a previous stroke. The MRI brain showed hyperintensity throughout the sulci (ivy sign) in the bilateral frontoparietal with acute infarct in the left frontomedial region, chronic infarct in right frontomedial, occlusion of bilateral carotid arteries (supraclinoid segment), bilateral MCA and ACA. The cerebral DSA study showed stenosis in the right ICA, stenosis in the M1-M2 junction with poor collateral to ACA territory with a puff of smoke appearance, occlusion in the left ICA (supraclinoid segment), and severe stenosis in M1. The patient had undergone direct bypass in the right MCA and right superficial temporal artery. Unfortunately, the bypass did not succeed because of infection of the bypass site and the patient got oral medication with a single antiplatelet (asetosal) and angiotensin receptor blocker (valsartan). Discussion: Moyamoya disease is a rare chronic cerebrovascular disorder that can manifest as an ischaemic stroke in young adult. This patient had a recurrent ischaemic stroke due to Moyamoya disease. According to a global multicenter stroke database, 90% of Moyamoya disease patients initially presented with an ischemic stroke, 7.5% with a transient ischemic attack, and 2.5% with a hemorrhagic stroke. DSA showed that the intracranial collateral system failed to fulfill the demand for brain circulation when the stroke occurred. The patient had failure to grow collateral after direct bypass surgery from the right superficial temporal artery to MCA and single oral antiplatelet as a secondary prevention for ischaemic stroke. Conclusion: Moyamoya disease is a rare disease that needs further studies for its treatment to halt the progression and prevent secondary complications. Young patients with ischaemic stroke needed to be asses with brain MRI, MRA, and DSA to evaluate the etiology of ischaemic stroke. Keywords: Moyamoya disease, Digital Substraction Angiography,ischaemic stroke

Calibration of the Mechanical Boundary Conditions for a Patient-Specific Thoracic Aorta Model Including the Heart Motion Effect.

We propose a procedure for calibrating 4 parameters governing the mechanical boundary conditions (BCs) of a thoracic aorta (TA) model derived from one patient with ascending aortic aneurysm. The BCs reproduce the visco-elastic structural support provided by the soft tissue and the spine and allow for the inclusion of the heart motion effect. We first segment the TA from magnetic resonance imaging (MRI) angiography and derive the heart motion by tracking the aortic annulus from cine-MRI. A rigid-wall fluid-dynamic simulation is performed to derive the time-varying wall pressure field. We build the finite element model considering patient-specific material properties and imposing the derived pressure field and the motion at the annulus boundary. The calibration, which involves the zero-pressure state computation, is based on purely structural simulations. After obtaining the vessel boundaries from the cine-MRI sequences, an iterative procedure is performed to minimize the distance between them and the corresponding boundaries derived from the deformed structural model. A strongly-coupled fluid-structure interaction (FSI) analysis is finally performed with the tuned parameters and compared to the purely structural simulation. The calibration with structural simulations allows to reduce maximum and mean distances between image-derived and simulation-derived boundaries from 8.64 mm to 6.37 mm and from 2.24 mm to 1.83 mm, respectively. The maximum root mean square error between the deformed structural and FSI surface meshes is 0.19 mm. This procedure may prove crucial for increasing the model fidelity in replicating the real aortic root kinematics.

Case 319: Multisystemic Smooth Muscle Dysfunction Syndrome.

A 7-year-old Chinese girl presented to a local hospital with a 5-day history of progressive right-sided hemiplegia, expressive aphasia, mild bulbar palsy, and reduced general responsiveness. At presentation, her Glasgow Coma Scale was 11/15 (E4 V1M6). Notably, she had two strokelike episodes approximately 7 and 3 months prior to the current episode, with headache, reduced movement, and numbness in the left hand. She also had an extensive medical history at a young age, including congenital mydriasis, patent ductus arteriosus with ligation, dysautonomia, low blood pressure, hypotonic bladder requiring intermittent catheterization, poor bowel transit, and gallstones. Her immunization record was up to date, and her development was otherwise unremarkable. Her parents and younger sibling were healthy. Her blood tests revealed a mildly increased venous lactate level at 2.3 mmol/L (normal range, 0.7-2.1 mmol/L), without acidosis. Results of a coagulopathy work-up (clotting profile and protein C, protein S, antithrombin 3, and fibrinogen levels) were normal. MRI and MR angiography of the brain were performed at presentation.

An Acute Metabolic Encephalopathy, Lactic Acidosis and Stroke-like Episodes Syndrome Patients with Hyperperfusion Responsive to Steroid Treatment

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a genetic disorder caused by mutation in mitochondrial DNA. Patients with stroke-like episodes show restrictive lesions in diffusion weighted image, whereas magnetic resonance angiography images show both vasodilation or vasoconstriction. Vasodilation may lead to hyperperfusion and cerebral edema, which may worsen clinical outcome. Here, we report a 25-year-old male patient diagnosed as MELAS, who presented with stroke-like episodes and seizures and showed cerebral edema with vasodilation which was normalized after steroid treatment.

Protective effects of GuanXinNing tablet (GXNT) on diabetic encephalopathy in zucker diabetic obesity (ZDF) rats

BackgroundDiabetic encephalopathy (DE) is a complication of diabetes that leads to cognitive and behavioral decline. Utilizing safe and effective complementary and alternative medications for its management is a wise choice. Previous studies have shown that GuanXinNing Tablet (GXNT), an oral preparation primarily derived from two Chinese herbs, Salvia miltiorrhiza Bge. and Ligusticum chuanxiong Hort., exerts a beneficial neuroprotective effect. In this study, we explored the protective effects of GXNT on DE in male Zucker diabetic fatty (ZDF) rats induced by a high-fat diet, aiming to ascertain its significance and potential mechanisms.MethodsZDF rats were induced to develop type 2 diabetes (T2DM) with DE by a high-fat diet and treated with GXNT for 8 weeks until they were 20 weeks old. Throughout the experiment, the animals’ vital parameters, such as body weight, were continuously monitored. Cognitive function was evaluated using the Y maze test. Biochemical kits were employed to analyze blood glucose, lipids, and vascular endothelial-related factors. Cerebrovascular lesions were assessed using magnetic resonance angiography (MRA) imaging. Brain lesions were evaluated using hematoxylin and eosin (H&E) staining and ultrastructure observation. IgG and albumin (ALB) leakage were detected using immunofluorescence.ResultsGXNT demonstrated an enhancement in the overall well-being of the animals. It notably improved cognitive and behavioral abilities, as demonstrated by extended retention time in the novel heterogeneous arm during the Y-maze test. GXNT effectively regulated glucose and lipid metabolism, reducing fasting and postprandial blood glucose, glycated hemoglobin (HbA1c), and total cholesterol (TC) levels. Additionally, it exhibited a protective effect on the vascular endothelium by reducing the serum TXB2/PGI2 ratio while elevating NO and PGI2 levels. Moreover, GXNT ameliorated stenosis and occlusion in cerebral vessel branches, increased the number of microvessels and neurons around the hippocampus, and improved microvascular occlusion in the cerebral cortex, along with addressing perivascular cell abnormalities. Immunofluorescence staining showed a decrease in the fluorescence intensity of IgG and ALB in the cerebral cortex.ConclusionsGXNT demonstrated a highly satisfactory protective effect on DE in ZDF rats. Its mechanism of action could be based on the regulation of glucolipid metabolism and its protective effect on the vascular endothelium.

Assessing Machine Learning Models for Predicting Age with Intracranial Vessel Tortuosity and Thickness Information.

This study aimed to develop and validate machine learning (ML) models that predict age using intracranial vessels' tortuosity and diameter features derived from magnetic resonance angiography (MRA) data. A total of 171 subjects' three-dimensional (3D) time-of-flight MRA image data were considered for analysis. After annotations of two endpoints in each arterial segment, tortuosity features such as the sum of the angle metrics, triangular index, relative length, and product of the angle distance, as well as the vessels' diameter features, were extracted and used to train and validate the ML models for age prediction. Features extracted from the right and left internal carotid arteries (ICA) and basilar arteries were considered as the inputs to train and validate six ML regression models with a four-fold cross validation. The random forest regression model resulted in the lowest root mean square error of 14.9 years and the highest average coefficient of determination of 0.186. The linear regression model showed the lowest average mean absolute percentage error (MAPE) and the highest average Pearson correlation coefficient (0.532). The mean diameter of the right ICA vessel segment was the most important feature contributing to prediction of age in two out of the four regression models considered. An ML of tortuosity descriptors and diameter features extracted from MRA data showed a modest correlation between real age and ML-predicted age. Further studies are warranted for the assessment of the model's age predictions in patients with intracranial vessel diseases.

The complexities in diagnosing intradiaphragmatic extrapulmonary sequestration: a case report

BackgroundExtralobar pulmonary sequestration–a congenital lung malformation characterized by nonfunctional lung tissue with its own visceral pleura and without a connection to the normal tracheobronchial tree–is often surgically resected given the potential for infectious complications. We report a case of a child with extralobar pulmonary sequestration in a rare and challenging intradiaphragmatic location, which made preoperative identification and planning difficult.Case presentationA 2-year-old boy presented for follow-up of a large left extralobar pulmonary sequestration initially diagnosed on an antenatal ultrasound. Follow-up imaging, including prenatal MRI and postnatal CT angiography, was inconclusive on the precise location of the extralobar pulmonary sequestration in relation to the diaphragm but did reveal a subdiaphragmatic arterial supply from a branch off the celiac trunk. Planned resection with diagnostic thoracoscopy revealed the mass to seemingly be below the diaphragm; however, subsequent abdominal laparoscopy identified it to be within the diaphragm. Once the supplying vessel off the celiac trunk was controlled and divided, the mass was circumferentially excised from the edges of the diaphragmatic muscle. The remaining diaphragmatic defect was then closed, and the patient did well postoperatively.ConclusionsThis case demonstrates the difficulty of making a definitive diagnosis of intradiaphragmatic extralobar pulmonary sequestration without operative intervention. CT angiography and identification of the sequestration’s arterial supply may not be conclusive in determining the precise location if in close proximity to the diaphragm.

Brand ferumoxytol vs. generic ferumoxytol comparison across two dosing regimens: a cardiac MRI image quality study.

Ferumoxytol is becoming more widely used as an off-label blood-pool contrast agent for MR angiography (MRA) and four-dimensional (4D) flow imaging in pediatric cardiovascular disease. Brand and generic versions of ferumoxytol are available with no information on relative efficacy as a contrast agent and safety profiles. This study evaluates patient safety and image quality of comparable dosages of generic ferumoxytol (GF) versus brand ferumoxytol (BF) with the following hypotheses: (1) Reducing the contrast dosage from 3 to 2mg/kg will not affect imaging quality and diagnostic accuracy of MRA and four-dimensional 4D flow. (2) GF and BF have similar image quality. (3) GF and BF have similar patient safety profiles. In an IRB-approved retrospective study, changes in vitals/clinical status between baseline, during infusion, and 30min post-infusion were analyzed in 3 groups: group 1 (3mg/kg BF, 216 patients, age: 19.29 ± 11.71years ranging from 2months to 62years), group 2 (2mg/kg BF, 47 patients, age: 15.35 ± 8.56years ranging from 10days to 41years), and group 3 (2mg/kg GF, 127 patients, age: 17.16 ± 12.18years ranging from 6days to 58years). Both pediatric and adult patients with congenital heart disease (CHD) indications were included within the study. Adverse reactions were classified as mild, moderate, or severe. Quantitative analysis of MR image quality was performed with signal-to-noise ratio (SNR) on MRA and velocity-to-noise ratio (VNR) on 4D flow. Qualitative grading of imaging features was performed by 2 experienced observers. Two-way analysis of variance (ANOVA) and chi-square tests were used for comparison with a P value of ≤ 0.05 used for significance. No statistical difference was found in clinical status and vital signs (P>0.05). No severe reactions were reported. 7.9% of GF patients experienced an adverse reaction compared to 2.3% with 3mg/kg BF and 8.4% with 2mg/kg BF. There was no statistical difference in SNR between the 3 groups (P>0.05). For 4D flow, 2mg/kg GF demonstrated an increase in VNR compared to 2mg/kg BF (P = 0.005). The qualitative scores for MRA and 4D flow were high (≥ 3) across all 3 groups. No significant difference was identified between 2mg/kg GF and BF in terms of safety profile and image quality. Given the small sample size of this study, further studies are required to confirm these results.

Detection rate of brain MR and MR angiography for neuroimaging abnormality in patients with newly diagnosed left-sided infective endocarditis

We aimed to investigate the detection rate of brain MR and MR angiography for neuroimaging abnormality in newly diagnosed left-sided infective endocarditis patients with/without neurological symptoms. This retrospective study included consecutive patients with definite or possible left-sided infective endocarditis according to the modified Duke criteria who underwent brain MRI and MR angiography between March 2015 and October 2020. The detection rate for neuroimaging abnormality on MRI was defined as the number of patients with positive brain MRI findings divided by the number of patients with left-sided infective endocarditis. Positive imaging findings included acute ischemic lesions, cerebral microbleeds, hemorrhagic lesions, and infectious aneurysms. In addition, aneurysm rupture rate and median period to aneurysm rupture were evaluated on follow-up studies. A total 115 patients (mean age: 55 years ± 19; 65 men) were included. The detection rate for neuroimaging abnormality was 77% (89/115). The detection rate in patients without neurological symptoms was 70% (56/80). Acute ischemic lesions, cerebral microbleeds, and hemorrhagic lesions including superficial siderosis and intracranial hemorrhage were detected on MRI in 56% (64/115), 57% (66/115), and 20% (23/115) of patients, respectively. In particular, infectious aneurysms were detected on MR angiography in 3% of patients (4/115), but MR angiography in 5 patients (4.3%) was insignificant for infectious aneurysm, which were detected using CT angiography (n = 3) and digital subtraction angiography (n = 2) during follow-up. Among the 9 infectious aneurysm patients, aneurysm rupture occurred in 4 (44%), with a median period of aneurysm rupture of 5 days. The detection rate of brain MRI for neuroimaging abnormality in newly diagnosed left-sided infective endocarditis patients was high (77%), even without neurological symptoms (70%).

Magnetic resonance angiography in assessment of anomalies of anterior cerebral artery in adults.

Anomalies of anterior cerebral artery (ACA) include aplasia, hypoplasia and variations in number. Magnetic resonance angiography (MRA) is a non-invasive diagnostic technique for assessment of anomalies of cerebral arteries. The aim of the study was to determine the role of MRA in detection of variants of ACA in adults. This study is an observational retrospective study. This study included forty-nine adult cases (28 males and 21 females), mean age 48±12.9 SD with anomalies of ACA in MRA. Magnetic resonance imaging of the brain and MRA were done to all patients. Cerebral MRA and magnetic resonance images were evaluated for frequency and distribution of variants of anterior cerebral arteries, associated aneurysms and infarctions. Odds ratios (ORs) and relative risk were calculated to determine risk of occurrence of cerebral infarctions in patients with anomalies of ACA. Hypoplasia of ACA was the commonest anomaly of ACA (51% of cases). Risk of occurrence of cerebral infarctions was higher in cases with azygos variant (OR, 3.3; P=0.35) than in those with hypoplastic ACA (OR, 2; P=0.58). MRA was highly reliable in identification of different variants of ACA and concomitant vascular changes.