Magnetic Resonance Angiography Scans Research Articles

Cerebral Artery Vasoconstriction After Galcanezumab Loading Dose for Migraine Prevention: A Case Report.

Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies that target CGRP ligands or receptors, may cause a very rare side effect of reversible cerebral vasoconstriction syndrome (RCVS). This study is a case report of a patient who developed cerebral artery vasoconstriction documented on serial brain magnetic resonance angiography (MRA) scans without the typical manifestations of RCVS following galcanezumab loading dose. Case report: A 40-year-old female patient with high-frequency episodic migraine with visual aura on topiramate 100mg/day developed transient numbness of the right upper and lower extremities and right face without headache and a normal neurological examination 10min after a loading dose of galcanezumab, which resolved over the next 2days. Magnetic resonance angiography brain imaging showed segmental arterial constriction of both middle cerebral arteries in the M1-2 segments and both posterior cerebral arteries in the P1-2 segments, which partial resolved in a subsequent study by the end of 6months. There were no other supporting examination data, such as transcranial Doppler, which might provide additional information on the progression and improvement of the vasoconstriction. Her differential diagnosis included prolonged migraine sensory aura without headache, RCVS, or cerebral vasoconstriction secondary to the effect of an anti-CGRP monoclonal antibody. Further research needs to be conducted.

Enhanced Preoperative Planning for Intracranial Aneurysms Through Multimodal Image Fusion of Silent/Time-of-Magnetic Resonance Angiography and Computed Tomography Using 3DSlicer

Objective: This study evaluates the effectiveness of multimodal image fusion (MIF) using silent and time-of-flight (TOF) magnetic resonance angiography (MRA) and computed tomography (CT) for preoperative planning in patients with intracranial aneurysms who have contraindications to contrast media. Materials and Methods: A retrospective study included 40 patients with intracranial aneurysms, diagnosed using three-dimensional computed tomography angiography (CTA). These patients underwent both Silent and TOF MRA scans, followed by a CTA scan. The multi-image fusion (MIF) technique, applied using 3DSlicer software, integrated the silent/TOF-MRA with CT images for preoperative assessment. This study compared the image quality, aneurysm detection sensitivity, and anatomic accuracy of the MIF images with those of three-dimensional CTA. Results: Silent-MRA-CT fusion images demonstrated higher sensitivity (95.5%) and lower false negative rates (4.5%) compared with TOF-MRA-CT. Furthermore, silent-MRA-CT fusion images outperformed TOF-MRA-CT in terms of signal homogeneity, venous signal interference suppression, and aneurysm visibility (all P < 0.05). The interclass correlation coefficient and kappa values for aneurysm morphology and shape indicated superior measurement consistency and shape concordance of silent-MRA-CT with CTA compared with TOF-MRA-CT (all P < 0.01). Conclusion: This study supports the use of silent/TOF-MRA-CT fusion imaging as a reliable alternative to CTA, noting that silent-MRA-CT closely mirrors CTA. Contrast-free MRA-CT fusion images have the potential to be used for preoperative planning in patients with intracranial aneurysms who have contraindications to contrast.

Robust data-driven segmentation of pulsatile cerebral vessels using functional magnetic resonance imaging.

Functional magnetic resonance imaging (fMRI) captures rich physiological and neuronal information that can offer insights into neurofluid dynamics, vascular health, and waste clearance function. The availability of cerebral vessel segmentation could facilitate fluid dynamics research in fMRI. However, without magnetic resonance angiography scans, cerebral vessel segmentation is challenging and time-consuming. This study leverages cardiac-induced pulsatile fMRI signal to develop a data-driven, automatic segmentation of large cerebral arteries and the superior sagittal sinus (SSS). The method was validated in a local dataset by comparing it to ground truth cerebral artery and SSS segmentations. Using the Human Connectome Project (HCP) aging dataset, the method's reproducibility was tested on 422 participants aged 36 to 100 years, each with four repeated fMRI scans. The method demonstrated high reproducibility, with an intraclass correlation coefficient > 0.7 in both cerebral artery and SSS segmentation volumes. This study demonstrates that the large cerebral arteries and SSS can be reproducibly and automatically segmented in fMRI datasets, facilitating the investigation of fluid dynamics in these regions.

Graph convolutional networks for automated intracranial artery labeling.

Unruptured intracranial aneurysms (UIAs) can cause aneurysmal subarachnoid hemorrhage, a severe and often lethal type of stroke. Automated labeling of intracranial arteries can facilitate the identification of risk factors associated with UIAs. This study aims to improve intracranial artery labeling using atlas-based features in graph convolutional networks. We included three-dimensional time-of-flight magnetic resonance angiography scans from 150 individuals. Two widely used graph convolutional operators, GCNConv and GraphConv, were employed in models trained to classify 12 bifurcations of interest. Cross-validation was applied to explore the effectiveness of atlas-based features in node classification. The results were tested for statistically significant differences using a Wilcoxon signed-rank test. Model repeatability and calibration were assessed on the test set for both operators. In addition, we evaluated model interpretability and node feature contribution using explainable artificial intelligence. Atlas-based features led to statistically significant improvements in node classification (). The results showed that the best discrimination and calibration performances were obtained using the GraphConv operator, which yielded a mean recall of 0.87, precision of 0.90, and expected calibration error of 0.02. The addition of atlas-based features improved node classification results. The GraphConv operator, which incorporates higher-order structural information during training, is recommended over the GCNConv operator based on the accuracy and calibration of predicted outcomes.

Clinical and radio-angiographic features of paediatric moyamoya disease in Bangladesh

Background: Moyamoya disease is a cerebrovascular arteriopathy of unknown origin characterized by progressive stenosis followed by occlusion of the cerebral arteries. Studies on moyamoya disease, especially in children in Bangladesh, are rare. We aimed to determine the clinical and neuroimaging features of moyamoya disease, particularly angiographic features. Methods: Forty children diagnosed with moyamoya disease were consecutively recruited from Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh. Each patient underwent a medical history and physical examination focusing on stroke, magnetic resonance imaging, and magnetic resonance angiography scans of the brain. In some instances, electroencephalogram and digital subtraction angiography were also performed. Results: Of the 40 patients, 22 experienced their first-ever stroke (median age, 84 months), and 18 had recurrent strokes (median age, 90 months). Common symptoms included hemiparesis, headache, seizure, and speech disorder. The commonly affected vessels were the internal carotid and middle cerebral arteries. Cortical involvement was found in 82.5% of cases. Bilateral involvement was observed in 37.5% of the patients, most of whom were in the Suzuki stage III. Conclusion: Hemiparesis, headache, seizure, and speech disorder were the common manifestations. Most patients reported late (Suzuki stages III and IV), indicating an advanced stage. Early detection is necessary, considering the severity of the disease and its inherent tendency for recurrence.

Quality assurance for magnetic resonance angiography of the chest in patients suspected of pulmonary embolism during iodinated contrast shortage in the emergency department setting.

COVID-19 lockdowns resulted in a global shortage of iodinated contrast media. Therefore, alternative imaging protocols were devised to evaluate patients arriving to the emergency department (ED) with suspicion of pulmonary embolism (PE). This quality assurance (QA) aims to compare diagnostic potential between alternative magnetic resonance angiography (MRA) protocol over the gold standard computed tomography angiography (CTA) by evaluating MRA imaging quality, scanner type/imaging sequence, and any risk of misdiagnosis in patients with symptoms of PE. This retrospective study compromised of 55 patients who arrived to ED and underwent MRA of the chest for suspicion of PE during the months of May to June 2022. Data regarding their chief complaints, imaging sequence, and MRA results were collected. Two fellowship-trained faculty radiologists reviewed the MRA scans of the patients and scored the quality using a Likert scale. Two patients were positive for PE and 53 patients showed negative results. Regarding the scan quality issues, motion was noted in 80% of the 55 studies that we reviewed. Significant associations (P < 0.009) between Likert scale scores and initial complaint category were found. The characteristic symptoms associated with suspicion of PE, namely, shortness of breath, chest pain, and cough were distributed among the 1 and 2 categories, reflecting the most optimal vessel opacification scores. We found no risk of misdiagnosis after reviewing the electronic medical record for follow-up appointments within 6 months of ED visit. Patients were screened for PE with MRA as an alternative imaging tool during times of contrast shortage. Further, evaluation of MRA with CTA, side by side, in a larger patient population is required to increase the validity of our QA study.

643 A Review of the Screening Protocols Investigating Intracranial Aneurysms in Polycystic Kidney Disease

Abstract Aim Intracranial aneurysms (ICA) are a common complication of polycystic kidney disease (PKD). Due to the lack of screening protocols that exist for PKD patients, without the appropriate preventative measures ICA rupture leads to significant morbidity and mortality. The aim is to analyse existing screening protocols by referencing the lead time between ICA diagnosis and rupture in PKD patients, the purpose and importance of screening, the types of imaging modalities used, and patient outcomes. We will also consider cost-effectiveness and its relation in establishing a screening protocol. Method A literature search was conducted in April 2022 for articles published between 1990-2022 with special interest in ICA, PKD, and screening protocols. Only exclusion criteria were patients who were diagnosed with PKD &amp;lt;30 years of age. An independent reviewer screened the relevant full papers prior to inclusion. Results Our findings suggest that if a PKD presents with either a positive family history of ICA and/or cerebrovascular events and/or is above 40 years of age, then they should have a magnetic resonance angiography (MRA) scan every 5 years to monitor ICA development with annual follow-ups. This will significantly decrease patient morbidity and mortality in PKD positive patients. Conclusions While there is significant evidence proving that screening protocols decrease the morbidity and mortality of PKD patients, none have been suggested. The screening protocol suggested in this review should be used as a guideline for future studies that will try and establish a national or international guidelines that can be used by nephrologists and neurosurgeons worldwide.

Comparison of 1.5T and 3T magnetic resonance angiography for detecting cerebral aneurysms using deep learning-based computer-assisted detection software.

To compare the diagnostic performance of 1.5T versus 3T magnetic resonance angiography (MRA) for detecting cerebral aneurysms with clinically available deep learning-based computer-assisted detection software (EIRL aneurysm® [EIRL_an]), which has been approved by the Japanese Pharmaceuticals and Medical Devices Agency. We also sought to analyze the causes of potential false positives. In this single-center, retrospective study, we evaluated the MRA scans of 90 patients who underwent head MRA (1.5T and 3T in 45 patients each) in clinical practice. Overall, 51 patients had 70 aneurysms. We used MRI from a vendor not included in the dataset used to create the EIRL_an algorithm. Two radiologists determined the ground truth, the accuracy of the candidates noted by EIRL_an, and the causes of false positives. The sensitivity, number of false positives per case (FPs/case), and the causes of false positives were compared between 1.5T and 3T MRA. Pearson's χ2 test, Fisher's exact test, and the Mann‒Whitney U test were used for the statistical analyses as appropriate. The sensitivity was high for 1.5T and 3T MRA (0.875‒1), but the number of FPs/case was significantly higher with 3T MRA (1.511 vs. 2.578, p < 0.001). The most common causes of false positives (descending order) were the origin/bifurcation of vessels/branches, flow-related artifacts, and atherosclerosis and were similar between 1.5T and 3T MRA. EIRL_an detected significantly more false-positive lesions with 3T than with 1.5T MRA in this external validation study. Our data may help physicians with limited experience with MRA to correctly diagnose aneurysms using EIRL_an.

Abstract WP138: Intracranial Artery Stenosis In Relation To Blood Pressure Components

Introduction: Vascular aging is characterized by structural and functional changes in blood vessels that lead to reduced perfusion pressure to distal organs and high blood pressure (BP). Cerebrovascular aging is strongly associated with high BP, however, systemic BP is constituted by the steady and pulsatile components. We aimed this study to investigate the association of intracranial artery stenosis in relation to the steady and pulsatile components of the systemic BP - such association remains undocumented. Methods: We used cross-sectional data from 292 participants from the Maracaibo Aging Study who underwent ambulatory BP monitoring, magnetic resonance angiography, and MRI between 2011 to 2016. The stenosis of eleven intracranial arteries was measured using magnetic resonance angiography scans and encompassed the right and left sides of the anterior (ACA), middle (MCA), posterior (PCA) cerebral arteries, and internal carotid arteries (ICA), vertebral arteries, and the basilar artery. The steady BP component included the 24-hour mean arterial pressure (MAP) while the pulsatile component included the 24-hour pulse pressure (PP). We performed multivariable logistic regression models to assess the association between intracranial artery stenosis and BP components. Models were accounted for age, sex, head circumference, years of education, body mass index, total and high-density cholesterol ratio, creatinine, diabetes mellitus, and antihypertensive treatments. Results: Mean age was 57.5±11 years, 75% women. After adjustment for confounders, 24-hour pulse pressure was associated (P≤ 0.020) with the stenosis of ICA (Odds ratios [OR], 2.00 per every 5 mmHg of PP; 95% confidence interval [CI], 1.49-2.69), ACA (OR, 1.50; 95% CI, 1.23-1.84), MCA (OR, 1.46; 95%, CI, 1.21-1.77), PCA (OR, 1.55; 95% CI, 1.26-1.91), basilar artery (OR, 1.28; 95% CI, 1.03-1.59) and vertebral arteries (OR, 1.42; 95% CI, 1.14-1.78). The ORs of ICA, ACA, MCA, PCA, basilar artery, and vertebral arteries in relation to high 24-hour MAP levels (P≤ 0.040) ranged from 1.27 (95% CI, 1.00-1.61) to 1.48 (95% CI, 1.15 - 1.91). Conclusion: Elevated levels in the steady and pulsatile components of the systemic BP are associated with intracranial artery stenosis.

Impact of magnetic resonance angiography parameters on stroke prevention therapy in pediatric patients with sickle cell anemia.

Degree of cerebrovascular stenosis in pediatric patients with sickle cell anemia (SCA) informs need for chronic transfusion therapy, which has significant risks. Flow artifact, intrinsic to magnetic resonance angiography (MRA), is dependent on technical parameters and can lead to overinterpretation of stenosis. The primary objective of this study was to document any change in stroke prevention therapy that could be attributed to the implementation of a standardized MRA scanning protocol for patients with SCA. A standardized MRA scanning protocol with an echo time of less than 5ms was implemented at Montefiore Medical Center (MMC), NY in May 2016. Retrospective chart review identified 21 pediatric patients with SCA, with an MRA head both pre- and post-May 2016. Arterial stenosis on MRA, machine parameters, and treatment plans were compared pre- and post-implementation. Ten of the 21 patients met inclusion criteria. Previously seen stenosis was re-classified to a lower degree in six of the 10 patients, leading to discontinuation of transfusions in five patients. No patients required escalation of therapy to chronic transfusions. Optimizing flow artifact by decreasing echo time to less than 5ms can improve accurate interpretation of cerebrovascular disease, and ensure appropriate treatment plans are in place for stroke prevention. This is especially important for implementing "TCD With Transfusions Changing to Hydroxyurea (TWiTCH)" clinical trial results in the real-world setting.

Impact of MRA Echo Time on Stroke Prevention Therapy in Pediatric Patients with Sickle Cell Disease

Background and Purpose: Magnetic Resonance Angiography (MRA) is performed on pediatric patients with sickle cell disease (SCD) to classify degree of cerebrovascular stenosis, informing stroke risk and treatment plan for stroke prevention. Flow artifact intrinsic to MRA and influenced primarily by TE (echo time) can lead to overinterpretation of stenosis. A standardized MRA protocol with shorter TE for patients with sickle cell disease was implemented at our institution. The primary objective of this study was to document any change in stroke prevention therapy that could be attributed to the implementation of this standardized MRA scanning protocol. Methods: A standardized MRA scanning protocol with an TE of <5msec based on the SWiTCH study protocol for patients with SCD was implemented at Montefiore Medical Center, NY (MMC) May 2016. This project included a retrospective chart review of patients at MMC ≤ 21 years with SCD who had one MRA head pre- AND one MRA post-May 2016. Of the 81 patients that met inclusion criteria, 29 patients were found to have vasculopathy on pre-May 2016 imaging and were included in this analysis. Level of arterial stenosis on MRA, TE, and treatment plans were documented both pre- and post-May 2016. McNemar analysis was used to determine the significance of change in treatment plans before and after implementation of the standardized scanning protocol. Results: 24/29 (83%) patients were on chronic transfusion therapy for CNS vasculopathy pre-May 2016 whereas 18/29 (62%) were on chronic transfusion therapy post May 2016. Notably, 6 patients had a resolution of vasculopathy on MRA post implementation of the scanning protocol, leading to discontinuation of chronic transfusion therapy. McNemar analysis showed this difference to be statistically significant (p = 0.042). Conclusion: Implementing a standardized MRA scanning protocol allowed for chronic transfusion therapy to be discontinued in 6 out of 24 patients due to minimizing flow artifact. Screening for arterial stenosis with TE <5msec can improve accurate interpretation of true cerebrovascular disease and ensure appropriate treatment plans are in place for SCD stroke prevention.

Day to Day Blood Pressure Variability Associated With Cerebral Arterial Dilation and White Matter Hyperintensity.

Background:Previous studies suggested blood pressure variability (BPV) might help reveal interactions between blood pressure fluctuation and white matter lesions, and the impact of elevated BPV on white matter hyperintensity (WMH) or cerebral arterial dilation is unclear.Methods:This retrospective observational study involved 2634 stroke-free individuals (68.6±11.1 years, 50.3% female), who underwent magnetic resonance imaging and magnetic resonance angiography scans, from a single center in Shanghai, China. Measurements for variability of blood pressure were made based on 7 days blood pressure recordings. WMHs were quantified from T2-FLAIR images and further classified as periventricular WMH or deep WMH. M1 segment of middle cerebral artery dilation was assessed from magnetic resonance angiography images. General linear model was used to examine the associations.Results:Both increased systolic and diastolic BPV were associated with increased WMH volume (systolic: β=0.02 [95% CI, 0.004–0.03], P=0.01; diastolic: β=0.05 [95% CI, 0.03–0.08], P<0.001). Only periventricular WMH was associated with BPV (systolic: β=0.02 [95% CI, 0.005–0.04], P=0.01; diastolic: β=0.06 [95% CI, 0.04–0.09], P<0.001). MCA dilation was found in 125 individuals (4.75%). Systolic BPV was associated with MCA dilation only in the hypertensive individuals (β=0.11 [95% CI, 0.06–0.17], P<0.001). Increased WMH volume was found associated with dilated MCA (β=0.17 [95% CI, 0.11–0.23], P<0.001).Conclusions:Increased BPV might be one of the pathophysiological phenomena involving in the small vessel disease independent of hypertension. Increased BPV might independently contribute to intracranial arterial dilation. Management of BPV might be a target to preserve cerebrovascular wellness.

Magnetic Resonance Angiography After Flow Diversion: The Use of Complementary Magnetic Resonance Angiography Techniques to Monitor Aneurysm Occlusion and Device and Arterial Branch Patency After Flow Diverter Placement

Few studies have evaluated flow diversion with magnetic resonance angiography (MRA). Studies have shown better success of MRA in assessing the aneurysm response, but limited success in assessing stent patency. The patency of arterial branches on MRA remains to be explored. Retrospective evaluation of 31 consecutive cases of carotid aneurysms treated with flow diversion was performed with noncontrast time-of-flight (TOF), contrast-enhanced TOF, and cine MRA (time-resolved angiography with interleaved stochastic trajectories) independently by 2 investigators for aneurysm occlusion, stent patency, and arterial branch patency. Digital subtraction angiography served as the gold standard technique. Patients were 6 men and 25 women with a mean ± SD age of 57.8 ± 12.27 years (range, 32-79 years). Stent patency, aneurysm occlusion, and branch patency mostly revealed substantial to perfect interobserver agreement (κ >0.60). Sensitivity, specificity, positive predictive value, and negative predictive value for stent patency on raw data images of TOF were 0.50, 0.86, 0.20, and 0.96 and on contrast-enhanced TOF were 1.0, 0.93, 0.50, and 1.0. Ranges for aneurysm response on the 3 MRA scans were 0.78-0.89 for sensitivity, 0.54-0.92 for specificity, 0.73-0.93 for positive predictive value, and 0.78-0.86 for negative predictive value. Ranges for arterial branch patency among the 3 MRA scans were 0.87-0.96 for sensitivity, 0.50-1.0 for specificity, 0.90-1.0 for positive predictive value, and 0.33-0.80 for negative predictive value. Aneurysm occlusion, stent patency, and arterial branch patency in flow diversion can be successfully evaluated with the combination of 3 MRA techniques.

DOP13 The Arborisation index: An MRI-based measure of mesenteric hyperaemia in Crohn’s Disease

Abstract Background Robust and sensitive therapeutic targets are key in effective management of Inflammatory Bowel Disease1. Mesenteric hyperaemia is a recognized sign of active disease and in cross-sectional image is described as the comb sign. Although it is subjectively described, no automated quantitative MRI-based measures have been developed. We aim to develop an automated methodology using contrast-less time of flight (TOF) Magnetic resonance angiography (MRA). Methods A MATLAB algorithm was developed to track the vessels on a 3D maximum intensity projection of a TOF MRA data set and calculate an arborization Index which is the number of branching points in the intrabdominal vessels (figure 1). 2D TOF scans were acquired in the transverse plane between the top of the hip joint and L4 vertebra using a 3T Ingenia Wide bore scanner (Philips, The Netherlands). The primary outcome was a comparison of the arborization index between Crohn’s disease (CD) and healthy volunteers (HV) groups. A planned sub-analysis was undertaken across CD and HV matched for BMI to investigate the effect of visceral fat on the arborization index. Repeated measures were undertaken to evaluate the variability of the quantification method. No contrast agents were used for the TOF MRA scans. Biological variations within each group and test-retest repeatability were assessed using the coefficient of variation (CV). Statistical analysis with unpaired, two-tailed t-tests were conducted and differences were considered significant when the p-value ≤0.05. All absolute values are presented as mean ±standard deviation (SD). Results In this prospective pilot study, 7 CD patients (C-Reactive Protein=5.2±6.1 mg/L, Faecal Calprotectin 611±981μg/g, BMI=23±3 kg/m2) and 15 HVs (BMI=29±7 kg/m2) were recruited. Patients showed a significantly higher arborization index when compared to HVs (mean arborization in HV=94±21 and CD=139±26; p-value=0.002). The difference in arborization index persisted in a sub-analysis of 7 HVs (BMI=24±2 kg/m2) and 7 CD patients (mean arborization in matched HVs=101±22 vs mean index in CD=139±26; p=0.01) (Figure 2). The CV was 23% for HVs and 18% for CD indicating biological variation. Test-retest variability calculated from multiple TOF scans of the same subjects gave a mean CV of 6±5% for both groups combined. Conclusion Our preliminary data suggest that the arborization index may be a useful measure of hypervascularity and hence intestinal inflammation in Inflammatory Bowel Disease. Further validation to standard disease activity measures is needed across larger cohorts to better investigate the utility of this potential biomarker as a non-invasive measure of disease activity and its reversibility to IBD therapies. Reference 1.Turner,D.,et al.Gastro.2021;160(5):1570–1583.

Intensity of arterial structure acquired by Silent MRA estimates cerebral blood flow

BackgroundCerebral blood flow (CBF) and the morphology of the cerebral arteries are important for characterizing cerebrovascular disease. Silent magnetic resonance angiography (Silent MRA) is a MRA technique focusing on arterial structural delineation. This study was conducted to investigate the correlation between Silent MRA and CBF quantification, which has not yet been reported.MethodsBoth the Silent MRA and time-of-flight magnetic resonance angiography scans were applied in seventeen healthy participants to acquire the arterial structure and to find arterial intensities. Phase-contrast MRA (PC-MRA) was then used to perform the quantitative CBF measurement of 13 cerebral arteries. Due to different dataset baseline signal level of Silent MRA, the signal intensities of the selected 13 cerebral arteries were normalized to the selected ROIs of bilateral internal carotid arteries. The normalized signal intensities were used to determine the relationship between Silent MRA and CBF.ResultsThe image intensity distribution of arterial regions generated by Silent MRA showed similar laminar shape as the phase distribution by PC-MRA (correlation coefficient > 0.62). Moreover, in both the results of individual and group-leveled analysis, the intensity value of arterial regions by Silent MRA showed positively correlation with the CBF by PC-MRA. The coefficient of determination (R2) of individual trends ranged from 0.242 to 0.956, and the R2 of group-leveled result was 0.550.ConclusionsThis study demonstrates that Silent MRA provides valuable CBF information despite arterial structure, rendering it a potential tool for screening for cerebrovascular disease.

Arterial tortuosity syndrome causing recurrent transient ischemic attacks in young adult: a case report

BackgroundArterial Tortuosity Syndrome (ATS) is a rare autosomal recessive disorder characterized by elongated and tortuous arteries. Although ATS showed a significant clinical and pathophysiological overlap with other syndromes involving connective tissues, only few cases of cerebrovascular events related to this syndrome have been described so far.Case presentationWe report the case of a 33-years-old male diagnosed with ATS since childhood, that experienced three sudden episodes of expressive aphasia and right hemiparesis with spontaneous resolution. He was treated with recombinant tissue plasminogen activator (r-TPA) at a dosage of 0.9 mg/kg with a complete recovery. Brain Magnetic Resonance Imaging (MRI) showed the absence of acute ischemic lesions and the patient was diagnosed with recurrent transient ischemic attacks (TIA).Intracranial and supra-aortic trunks Magnetic Resonance Angiography (MRA) and Angio-CT scan of the thoracic and abdominal aorta showed marked vessel tortuosity without stenosis.To our knowledge, this is the first reported case of an ATS patient with TIA in young age that was treated with intravenous thrombolysis with recombinant plasminogen activator.ConclusionOur report strengthens the relationship between ATS and juvenile cerebrovascular events, suggesting that an extensive study of body vessels in order to detect potential stenoses or occlusions in these cases is needed.The greater predisposition to cerebrovascular events in ATS could benefit from a more aggressive primary and secondary prevention therapy.

The association between carotid intima-media thickness and cognitive performance is affected by intracranial artery stenosis in Chinese elderly people: An outpatient-based study

Background and AimsThe association between carotid intima-media thickness (cIMT) and cognitive function remains controversial, and whether this relationship is affected by intracranial artery stenosis (ICAS) remains unclear. We investigated these questions among elderly participants who sought health consultations in an outpatient clinic. MethodsWe conducted a cross-sectional study based on participants from an outpatient clinic, enrolling residents over 60 years of age seeking outpatient services because of abnormal transcranial Doppler reports at Shandong Provincial Third Hospital in Jinan, Shandong province. We performed physical examinations, blood tests, cIMT measurement using carotid ultrasonography, ICAS measurement using brain magnetic resonance angiography scanning, and global cognitive function assessment using the Montreal Cognitive Assessment (MoCA)in the outpatient clinic from May 2020 to December 2020. We subsequently performed a regression analysis to explore the relationship between cIMT and cognitive function and a stratified analysis to explore whether the relationship was different between the ICAS and non-ICAS participants. ResultsIn total, 167 participants (age: 65.56 ± 10.39 years, female: 53.89%) were included in the present study. The MoCA score was significantly lower in the intimal thickening group (cIMT ≥ 1.0 mm) than in the normal group (mean [SD]: 16.23 [5.16] vs. 19.97 [4.59], P < 0.001). Univariate analysis showed that a greater cIMT was negatively correlated with cognitive function. After adjustment for several potential confounders in the multivariable analyses, the association between cIMT and cognitive function disappeared. When further stratified by ICAS, a negative association between increased cIMT (cIMT ≥ 1.0 mm) and cognitive function was found in those without ICAS (β: −2.80 [-5.13, −0.48], p = 0.021); however, in subjects with ICAS, the relationship between cIMT and cognitive function was insignificant. ConclusionGreater cIMT was associated with low cognitive function in participants without ICAS who sought consultation due to abnormal transcranial Doppler reports in outpatient clinics.

Diagnosis and classification of headache associated with sexual activity using a composite algorithm: A cohort study.

To differentiate primary headache associated with sexual activity from other devastating secondary causes. In this prospective cohort, we recruited consecutive patients with at least 2 attacks of headache associated with sexual activity from the headache clinics or emergency department of a national medical center from 2005 to 2020. Detailed interview, neurological examination, and serial thorough neuroimaging including brain magnetic resonance imaging and magnetic resonance angiography scans were performed on registration and during follow-ups. Patients were categorized into four groups, i.e. primary headache associated with sexual activity, reversible cerebral vasoconstriction syndrome, probable reversible cerebral vasoconstriction syndrome, and other secondary headache associated with sexual activity through a composite clinic-radiological diagnostic algorithm. We compared the clinical profiles among these groups, including sex, age of onset, duration, quality, and clinical course ("chronic" indicates disease course ≥ 1 year). In addition, we also calculated the score of the reversible cerebral vasoconstriction syndrome2, a scale developed to differentiate reversible cerebral vasoconstriction syndrome from other intracranial vascular disorders. Overall, 245 patients with headache associated with sexual activity were enrolled. Our clinic-radiologic composite algorithm diagnosed and classified all patients into four groups, including 38 (15.5%) with primary headache associated with sexual activity, 174 (71.0%) with reversible cerebral vasoconstriction syndrome, 26 (10.6%) with probable reversible cerebral vasoconstriction syndrome, and 7 (2.9%) with other secondary causes (aneurysmal subarachnoid hemorrhage (n = 4), right internal carotid artery dissection (n = 1), Moyamoya disease (n = 1), and meningioma with hemorrhage (n = 1)). These four groups shared similar clinical profiles, except 26% of the patients with primary headache associated with sexual activity had a 3 times greater chance of running a chronic course (≥ 1 year) than patients with reversible cerebral vasoconstriction syndrome. Of note, the reversible cerebral vasoconstriction syndrome2 score could not differentiate reversible cerebral vasoconstriction syndrome from other groups. Our composite clinic-radiological diagnostic algorithm successfully classified repeated headaches associated with sexual activity, which were predominantly secondary and related to vascular disorders, and predicted the prognosis. Primary headache associated with sexual activity and reversible cerebral vasoconstriction syndrome presented with repeated attacks of headache associated with sexual activity may be of the same disease spectrum.

Abstract P587: A Standardized MRA Scanning Protocol Leading to Changes in Stroke Prevention Treatment Plan for Pediatric Sickle Cell Patients

Background and Purpose: Magnetic Resonance Angiography (MRA) is performed on pediatric patients with sickle cell disease (SCD) to classify degree of cerebrovascular stenosis, informing stroke risk and treatment plan for stroke prevention. Flow artifact intrinsic to MRA with technician dependent factors can lead to over-interpretation of stenosis. The primary objective of this study was to document any change in stroke prevention therapy that could be attributed to the implementation of a standardized MRA scanning protocol. Methods: A standardized MRA scanning protocol with an echo time (TE) of &lt;5msec based on the SWiTCH (Stroke With Transfusions Changing to Hydroxyurea) study protocol for patients with SCD was implemented at Montefiore Medical Center, NY (MMC) in May 2016. This project included a retrospective chart review of patients at MMC ≤ 21 years of age with SCD who had one MRA head pre-May 2016 AND one MRA post-May 2016. Of the 81 patients that met inclusion criteria, 29 patients were found to have cerebral vasculopathy on pre-May 2016 imaging and included in the analysis. Level of arterial stenosis on MRA, TE, and treatment plans were documented both pre- and post-May 2016. McNemar analysis was used to determine the significance of change in treatment plans before and after implementation of the standardized MRA scanning protocol. Results: 24/29 (83%) patients were on chronic transfusion therapy for cerebrovascular disease pre-May 2016 whereas 18/29 (62%) required chronic transfusion therapy post May 2016. Notably, 6 patients had a resolution of cerebral vasculopathy leading to discontinuation of chronic transfusion therapy whereas 0 patients required escalation of therapy to chronic transfusions. McNemar analysis showed this difference to be statistically significant (p = 0.042). Conclusion: Implementing a standardized MRA scanning protocol allowed for chronic transfusion therapy, which has potentially significant side effects, to be discontinued in 6 out of 24 patients. Minimizing flow artifact with TE &lt;5msec can improve accurate interpretation of true cerebrovascular disease and ensure appropriate treatment plans are in place for stroke prevention.

STITCH TO STENT: A VASCULAR COMPLICATION OF LUNG TRANSPLANTATION

SESSION TITLE: Medical Student/Resident Transplantation Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung transplantation (LTx) is an established treatment for end-stage lung diseases. Pulmonologists will be well-served to be familiar with its complications. We describe a patient with a vascular complication of LTx which is often associated with significant mortality and morbidity. CASE PRESENTATION: A 61-year-old man was admitted with hypoxic respiratory failure 3 months following bilateral LTx for bronchiectasis from Kartagener’s syndrome. Infection, rejection, and heart failure were all ruled out with x-ray, non-contrast CT scan and echocardiography. Bronchoscopy revealed scant clear secretions with negative cultures and no evidence of rejection on transbronchial biopsy. CT pulmonary angiography (CTPA) performed to rule out embolism revealed a severe right pulmonary artery stenosis (PAS) at the anastomotic site. The lesion was dilated with balloon angioplasty resulting in mild improvement on follow up CT scans. Quantitative perfusion scan estimated only 18% perfusion in the right lung due to stenosis of the right pulmonary artery. Angiography was repeated and an Express LD ® 10 mm x 25 mm balloon-expandable stent was placed across the stenosis. Right pulmonary artery blood flow and hypoxia improved, and the patient was soon discharged. At 1 month follow up, right lung perfusion improved to 41%. DISCUSSION: Anastomotic PAS is defined as an anastomotic diameter of 75% or less that of the neighboring vessels. Causes include mismatched lengths of donor and recipient pulmonary artery segments, twisting of the anastomosis, and thrombosis. Clinical presentation is usually within 6 weeks of LTx with unexplained hypoxia and pulmonary hypertension. Delays in diagnosis and correction of PAS can lead to respiratory failure, hemodynamic compromise, and graft failure. Modalities for diagnosis include CTPA, magnetic resonance angiography, echocardiography and quantitative perfusion scanning. CTPA shows detailed anatomy after surgery thus helping to rule out other causes of hypoxia. Invasive pulmonary angiography is the gold standard for confirmation but is usually reserved for cases in which catheter-based intervention (CBI) is required. PAS can be corrected by surgical revision or CBI (angioplasty with or without stenting). The latter is becoming more common due to lower procedural risk, better tolerability and utility in late-presenting cases. Anticoagulants are used if thrombosis is present. CONCLUSIONS: LTx patients with persistent unexplained hypoxia should be evaluated for vascular complications, including anastomotic PAS, given high risk of mortality and morbidity. CTPA is a popular choice for diagnostic imaging. Although historically LTx patients with PAS had extremely poor prognosis, catheter-based stent intervention has the potential to prevent graft failure. Reference #1: Anaya-Ayala JE, Loebe M, Davies MG. Endovascular management of early lung transplant-related anastomotic pulmonary artery stenosis. J Vasc Interv Radiol 2015;26:878–882 Reference #2: Siddique A, Bose AK, Özalp F, Butt TA, Muse H, Morley KE, Dark JH, Parry G, Clark SC. Vascular anastomotic complications in lung transplantation: a single institution's experience. Interact Cardiovasc Thorac Surg. 2013 Oct;17(4):625-31 Reference #3: Batra K, Chamarthy MR, Reddick M, Roda MS, Wait M, Kalva SP. Diagnosis and interventions of vascular complications in lung transplant. Cardiovasc Diagn Ther. 2018 Jun;8(3):378-386. DISCLOSURES: no disclosure on file for Usman Ahmad; No relevant relationships by Christian Cuvillier Padilla, source=Web Response No relevant relationships by ihab Haddadin, source=Web Response No relevant relationships by Lirim Krveshi, source=Web Response No relevant relationships by Carli Lehr, source=Web Response No relevant relationships by Uddalak Majumdar, source=Web Response No relevant relationships by Atul Mehta, source=Web Response No relevant relationships by Wayne Tsuang, source=Web Response No relevant relationships by Maryam Valapour, source=Web Response