Recent advances in 3D time-resolved contrast-enhanced MR angiography

Magnetic Resonance Imaging Techniques in Peripheral Arterial Disease

Significance: Peripheral arterial disease (PAD) leads to a significant burden of morbidity and impaired quality of life globally. Diabetes is a significant risk factor accelerating the development of PAD with an associated increase in the risk of chronic wounds, tissue, and limb loss. Various magnetic resonance imaging (MRI) techniques are being increasingly acknowledged as useful methods of accurately assessing PAD. Recent Advances: Conventionally utilized MRI techniques for assessing macrovascular disease have included contrast enhanced magnetic resonance angiography (MRA), noncontrast time of flight MRA, and phase contrast MRI, but have significant limitations. In recent years, novel noncontrast MRI methods assessing skeletal muscle perfusion and metabolism such as arterial spin labeling (ASL), blood-oxygen-level dependent (BOLD) imaging, and chemical exchange saturation transfer (CEST) have emerged. Critical Issues: Conventional non-MRI (such as ankle-brachial index, arterial duplex ultrasonography, and computed tomographic angiography) and MRI based modalities image the macrovasculature. The underlying mechanisms of PAD that result in clinical manifestations are, however, complex, and imaging modalities that can assess the interaction between impaired blood flow, microvascular tissue perfusion, and muscular metabolism are necessary. Future Directions: Further development and clinical validation of noncontrast MRI methods assessing skeletal muscle perfusion and metabolism, such as ASL, BOLD, CEST, intravoxel incoherent motion microperfusion, and techniques that assess plaque composition, are advancing this field. These modalities can provide useful prognostic data and help in reliable surveillance of outcomes after interventions.

Imaging to intervention: Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.

MRI and MR angiography evaluation of pulsatile tinnitus: A focused, physiology-based protocol

BACKGROUND AND PURPOSE

Pulsatile tinnitus (PT) is the subjective sensation of a pulse-synchronous sound, most often due to a cerebrovascular etiology. PT can severely impact quality of life and may indicate a life-threatening process, yet a timely and accurate diagnosis can often lead to effective treatment. Clinical assessment with a history and physical examination can often suggest a diagnosis for PT, but is rarely definitive. Therefore, PT should be evaluated with a comprehensive and targeted radiographic imaging protocol. MR imaging provides a safe and effective means to evaluate PT. Specific MR sequences may be used to highlight different elements of cerebrovascular anatomy and physiology. However, routine MR evaluation of PT must comply with economic and practical constraints, while effectively capturing both common and rarer, life-threatening etiologies of PT.

METHODS

In this state-of-the-art review, we describe our institutional MR protocol for evaluating PT.

RESULTS

This protocol includes the following dedicated sequences: time-of-flight magnetic resonance angiography; arterial spin labeling; spoiled gradient recalled acquisition in the steady state; time-resolved imaging of contrast kinetics; diffusion weighted imaging, and 3-dimensional fluid-attenuated inversion recovery.

CONCLUSIONS

We describe the physiologic and clinical rationale for including each MR sequence in a comprehensive PT imaging protocol, and detail the role of MR within the broader evaluation of PT, from clinical presentation to treatment.

Real-Time Magnetic Resonance Imaging

Real-time magnetic resonance imaging (RT-MRI) allows for imaging dynamic processes as they occur, without relying on any repetition or synchronization. This is made possible by modern MRI technology such as fast-switching gradients and parallel imaging. It is compatible with many (but not all) MRI sequences, including spoiled gradient echo, balanced steady-state free precession, and single-shot rapid acquisition with relaxation enhancement. RT-MRI has earned an important role in both diagnostic imaging and image guidance of invasive procedures. Its unique diagnostic value is prominent in areas of the body that undergo substantial and often irregular motion, such as the heart, gastrointestinal system, upper airway vocal tract, and joints. Its value in interventional procedure guidance is prominent for procedures that require multiple forms of soft-tissue contrast, as well as flow information. In this review, we discuss the history of RT-MRI, fundamental tradeoffs, enabling technology, established applications, and current trends. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 1.

The use of 4-dimensional magnetic resonance angiography as a noninvasive procedure to diagnose subclavian steal syndrome in a dog

CASE DESCRIPTION

A 5-year-old 4.1-kg (9.0-lb) spayed female Toy Poodle was referred because of a 6-month history of sporadic signs of neck pain.

CLINICAL FINDINGS

Diagnostic imaging with MRI and CT revealed a dilated radicular artery connecting the right and left vertebral arteries and causing mild compression of the spinal cord. The left subclavian artery caudal to the origin of the left vertebral artery was absent. Subclavian steal syndrome (SSS) was suspected.

TREATMENT AND OUTCOME

The owner declined surgical treatment; thus, the dog was treated conservatively with glucocorticoids and analgesics. Eight months later, the dog's clinical signs were unchanged but palliated with the administration of glucocorticoids and analgesics, and 4-dimensional (4-D) magnetic resonance angiography (MRA) revealed that the left vertebral artery received blood supply from the right vertebral artery through the dilated radicular artery and that the left vertebral artery caudal to this site had retrograde flow and drained into the left subclavian artery, confirming the diagnosis of SSS. The owner again declined surgery, and conservative treatment continued. The dog's condition was unchanged at the last follow-up communication 11 months after 4-D MRA.

CLINICAL RELEVANCE

Subclavian steal syndrome is an extremely rare condition in dogs, and our findings suggested that 4-D MRA could be used to definitively diagnose SSS in dogs.

Updates in Magnetic Resonance Venous Imaging

For years, magnetic resonance angiography (MRA) has been a leading imaging modality in the assessment of venous disease involving the pelvis and lower extremities. Current advancement in noncontrast MRA techniques enables imaging of a larger subset of patients previously excluded due to allergy or renal insufficiency, allowing for preintervention assessment and planning. In this article, the current status of MR venography, with a focus on current advancements, will be presented. Protocols and parameters for MR venographic imaging of the pelvis and lower extremities, including contrast and noncontrast enhanced techniques, will be reviewed based on a recent literature review of applied MR venographic techniques. Finally, several disease-specific entities, including pelvic congestion and compression syndromes, will be discussed with a focus on imaging parameters that may best characterize these disease processes and optimize anatomical planning prior to intervention.

Techniques for Imaging Vascular Supply of Peripheral Nerves

Few studies have been developed to map the vascular structures feeding peripheral nerves, with the majority using cadaveric models and inadequate sample sizes. Preliminary evidence, while limited, indicates that the mapping of these vessels may allow or preclude certain procedures in nerve reconstruction due to the location of essential arterial inflow to the vasa nervorum. This review evaluates the evidence regarding historical, current, and emerging techniques for visualizing these vascular structures in vivo and considers their potential application in peripheral nerve vasculature.

Technique and protocols for cardiothoracic time-resolved contrast-enhanced magnetic resonance angiography sequences: a systematic review

AIM

To review contrast medium administration protocols used for cardiothoracic applications of time-resolved, contrast-enhanced magnetic resonance angiography (MRA) sequences.

MATERIALS AND METHODS

A systematic search of the literature (Medline/EMBASE) was performed to identify articles utilising time-resolved MRA sequences, focusing on type of sequence, adopted technical parameters, contrast agent (CA) issues, and acquisition workflow. Study design, year of publication, population, magnetic field strength, type, dose, and injection parameters of CA, as well as technical parameters of time-resolved MRA sequences were extracted.

RESULTS

Of 117 retrieved articles, 16 matched the inclusion criteria. The study design was prospective in 9/16 (56%) articles, and study population ranged from 5 to 185 patients, for a total of 506 patients who underwent cardiothoracic time-resolved MRA. Magnetic field strength was 1.5 T in 13/16 (81%), and 3 T in 3/16 (19%) articles. The administered CA was gadobutrol (Gadovist) in 6/16 (37%) articles, gadopentetate dimeglumine (Magnevist) in 5/16 (31%), gadobenate dimeglumine (MultiHance) in 2/16 (13%), gadodiamide (Omniscan) in 2/16 (13%), gadofosveset trisodium (Ablavar, previously Vasovist) in 1/16 (6%). CA showed highly variable doses among studies: fixed amount or based on patient body weight (0.02-0.2 mmol/kg) and was injected with a flow rate ranging 1-5 ml/s. Sequences were TWIST in 13/16 (81%), TRICKS in 2/16 (13%), and CENTRA 1/16 articles (6%).

CONCLUSION

Time-resolved MRA sequences were adopted in different clinical settings with a large spectrum of technical approaches, mostly in association with different CA dose, type, and injection method. Further studies in relation to specific clinical indications are warranted to provide a common standardised acquisition protocol.

Magnetic Resonance Angiography of the Thoracic Vasculature: Technique and Applications

Magnetic resonance angiography (MRA) is a powerful clinical tool for evaluation of the thoracic vasculature. MRA can be performed on nearly any magnetic resonance imaging (MRI) scanner, and provides images of high diagnostic quality without the use of ionizing radiation. While computed tomographic angiography (CTA) is preferred in the evaluation of hemodynamically unstable patients, MRA represents an important tool for evaluation of the thoracic vasculature in stable patients. Contrast-enhanced MRA is generally performed unless there is a specific contraindication, as it shortens the duration of the exam and provides images of higher diagnostic quality than noncontrast MRA. However, intravenous contrast is often not required to obtain a diagnostic evaluation for most clinical indications. Indeed, a variety of noncontrast MRA techniques are used for thoracic imaging, often in conjunction with contrast-enhanced MRA, each of which has a differing degree of reliance on flowing blood to produce the desired vascular signal. In this article we review contrast-enhanced MRA, with a focus on contrast agents, methods of bolus timing, and considerations in imaging acquisition. Next, we cover the mechanism of contrast, strengths, and weaknesses of various noncontrast MRA techniques. Finally, we present an approach to protocol development and review representative protocols used at our institution for a variety of thoracic applications. Further attention will be devoted to additional techniques employed to address specific clinical questions, such as delayed contrast-enhanced imaging, provocative maneuvers, electrocardiogram and respiratory gating, and phase-contrast imaging. The purpose of this article is to review basic techniques and methodology in thoracic MRA, discuss an approach to protocol development, and illustrate commonly encountered pathology on thoracic MRA examinations. Level of Evidence 5 Technical Efficacy Stage 3.

Quantitative renal function assessment of atheroembolic renal disease using view-shared compressed sensing based dynamic-contrast enhanced MR imaging: An in vivo study

Atheroembolic renal disease (AERD) is the major cause of renal insufficiency in the elderly, and particularly, the diagnose of AERD is often delayed and even missed due to its nonspecific presentation and the sudden occurrence of an embolic event. To investigate the feasibility of the view-shared compressed sensing (VCS) based dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) in the assessment of AERD in animal models. The reproducibility of VCS DCE-MRI based glomerular filtration rate (GFR) estimation was first evaluated using the three healthy rabbits. Animal models of unilateral AERD were then conducted. All the rabbits underwent VCS DCE-MRI and the GFR maps were estimated by a commonly used cortical-compartment model. The whole kidney and suspicious lesion region GFR values of embolized kidneys were then compared with the corresponding values of normal kidneys. Finally, the suspicious lesion regions were confirmed by the corresponding renal specimens and histological findings. The reproducibility of GFR measurements was analyzed using the coefficient of variation and Bland-Altman analysis. The GFR values of normal and embolized kidneys were compared using the Student t-test. Contrast-enhanced images with sufficient diagnostic quality and reduced motion artifacts are obtained at a temporal resolution of 2.5 s. The Bland-Altman plot indicated close agreement between the GFR values estimated from between-day scans in healthy rabbits. Besides, there existed significant differences between the pixel-wise GFR values of normal and AERD kidneys in region-based comparison(P < 0.0001). The suspicious lesions are consistent well with the renal specimen and histological findings. The preliminary animal study verified the feasibility of VCS DCE-MRI for renal function evaluation, and the strategy could potentially provide a valuable tool to identify AERD.

Vascular CT and MRI: a practical guide to imaging protocols

Non-invasive cross-sectional imaging techniques play a crucial role in the assessment of the varied manifestations of vascular disease. Vascular imaging encompasses a wide variety of pathology. Designing vascular imaging protocols can be challenging owing to the non-uniform velocity of blood in the aorta, differences in cardiac output between patients, and the effect of different disease states on blood flow. In this review, we provide the rationale behind—and a practical guide to—designing and implementing straightforward vascular computed tomography (CT) and magnetic resonance imaging (MRI) protocols.

Teaching Points

• There is a wide range of vascular pathologies requiring bespoke imaging protocols.

• Variations in cardiac output and non-uniform blood velocity complicate vascular imaging.

• Contrast media dose, injection rate and duration affect arterial enhancement in CTA.

• Iterative CT reconstruction can improve image quality and reduce radiation dose.

• MRA is of particular value when imaging small arteries and venous studies.

Non-contrast enhanced 4D intracranial MR angiography based on pseudo-continuous arterial spin labeling with the keyhole and view-sharing technique

PURPOSE

4D dynamic MR angiography (4D-MRA) using pseudo-continuous arterial spin labeling (pCASL), combined with Keyhole and View-sharing (4D-PACK) for scan acceleration, is introduced. Its validity for arterial inflow dynamics visualization was investigated through comparison with 4D-pCASL and contrast inherent inflow enhanced multiphase angiography (CINEMA).

METHODS

Six healthy volunteers were included in the study. The arterial transit time (ATT) in 4D-PACK was measured at multiple regions in middle cerebral artery (MCA), and Pearson's correlation coefficient with ATT in 4D-pCASL was calculated. The contrast-to-noise ratio (CNR) in 4D-PACK was measured in four MCA segments and compared with that in 4D-pCASL and CINEMA. Arterial visualization in 4D-PACK was assessed qualitatively in patients with moyamoya disease and arteriovenous malformation by comparing with CINEMA.

RESULTS

4D-PACK achieved a 36% scan time reduction compared with 4D-pCASL. The correlation coefficient for ATT measured by 4D-pCASL and 4D-PACK was greater than 0.96. The CNR was significantly higher using 4D-PACK compared with CINEMA in the M4 segment (P < 0.01). In patient examinations, the flow in the collateral artery or draining vein was better visualized in 4D-PACK compared with CINEMA.

CONCLUSION

4D-PACK accelerates 4D-pCASL, shows similar inflow dynamics as 4D-pCASL and shows better peripheral visualization compared with CINEMA. Magn Reson Med 80:719-725, 2018. © 2018 International Society for Magnetic Resonance in Medicine.

Technical Aspects of Contrast-enhanced MR Angiography: Current Status and New Applications

This article is based on a presentation at the meeting of the Japanese Society of Magnetic Resonance in Medicine in September 2016. The purpose is to review the technical developments which have contributed to the current status of contrast-enhanced magnetic resonance angiography (CE-MRA) and to indicate related emerging areas of study. Technical developments include MRI physics-based innovations as well as improvements in MRI engineering. These have collectively addressed not only early issues of timing and venous suppression but more importantly have led to an improvement in spatiotemporal resolution of CE-MRA of more than two orders of magnitude compared to early results. This has allowed CE-MRA to be successfully performed in virtually all vascular territories of the body. Contemporary technical areas of study include improvements in implementation of high rate acceleration, extension of high performance first-pass CE-MRA across multiple imaging stations, expanded use of compressive sensing techniques, integration of Dixon-based fat suppression into CE-MRA sequences, and application of CE-MRA sequences to dynamic-contrast-enhanced perfusion imaging.

Appropriate Minimal Dose of Gadobutrol for 3D Time-Resolved MRA of the Supra-Aortic Arteries: Comparison with Conventional Single-Phase High-Resolution 3D Contrast-Enhanced MRA

BACKGROUND AND PURPOSE

The development of nephrogenic systemic fibrosis and neural tissue deposition is gadolinium dose-dependent. The purpose of this study was to determine the appropriate minimal dose of gadobutrol with time-resolved MRA to assess supra-aortic arterial stenosis with contrast-enhanced MRA as a reference standard.

MATERIALS AND METHODS

Four hundred sixty-two consecutive patients underwent both standard-dose contrast-enhanced MRA and low-dose time-resolved MRA and were classified into 3 groups; group A (a constant dose of 1 mL for time-resolved MRA), group B (2 mL), or group C (3 mL). All studies were independently evaluated by 2 radiologists for image quality by using a 5-point scale (from 0 = failure to 4 = excellent), grading of arterial stenosis (0 = normal, 1 = mild [<30%], 2 = moderate [30%-69%], 3 = severe to occlusion [≥70%]), and signal-to-noise ratio.

RESULTS

The image quality of time-resolved MRA was similar to that of contrast-enhanced MRA in groups B and C, but it was inferior to contrast-enhanced MRA in group A. For the grading of arterial stenosis, there was an excellent correlation between contrast-enhanced MRA and time-resolved MRA (R = 0.957 for group A, R = 0.988 for group B, R = 0.991 for group C). The SNR of time-resolved MRA tended to be lower than that of contrast-enhanced MRA in groups A and B. However, SNR was higher for time-resolved MRA compared with contrast-enhanced MRA in group C.

CONCLUSIONS

Low-dose time-resolved MRA is feasible in the evaluation of supra-aortic stenosis and could be used as an alternative to contrast-enhanced MRA for a diagnostic technique in high-risk populations.

Brain Vascular Imaging Techniques

Recent major improvements in a number of imaging techniques now allow for the study of the brain in ways that could not be considered previously. Researchers today have well-developed tools to specifically examine the dynamic nature of the blood vessels in the brain during development and adulthood; as well as to observe the vascular responses in disease situations in vivo. This review offers a concise summary and brief historical reference of different imaging techniques and how these tools can be applied to study the brain vasculature and the blood-brain barrier integrity in both healthy and disease states. Moreover, it offers an overview on available transgenic animal models to study vascular biology and a description of useful online brain atlases.

Hyaluronic acid-modified manganese-chelated dendrimer-entrapped gold nanoparticles for the targeted CT/MR dual-mode imaging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common malignant tumor of the liver. The early and effective diagnosis has always been desired. Herein, we present the preparation and characterization of hyaluronic acid (HA)-modified, multifunctional nanoparticles (NPs) targeting CD44 receptor-expressing cancer cells for computed tomography (CT)/magnetic resonance (MR) dual-mode imaging. We first modified amine-terminated generation 5 poly(amidoamine) dendrimers (G5.NH2) with an Mn chelator, 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA), fluorescein isothiocyanate (FI), and HA. Then, gold nanoparticles (AuNPs) were entrapped within the above raw product, denoted as G5.NH2-FI-DOTA-HA. The designed multifunctional NPs were formed after further Mn chelation and purification and were denoted as {(Au0)100G5.NH2-FI-DOTA(Mn)-HA}. These NPs were characterized via several different techniques. We found that the {(Au0)100G5.NH2-FI-DOTA(Mn)-HA} NPs exhibited good water dispersibility, stability under different conditions, and cytocompatibility within a given concentration range. Because both AuNPs and Mn were present in the product, {(Au0)100G5.NH2-FI-DOTA(Mn)-HA} displayed a high X-ray attenuation intensity and favorable r1 relaxivity, which are advantageous properties for targeted CT/MR dual-mode imaging. This approach was used to image HCC cells in vitro and orthotopically transplanted HCC tumors in a unique in vivo model through the CD44 receptor-mediated endocytosis pathway. This work introduces a novel strategy for preparing multifunctional NPs via dendrimer nanotechnology.

Impact of non-contrast enhanced volumetric MRI-based feeder localization in the treatment of spinal dural arteriovenous fistula

BACKGROUND

The preoperative localization of the feeder of spinal dural arteriovenous fistula (SDAVF) could simplify the diagnostic spinal angiographic procedure. Localization by non-contrast-enhanced MRI-based techniques is an attractive option. However, the usefulness of such an approach for evaluation of SDAVF has not yet been reported.

OBJECTIVE

To study the impact of non-contrast MRI-based feeder localization, followed by targeted spinal angiography, in the evaluation of SDAVF before endovascular intervention.

MATERIALS AND METHODS

Prospectively collected data were analyzed and the level of the feeder was localized preoperatively. The procedural time for targeted spinal angiography was calculated and compared with that of a historical cohort, who underwent routine spinal angiographic examination before the study period. Follow-up MRI was carried out to assess the reliability of this model for detection of occasional metachronous lesions that might be missed with this approach.

RESULTS

Seven patients underwent targeted spinal angiography during the study. The feeder level was accurately identified in five patients and was localized to one vertebral level in six patients. The correlation between MRI and DSA was statistically significant. The number of spinal levels assessed was fewer and overall procedure time was significantly shorter compared to historical cohort (58 min vs 162 min, respectively; p<0.001). Intervention was coupled with targeted angiography in two patients. Follow-up MRI demonstrated flow voids in one patient, who had recurrent fistula at one vertebral level below the previously embolized feeder.

CONCLUSIONS

The non-contrast MRI-based localization technique can reliably detect the level of feeder and help in therapeutic planning of SDAVF. The localization techniques potentially shorten the angiographic procedure and may facilitate simultaneous endovascular definitive treatment. Inclusion of follow-up MRI may be useful for detection of synchronous or metachronous lesions if a targeted approach is adopted. Additionally, this helps to identify failed endovascular therapy.

Advances in axial imaging of peripheral vascular disease

Peripheral artery disease (PAD) has become increasingly common in the US patient population and can be a highly symptomatic and significant source of morbidity. When PAD is suspected, the first-line screening study that is obtained is typically a noninvasive evaluation that includes the ankle brachial index (ABI). Following a positive screening study, invasive catheter digital subtraction angiography (DSA) has been historically used to image the peripheral artery system and still remains the gold standard. However, newer developments in axial imaging including computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have in large part supplanted DSA for imaging the peripheral artery system in clinical practice. Benefits of CTA include rapid noninvasive acquisition, wide availability, high spatial resolution, and the ability to generate isotropic datasets on 64-detector row and higher CT scanners, thereby allowing for multiplanar 3D reformatting. Drawbacks of CTA include the exposure to both iodinated contrast and ionizing radiation, although the radiation dose exposure is lower than for DSA, and newer techniques such as using low tube voltage and rapid acquisition times allow for lower contrast doses. The presence of vascular calcification also limits the evaluation of small distal arteries using CTA, although the development of dual-energy CT techniques has significantly addressed this issue. Benefits of MRA include the avoidance of exposure to ionizing radiation and high diagnostic accuracy, while drawbacks include limited availability and increased cost along with the risk of nephrogenic systemic fibrosis that is associated with gadolinium-based contrast agents, although the latter can be mitigated by using newer non-contrast MR angiography techniques. Future technical advances in CT and MR hardware and software and MR pulse sequences will likely lead to the broader applicability and increased accuracy of noninvasive axial imaging in the evaluation of patients with peripheral artery disease.

Functional assessment of the stenotic carotid artery by CFD-based pressure gradient evaluation

The functional assessment of a hemodynamic significant stenosis base on blood pressure variation has been applied for evaluation of the myocardial ischemic event. This functional assessment shows great potential for improving the accuracy of the classification of the severity of carotid stenosis. To explore the value of grading the stenosis using a pressure gradient (PG)-we had reconstructed patient-specific carotid geometries based on MRI images-computational fluid dynamics were performed to analyze the PG in their stenotic arteries. Doppler ultrasound image data and the corresponding MRI image data of 19 patients with carotid stenosis were collected. Based on these, 31 stenotic carotid arterial geometries were reconstructed. A combinatorial boundary condition method was implemented for steady-state computer fluid dynamics simulations. Anatomic parameters, including tortuosity (T), the angle of bifurcation, and the cross-sectional area of the remaining lumen, were collected to investigate the effect on the pressure distribution. The PG is highly correlated with the severe stenosis (r = 0.902), whereas generally, the T and the angle of the bifurcation negatively correlate to the pressure drop of the internal carotid artery stenosis. The calculation required <10 min/case, which made it prepared for the fast diagnosis of the severe stenosis. According to the results, we had proposed a potential threshold value for distinguishing severe stenosis from mild-moderate stenosis (PG = 0.88). In conclusion, the PG could serve as the additional factor for improving the accuracy of grading the severity of the stenosis.