4D radial contrast-enhanced MR angiography with sliding subtraction

Free-breathing, fat-corrected T1 mapping of the liver with stack-of-stars MRI, and joint estimation of T1, PDFF, R 2 * , and B 1 +

PURPOSE

Quantitative T1 mapping has the potential to replace biopsy for noninvasive diagnosis and quantitative staging of chronic liver disease. Conventional T1 mapping methods are confounded by fat andB 1 + $$ {B}_1^{+} $$ inhomogeneities, resulting in unreliable T1 estimations. Furthermore, these methods trade off spatial resolution and volumetric coverage for shorter acquisitions with only a few images obtained within a breath-hold. This work proposes a novel, volumetric (3D), free-breathing T1 mapping method to account for multiple confounding factors in a single acquisition.

THEORY AND METHODS

Free-breathing, confounder-corrected T1 mapping was achieved through the combination of non-Cartesian imaging, magnetization preparation, chemical shift encoding, and a variable flip angle acquisition. A subspace-constrained, locally low-rank image reconstruction algorithm was employed for image reconstruction. The accuracy of the proposed method was evaluated through numerical simulations and phantom experiments with a T1/proton density fat fraction phantom at 3.0 T. Further, the feasibility of the proposed method was investigated through contrast-enhanced imaging in healthy volunteers, also at 3.0 T.

RESULTS

The method showed excellent agreement with reference measurements in phantoms across a wide range of T1 values (200 to 1000 ms, slope = 0.998 (95% confidence interval (CI) [0.963 to 1.035]), intercept = 27.1 ms (95% CI [0.4 54.6]), r2 = 0.996), and a high level of repeatability. In vivo imaging studies demonstrated moderate agreement (slope = 1.099 (95% CI [1.067 to 1.132]), intercept = -96.3 ms (95% CI [-82.1 to -110.5]), r2 = 0.981) compared to saturation recovery-based T1 maps.

CONCLUSION

The proposed method produces whole-liver, confounder-corrected T1 maps through simultaneous estimation of T1, proton density fat fraction, andB 1 + $$ {B}_1^{+} $$ in a single, free-breathing acquisition and has excellent agreement with reference measurements in phantoms.

Virtual injections using 4D flow MRI with displacement corrections and constrained probabilistic streamlines

PURPOSE

Streamlines from 4D-flow MRI have been used clinically for intracranial blood-flow tracking. However, deterministic and stochastic errors degrade streamline quality. The purpose of this study is to integrate displacement corrections, probabilistic streamlines, and novel fluid constraints to improve selective blood-flow tracking and emulate "virtual bolus injections."

METHODS

Both displacement artifacts (deterministic) and velocity noise (stochastic) inherently occur during phase-contrast MRI acquisitions. Here, two displacement correction methods, single-step and iterative, were tested in silico with simulated displacements and were compared with ground-truth velocity fields. Next, the effects of combining displacement corrections and constrained probabilistic streamlines were performed in 10 healthy volunteers using time-averaged 4D-flow data. Measures of streamline length and depth into vasculature were then compared with streamlines generated with no corrections and displacement correction alone using one-way repeated-measures analysis of variance and Friedman's tests. Finally, virtual injections with improved streamlines were generated for three intracranial pathology cases.

RESULTS

Iterative displacement correction outperformed the single-step method in silico. In volunteers, the combination of displacement corrections and constrained probabilistic streamlines allowed for significant improvements in streamline length and increased the number of streamlines entering the circle of Willis relative to streamlines with no corrections and displacement correction alone. In the pathology cases, virtual injections with improved streamlines were qualitatively similar to dynamic arterial spin labeling images and allowed for forward/reverse selective flow tracking to characterize cerebrovascular malformations.

CONCLUSION

Virtual injections with improved streamlines from 4D-flow MRI allow for flexible, robust, intracranial flow tracking.

Intracranial 3D and 4D MR Angiography Using Arterial Spin Labeling: Technical Considerations

In the 1980’s some of the earliest studies of arterial spin labeling (ASL) MRI have demonstrated its ability to generate MR angiography (MRA) images. Thanks to many technical improvements, ASL has been successfully moving its position from the realm of research into the clinical area, albeit more known as perfusion imaging than as MRA. For MRA imaging, other techniques such as time-of-flight, phase contrast MRA and contrast-enhanced (CE) MRA are more popular choices for clinical applications. In the last decade, however, ASL-MRA has been experiencing a remarkable revival, especially because of its non-invasive nature, i.e. the fact that it does not rely on the use of contrast agent. Very importantly, there are additional benefits of using ASL for MRA. For example, its higher flexibility to achieve both high spatial and temporal resolution than CE dynamic MRA, and the capability of vessel specific visualization, in which the vascular tree arising from a selected artery can be exclusively visualized. In this article, the implementation and recent developments of ASL-based MRA are discussed; not only focusing on the basic sequences based upon pulsed ASL or pseudo-continuous ASL, but also including more recent labeling approaches, such as vessel-selective labeling, velocity-selective ASL, vessel-encoded ASL and time-encoded ASL. Although these ASL techniques have been already utilized in perfusion imaging and their usefulness has been suggested by many studies, some additional considerations should be made when employing them for MRA, since there is something more than the difference of the spatial resolution of the readout sequence. Moreover, extensive discussion is included on what readout sequence to use, especially by highlighting how to achieve high spatial resolution while keeping scan-time reasonable such that the ASL-MRA sequence can easily be included into a clinical examination.

Time-of-Arrival Parametric Maps and Virtual Bolus Images Derived From Contrast-Enhanced Time-Resolved Radial Magnetic Resonance Angiography Improve the Display of Brain Arteriovenous Malformation Vascular Anatomy

OBJECTIVES

Time-of-arrival (TOA) maps can be derived from high-resolution 4-dimensional (4D) contrast-enhanced magnetic resonance angiography (MRA) data sets to provide a quantitative description of contrast material arrival time in each voxel. This information can further be processed to create a compressed time evolution curve that virtually shortens the contrast bolus (virtual bolus [VB]). The purpose of this project was to determine whether TOA-enhanced 4D MRA and/or VB imaging improve the display of contrast kinetics in patients with vascular disease.

METHODS

High-resolution whole-brain contrast-enhanced 4D MRA examinations with 1.2-second temporal reconstruction were acquired by using radial acquisition and highly constrained projection reconstruction (radial 4D contrast-enhanced HYPRFlow, abbreviated as HFMRA in this article) in 10 patients (8 patients with arteriovenous malformations [AVM], 1 patient with an arteriovenous fistula, and 1 patient with a high-grade intracranial stenosis). The TOA for each voxel was defined as the time point when the signal intensity reached 20% of its maximum. In the first method, TOA maps were generated, color-encoded, and then multiplied with the time-resolved contrast-enhanced MRA images at each time frame to form new 4D MRA images (TOA-enhanced HFMRA), which contains the contrast arrival times with defined color encoding. In the second method, each time frame was weighted by a Gaussian distribution in the time domain to form a virtual 4D bolus map. This 4D bolus map was then color-coded and multiplied with the HFMRA images to form a digital subtraction angiography (DSA)-like VB, where at each time frame, only vessels with certain TOA values within the defined bolus length appear. HFMRA, TOA maps, and VB images were scored qualitatively with regard to delineation of arteries, veins, and nidus, as well as artifacts. Furthermore, diagnostic confidence and arteriovenous overlap were evaluated and compared between techniques. A comparison with DSA was performed where DSA served as the reference standard in terms of number of arterial feeders, draining veins, and Spetzler-Martin score of AVMs. In addition, TOA maps were evaluated quantitatively.

RESULTS

Overall, diagnostic confidence score of TOA was significantly higher compared with that of HFMRA (P = 0.03). Virtual bolus showed significantly higher scores for overall diagnostic confidence (P = 0.02) and reduced arteriovenous overlap (0.01) compared with HFMRA. Furthermore, VB-reduced arteriovenous overlap scores were significantly higher compared with TOA (P = 0.04). Agreement regarding AVM draining veins was lower between DSA and HFMRA (κ = 0.3) compared with TOA and VB (κ = 0.56). Agreement regarding Spetzler-Martin score was lower between DSA and HFMRA (κ = 0.56) compared with TOA and VB (κ = 0.74).

CONCLUSIONS

TOA-enhanced HFMRA provides serial images and time of arrival maps in one inclusive display. In this study, TOA mapping combined with Virtual Bolus imaging improved diagnostic confidence in AVM patients and facilitated arteriovenous separation. The VB method further reduced overlap of arterial and venous structures.

Golden-ratio rotated stack-of-stars acquisition for improved volumetric MRI

PURPOSE

To develop and evaluate an improved stack-of-stars radial sampling strategy for reducing streaking artifacts.

METHODS

The conventional stack-of-stars sampling strategy collects the same radial angle for every partition (slice) encoding. In an undersampled acquisition, such an aligned acquisition generates coherent aliasing patterns and introduces strong streaking artifacts. We show that by rotating the radial spokes in a golden-angle manner along the partition-encoding direction, the aliasing pattern is modified, resulting in improved image quality for gridding and more advanced reconstruction methods. Computer simulations were performed and phantom as well as in vivo images for three different applications were acquired.

RESULTS

Simulation, phantom, and in vivo experiments confirmed that the proposed method was able to generate images with less streaking artifact and sharper structures based on undersampled acquisitions in comparison with the conventional aligned approach at the same acceleration factors. By combining parallel imaging and compressed sensing in the reconstruction, streaking artifacts were mostly removed with improved delineation of fine structures using the proposed strategy.

CONCLUSIONS

We present a simple method to reduce streaking artifacts and improve image quality in 3D stack-of-stars acquisitions by re-arranging the radial spoke angles in the 3D partition direction, which can be used for rapid volumetric imaging. Magn Reson Med 78:2290-2298, 2017. © 2017 International Society for Magnetic Resonance in Medicine.

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

Contrast-enhanced magnetic resonance angiography (CE-MRA) was first introduced for clinical studies approximately 20 years ago. Early work provided 3-4 mm spatial resolution with acquisition times in the 30-second range. Since that time there has been continuing effort to provide improved spatial resolution with reduced acquisition time, allowing high resolution 3D time-resolved studies. The purpose of this work is to describe how this has been accomplished. Specific technical enablers have been: improved gradients allowing reduced repetition times, improved k-space sampling and reconstruction methods, parallel acquisition, particularly in two directions, and improved and higher count receiver coil arrays. These have collectively made high-resolution time-resolved studies readily available for many anatomic regions. Depending on the application, ∼1 mm isotropic resolution is now possible with frame times of several seconds. Clinical applications of time-resolved CE-MRA are briefly reviewed.

Fast contrast-enhanced 4D MRA and 4D flow MRI using constrained reconstruction (HYPRFlow): potential applications for brain arteriovenous malformations

BACKGROUND AND PURPOSE

HYPRFlow is a novel imaging strategy that provides fast, high-resolution contrast-enhanced time-resolved images and measurement of the velocity of the entire cerebrovascular system. Our hypothesis was that the images obtained with this strategy are of adequate diagnostic image quality to delineate the major components of AVMs.

MATERIALS AND METHODS

HYPRFlow and 3D TOF scans were obtained in 21 patients with AVMs with correlative DSA examinations in 14 patients. The examinations were scored for image quality and graded by using the Spetzler-Martin criteria. Mean arterial transit time and overlap integrals were calculated from the dynamic image data. Volume flow rates in normal arteries and AVM feeding arteries were measured from the phase contrast data.

RESULTS

HYPRFlow was equivalent to 3D-TOF in delineating normal arterial anatomy, arterial feeders, and nidus size and was concordant with DSA for AVM grading and venous drainage in 13 of the 14 examinations. Mean arterial transit time on the AVM side was 0.49 seconds, and on the normal contralateral side, 2.53 seconds with P < .001. Across all 21 subjects, the mean arterial volume flow rate in the M1 segment ipsilateral to the AVM was 4.07 ± 3.04 mL/s; on the contralateral M1 segment, it was 2.09 ± 0.64 mL/s. The mean volume flow rate in the largest feeding artery to the AVM was 3.86 ± 2.74 mL/s.

CONCLUSIONS

HYPRFlow provides an alternative approach to the MRA evaluation of AVMs, with the advantages of increased coverage, 0.75-second temporal resolution, 0.68-mm isotropic spatial resolution, and quantitative measurement of flow in 6 minutes.

Advances and innovations in brain arteriovenous malformation surgery

Arteriovenous malformations (AVMs) of the brain are very complex and intriguing pathologies. Since their initial description by Luschka and Virchow in the middle of the 19th century, multiple advances and innovations have revolutionized their management and surgical treatment. Here, we review the historical landmarks in the surgical treatment of AVMs and then illustrate the most recent and futuristic technologies aiming to improve outcomes in AVM surgeries. In particular, we examine potential advances in patient selection, imaging, surgical technique, neuroanesthesia, and postoperative neuro-rehabilitation and quantitative assessments. Finally, we illustrate how concurrent advances in radiosurgery and endovascular techniques might present new opportunities to treat AVMs more safely from a surgical perspective.

RAZER: a pulse sequence for whole-brain bolus tracking at high frame rates

PURPOSE

To introduce a pulse sequence that obtains whole-brain perfusion measurements at 1.7 mm isotropic voxel resolution by dynamic susceptibility contrast MRI bolus tracking despite using a temporal resolution of 10.3 s: RAdial kZ-blipped 3D GRE-echo-planar imaging (GRE-EPI) for whole-brain pERfusion (RAZER).

METHODS

In RAZER, in-plane radial and through-plane 3D GRE-EPI Cartesian sampling was used to produce a 3D stack-of-stars k-space. In vivo scans on one healthy volunteer and one patient with Moyamoya disease were performed using RAZER and a typical 2D GRE-EPI pulse sequence as a reference standard. Agreement in perfusion metrics was reported using linear regression analysis and Bland-Altman plots.

RESULTS

Sliding window reconstruction recovered dynamic information lost in the large temporal acquisition window of RAZER. Inline phase correction scans corrected N/2 ghosting artifacts and view-dependent phase variations. Whole-brain images of cerebral blood volume, cerebral blood flow, and mean transit time were calculated with RAZER at 1.7 mm isotropic voxel resolution and good reference standard agreement in both subjects when sliding window reconstruction was used (r(2) > 0.7, mean bias in mean transit time measurements < 0.5 s).

CONCLUSIONS

Despite using a temporal resolution of 10.3 s, in vivo data indicates that RAZER is able to obtain whole-brain perfusion measurements at 1.7 mm isotropic voxel resolution and good reference standard agreement.

Combined renal MRA and perfusion with a single dose of contrast

Both anatomical and functional scans are often performed when diagnosing renovascular diseases, which in many cases require two separate contrast injections. With nephrogenic systemic fibrosis being associated with gadolinium, minimizing contrast injection dosage is desirable. In this study, a technique which performs time-resolved renal magnetic resonance angiography (MRA) and perfusion with a single scan and single dose of contrast has been evaluated in six healthy volunteers. A previously developed three-dimensional MRA technique called Contrast-enhanced Angiography with Multi-Echo and Radial k-space (CAMERA) has been used to acquire images, and perfusion analysis was performed using deconvolution methods. Time-resolved MRA, as well as renal blood flow, renal volume of distribution and mean transit time maps, were acquired.

Magnetization spoiling in radial FLASH contrast-enhanced MR digital subtraction angiography

PURPOSE

To increase the in-plane spatial resolution and image update rates of 2D magnetic resonance (MR) digital subtraction angiography (DSA) pulse sequences to 0.57 × 0.57 mm and 6 frames/sec, respectively, for intracranial vascular disease applications by developing a radial FLASH protocol and to characterize a new artifact, not previously described in the literature, which arises in the presence of such pulse sequences.

MATERIALS AND METHODS

The pulse sequence was optimized and artifacts were characterized using simulation and phantom studies. With Institutional Review Board (IRB) approval, the pulse sequence was used to acquire time-resolved images from healthy human volunteers and patients with x-ray DSA-confirmed intracranial vascular disease.

RESULTS

Artifacts were shown to derive from inhomogeneous spoiling due to the nature of radial waveforms. Gradient spoiling strategies were proposed to eliminate the observed artifact by balancing gradient moments across TR intervals. The resulting radial 2D MR DSA sequence (2.6 sec temporal footprint, 6 frames/sec with sliding window factor 16, 0.57 × 0.57 mm in-plane) demonstrated small vessel detail and corroborated x-ray DSA findings in intracranial vascular imaging studies.

CONCLUSION

Appropriate gradient spoiling in radial 2D MR DSA pulse sequences improves intracranial vascular depiction by eliminating circular banding artifacts. The proposed pulse sequence may provide a useful addition to clinically applied 2D MR DSA scans.

Time-resolved magnetic resonance angiography: evaluation of intrapulmonary circulation parameters in pulmonary arterial hypertension

PURPOSE

To determine whether pulmonary arterial and venous transit times measured by time-resolved magnetic resonance angiography (MRA) can be used as a diagnostic tool for pulmonary arterial hypertension (PAH).

MATERIALS AND METHODS

Twelve patients with confirmed PAH and 10 healthy volunteers were scanned with Institutional Review Board (IRB) approval. Time-resolved MRA and 2D phase contrast flow images of the pulmonary vasculature were acquired. Pulmonary arterial and venous transit times (PaTT and PvTT) and pulmonary valve flow (PVF) were obtained. Pulmonary arterial and pulmonary venous blood volumes (PaBV and PvBV) were calculated as the product of flow and transit time.

RESULTS

Patients with PAH showed statistically significant increases in PaTT and PvTT (P < 0.0004, P < 0.05, respectively) compared to controls. PaBV (165.2 ± 92.0 mL) was significantly higher in PAH subjects than controls (97.0 ± 47.1 mL) (P < 0.04), whereas PvBV (127.9 ± 148.9 mL) of PAH subjects had no significant increase from those of healthy controls (142.5 ± 104.1 mL) (P < 0.38).

CONCLUSION

Pulmonary arterial transit times measured using time-resolved MRA can be used as a simple, noninvasive metric for detection of altered hemodynamics in PAH.

Time resolved contrast enhanced intracranial MRA using a single dose delivered as sequential injections and highly constrained projection reconstruction (HYPR CE)

Time-resolved contrast-enhanced magnetic resonance angiography of the brain is challenging due to the need for rapid imaging and high spatial resolution. Moreover, the significant dispersion of the intravenous contrast bolus as it passes through the heart and lungs increases the overlap between arterial and venous structures, regardless of the acquisition speed and reconstruction window. An innovative technique is presented that divides a single dose contrast into two injections. Initially a small volume of contrast material (2-3 mL) is used to acquiring time-resolved weighting images with a high frame rate (2 frames/s) during the first pass of the contrast agent. The remaining contrast material is used to obtain a high resolution whole brain contrast-enhanced (CE) magnetic resonance angiography (0.57 × 0.57 × 1 mm(3) ) that is used as the spatial constraint for Local Highly Constrained Projection Reconstruction (HYPR LR) reconstruction. After HYPR reconstruction, the final dynamic images (HYPR CE) have both high temporal and spatial resolution. Furthermore, studies of contrast kinetics demonstrate that the shorter bolus length from the reduced contrast volume used for the first injection significantly improves the arterial and venous separation.

Accelerating time-resolved MRA with multiecho acquisition

A new four-dimensional magnetic resonance angiography (MRA) technique called contrast-enhanced angiography with multiecho and radial k-space is introduced, which accelerates the acquisition using multiecho while maintaining a high spatial resolution and increasing the signal-to-noise ratio (SNR). An acceleration factor of approximately 2 is achieved without parallel imaging or undersampling by multiecho (i.e., echo-planar imaging) acquisition. SNR is gained from (1) longer pulse repetition times, which allow more time for T(1) regrowth; (2) decreased specific absorption rate, which allows use of flip angles that maximize contrast at high field; and (3) minimized effects of a transient contrast bolus signal with a shorter temporal footprint. Simulations, phantom studies, and in vivo scans were performed. Contrast-enhanced angiography with multiecho and radial k-space can be combined with parallel imaging techniques such as Generalized Autocalibrating Partially Parallel Acquisitions (GRAPPA) to provide additional 2-fold acceleration in addition to higher SNR to trade off for parallel imaging. This technique can be useful in diagnosing vascular lesions where accurate dynamic information is necessary.

Impact of virtual imaging procedures on treatment strategies in children with hepatic vascular malformations

OBJECTIVES

Virtual imaging procedures have only rarely been analyzed in pediatric populations. We evaluated the role of CT-based virtual surgery planning in pediatric patients experiencing hepatic vascular malformations (HVM).

METHODS

We analyzed 12 children with complex hepatic vascular malformations. All of the children received multislice CT scans with contrast medium followed by virtual 3-dimensional reconstructions using the software assistants MeVis LiverAnalyzer and MeVis LiverExplorer. The impact on treatment planning and the correspondence to clinical findings was assessed.

RESULTS

Highest accuracies of virtual data were found in cases of intrahepatic portocaval shunt and persistent ductus venosus. Here, virtual data revealed congenital vascular conditions, which were not always seen using standard imaging diagnostics. In some patients with portalvenous thrombosis, virtual imaging provided important contributions to determining the feasibility of different shunt procedures. However, in some patients experiencing portalvenous thrombosis or liver diffuse hemangioma, virtual methods were not as accurate as standard diagnostic procedures. Nevertheless, these tools facilitated simultaneous and continuous illustrations of the different vascular systems.

CONCLUSIONS

Virtual imaging and planning procedures had an important impact on treatment strategies and outcomes in children with HVM. Their use as standard diagnostic tools in selected cases of HVM should be considered.

4D radial acquisition contrast-enhanced MR angiography and intracranial arteriovenous malformations: quickly approaching digital subtraction angiography

BACKGROUND AND PURPOSE

The current gold standard for imaging intracranial AVMs involves catheter-based techniques, namely cerebral digital subtraction angiography (DSA). However, DSA presents some procedural risks to the patient. Unfortunately, AVM patients usually undergo multiple DSA exams throughout their diagnostic and therapeutic course, significantly increasing their procedural risk exposure. As such, high-quality noninvasive imaging is desired. We hypothesize that 4D radial acquisition contrast-enhanced MRA approximates the vascular architecture and hemodynamics of AVMs compared to conventional angiography.

METHODS

Thirteen consecutive AVM patients were assessed by 4D radial acquisition contrast-enhanced MRA and DSA. The 4D rCE-MRA images were independently assessed regarding the location, nidal size, Spetzler-Martin grade, and identification of arterial feeders, drainage pattern, and any other vascular anomalies.

RESULTS

4D rCE-MRA correctly depicted the size, venous drainage pattern, and prominent arterial feeders in all cases. Spetzler-Martin grade was correctly determined between reviewers and between the different imaging modalities in all cases except 1. The nidus size was in good correlation between the reviewers, where r=0.99, P<0.000001. There was very good agreement between reviewers regarding the individual scans (kappa=0.63 to 1), whereas the agreement between the DSA and 4D rCE-MRA images was also good (kappa=0.61 to 0.85).

CONCLUSIONS

We have developed a 4D radial acquisition contrast-enhanced MRA sequence capable of imaging intracranial AVMs approximating that of DSA. Image analysis demonstrates equivalency in terms of grading AVMs using the Spetzler-Martin grading scale. This 4D rCE-MRA sequence has the potential to avoid some applications of DSA, thus saving patients from potential procedural risks.

Radial sliding-window magnetic resonance angiography (MRA) with highly-constrained projection reconstruction (HYPR)

Sufficient temporal resolution is required to image the dynamics of blood flow, which may be critical for accurate diagnosis and treatment of various intracranial vascular diseases, such as arteriovenous malformations (AVMs) and aneurysms. Highly-constrained projection reconstruction (HYPR) has recently become a technique of interest for high-speed contrast-enhanced magnetic resonance angiography (CE-MRA). HYPR provides high frame rates by preferential weighting of radial projections while maintaining signal-to-noise ratio (SNR) by using a high SNR composite. An analysis was done to quantify the effects of HYPR on SNR, contrast-to-noise ratio (CNR), and temporal blur compared to the previously developed radial sliding-window technique using standard filtered backprojection or regridding methods. Computer simulations were performed to study the effects of HYPR processing on image error and the temporal information. Additionally, in vivo imaging was done on patients with angiographically confirmed AVMs to measure the effects of alteration of various HYPR parameters on SNR as well as the fidelity of the temporal information. The images were scored by an interventional radiologist in a blinded read and were compared with X-ray digital subtraction angiography (DSA). It was found that with the right choice of parameters, modest improvements in both SNR and dynamic information can be achieved as compared to radial sliding-window MRA.

Advanced noninvasive imaging of spinal vascular malformations

Spinal vascular malformations (SVMs) are an uncommon, heterogeneous group of vascular anomalies that can render devastating neurological consequences if they are not diagnosed and treated in a timely fashion. Imaging SVMs has always presented a formidable challenge because their clinical and imaging presentations resemble those of neoplasms, demyelination diseases, and infection. Advancements in noninvasive imaging modalities (MR and CT angiography) have increased during the last decade and have improved the ability to accurately diagnose spinal vascular anomalies. In addition, intraoperative imaging techniques have been developed that aid in the intraoperative assessment before, during, and after resection of these lesions with minimal and/or optimal use of spinal digital subtraction angiography. In this report, the authors review recent advancements in the imaging of SVMs that will likely lead to more timely diagnoses and treatment while reducing procedural risk exposure to the patients who harbor these uncommon spinal lesions.