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Manini C, Hüllebrand M, Walczak L, Nordmeyer S, Jarmatz L, Kuehne T, Stern H, Meierhofer C, Harloff A, Erley J, Kelle S, Bannas P, Trauzeddel RF, Schulz-Menger J, Hennemuth A. Impact of training data composition on the generalizability of convolutional neural network aortic cross-section segmentation in four-dimensional magnetic resonance flow imaging. J Cardiovasc Magn Reson 2024; 26:101081. [PMID: 39127260 PMCID: PMC11422555 DOI: 10.1016/j.jocmr.2024.101081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 07/08/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Four-dimensional cardiovascular magnetic resonance flow imaging (4D flow CMR) plays an important role in assessing cardiovascular diseases. However, the manual or semi-automatic segmentation of aortic vessel boundaries in 4D flow data introduces variability and limits the reproducibility of aortic hemodynamics visualization and quantitative flow-related parameter computation. This paper explores the potential of deep learning to improve 4D flow CMR segmentation by developing models for automatic segmentation and analyzes the impact of the training data on the generalization of the model across different sites, scanner vendors, sequences, and pathologies. METHODS The study population consists of 260 4D flow CMR datasets, including subjects without known aortic pathology, healthy volunteers, and patients with bicuspid aortic valve (BAV) examined at different hospitals. The dataset was split to train segmentation models on subsets with different representations of characteristics, such as pathology, gender, age, scanner model, vendor, and field strength. An enhanced three-dimensional U-net convolutional neural network (CNN) architecture with residual units was trained for time-resolved two-dimensional aortic cross-sectional segmentation. Model performance was evaluated using Dice score, Hausdorff distance, and average symmetric surface distance on test data, datasets with characteristics not represented in the training set (model-specific), and an overall evaluation set. Standard diagnostic flow parameters were computed and compared with manual segmentation results using Bland-Altman analysis and interclass correlation. RESULTS The representation of technical factors, such as scanner vendor and field strength, in the training dataset had the strongest influence on the overall segmentation performance. Age had a greater impact than gender. Models solely trained on BAV patients' datasets performed well on datasets of healthy subjects but not vice versa. CONCLUSION This study highlights the importance of considering a heterogeneous dataset for the training of widely applicable automatic CNN segmentations in 4D flow CMR, with a particular focus on the inclusion of different pathologies and technical aspects of data acquisition.
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Affiliation(s)
- Chiara Manini
- Deutsches Herzzentrum der Charité (DHZC), Institute of Computer-assisted Cardiovascular Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | - Markus Hüllebrand
- Deutsches Herzzentrum der Charité (DHZC), Institute of Computer-assisted Cardiovascular Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; Fraunhofer MEVIS, Berlin, Germany
| | - Lars Walczak
- Deutsches Herzzentrum der Charité (DHZC), Institute of Computer-assisted Cardiovascular Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; Fraunhofer MEVIS, Berlin, Germany
| | - Sarah Nordmeyer
- Department of Diagnostic and Interventional Radiology, Tübingen University Hospital, Tübingen, Germany
| | - Lina Jarmatz
- Deutsches Herzzentrum der Charité (DHZC), Institute of Computer-assisted Cardiovascular Medicine, Berlin, Germany
| | - Titus Kuehne
- Deutsches Herzzentrum der Charité (DHZC), Institute of Computer-assisted Cardiovascular Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Heiko Stern
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Munich, Germany
| | - Christian Meierhofer
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Munich, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, University Medical Center Freiburg - Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jennifer Erley
- German Center for Cardiovascular Research (DZHK), Berlin, Germany; Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Sebastian Kelle
- German Center for Cardiovascular Research (DZHK), Berlin, Germany; Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Felix Trauzeddel
- German Center for Cardiovascular Research (DZHK), Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC Experimental and Clinical Research Center, Lindenberger Weg 80, 13125 Berlin, Germany; Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a joint cooperation between the Charité - Universitätsmedizin Berlin and the Max-Delbrück-Center for Molecular Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jeanette Schulz-Menger
- German Center for Cardiovascular Research (DZHK), Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC Experimental and Clinical Research Center, Lindenberger Weg 80, 13125 Berlin, Germany; Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a joint cooperation between the Charité - Universitätsmedizin Berlin and the Max-Delbrück-Center for Molecular Medicine, Berlin, Germany; Department of Cardiology and Nephrology, Helios Hospital Berlin-Buch, Berlin, Germany
| | - Anja Hennemuth
- Deutsches Herzzentrum der Charité (DHZC), Institute of Computer-assisted Cardiovascular Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; Fraunhofer MEVIS, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Berlin, Germany; Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Cao J, Yuan C, Zhang Y, Quan Y, Chang P, Yang J, Song Q, Miao Y. Observation of intracranial artery and venous sinus hemodynamics using compressed sensing-accelerated 4D flow MRI: performance at different acceleration factors. Front Neurosci 2024; 18:1438003. [PMID: 39119457 PMCID: PMC11306029 DOI: 10.3389/fnins.2024.1438003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024] Open
Abstract
Objective To investigate the feasibility and performance of 4D flow MRI accelerated by compressed sensing (CS) for the hemodynamic quantification of intracranial artery and venous sinus. Materials and methods Forty healthy volunteers were prospectively recruited, and 20 volunteers underwent 4D flow MRI of cerebral artery, and the remaining volunteers underwent 4D flow MRI of venous sinus. A series of 4D flow MRI was acquired with different acceleration factors (AFs), including sensitivity encoding (SENSE, AF = 4) and CS (AF = CS4, CS6, CS8, and CS10) at a 3.0 T MRI scanner. The hemodynamic parameters, including flow rate, mean velocity, peak velocity, max axial wall shear stress (WSS), average axial WSS, max circumferential WSS, average circumferential WSS, and 3D WSS, were calculated at the internal carotid artery (ICA), transverse sinus (TS), straight sinus (SS), and superior sagittal sinus (SSS). Results Compared to the SENSE4 scan, for the left ICA C2, mean velocity measured by CS8 and CS10 groups, and 3D WSS measured by CS6, CS8, and CS10 groups were underestimated; for the right ICA C2, mean velocity measured by CS10 group, and 3D WSS measured by CS8 and CS10 groups were underestimated; for the right ICA C4, mean velocity measured by CS10 group, and 3D WSS measured by CS8 and CS10 groups were underestimated; and for the right ICA C7, mean velocity and 3D WSS measured by CS8 and CS10 groups, and average axial WSS measured by CS8 group were also underestimated (all p < 0.05). For the left TS, max axial WSS and 3D WSS measured by CS10 group were significantly underestimated (p = 0.032 and 0.003). Similarly, for SS, mean velocity, peak velocity, average axial WSS measured by the CS8 and CS10 groups, max axial WSS measured by CS6, CS8, and CS10 groups, and 3D WSS measured by CS10 group were significantly underestimated compared to the SENSE4 scan (p = 0.000-0.021). The hemodynamic parameters measured by CS4 group had only minimal bias and great limits of agreement compared to conventional 4D flow (SENSE4) in the ICA and every venous sinus (the max/min upper limit to low limit of the 95% limits of agreement = 11.4/0.03 to 0.004/-5.7, 14.4/0.05 to -0.03/-9.0, 12.6/0.04 to -0.03/-9.4, 16.8/0.04 to 0.6/-14.1; the max/min bias = 5.0/-1.2, 3.5/-1.4, 4.5/-1.1, 6.6/-4.0 for CS4, CS6, CS8, and CS10, respectively). Conclusion CS4 strikes a good balance in 4D flow between flow quantifications and scan time, which could be recommended for routine clinical use.
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Affiliation(s)
| | | | | | | | | | | | | | - Yanwei Miao
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Kong Q, Ma X, Li L, Wang C, Du X, Wan Y. Evaluating Total Atherosclerosis Burden of Baroreceptor-Resident Arteries after Ischemic Cerebrovascular Disease for Identifying Patients with Heavy Coronary Atherosclerosis Burden. J Atheroscler Thromb 2024; 31:429-443. [PMID: 37866928 PMCID: PMC10999717 DOI: 10.5551/jat.64457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/20/2023] [Indexed: 10/24/2023] Open
Abstract
AIM The carotid sinuses and aortic arch are baroreceptor-resident arteries (BRAs) and atherosclerosis-susceptible sites of brain-supplying arteries, which would impair baroreflex-mediated blood pressure (BP) regulation and prompt coronary atherosclerosis. We sought to determine the relationship between total atherosclerosis burden (TAB) of BRAs and coronary atherosclerosis burden (AB) in patients with ischemic cerebrovascular disease (ICVD) and explore the potential contribution of BP profiles to this relationship. METHODS In this cross-sectional analysis of patients with ICVD who simultaneously undertook computed tomography angiography and 24-hour ambulatory BP monitoring, TAB of BRAs was scored based on the atherosclerotic vessel circumference ratio of the carotid sinuses and aortic arch, while the ABs of the intracranial, cervical, aortic, and coronary arteries were scored based on stenosis severity and plaque complexity as routine. RESULTS Among the 230 patients analyzed, coronary AB was significantly correlated with TAB of BRAs, independently of, and more tightly than the ABs of the intracranial, cervical, and aortic arteries, and the stenosis- and complexity-based AB of BRA-located arteries (bilateral common and extracranial internal carotid arteries and aortic arch). Both coronary AB and TAB of BRAs were negatively associated with the night-to-day BP dipping ratios, which was quite different from the relationship between intracranial AB and 24-hour BP characteristics. These findings were also true for patients with ICVD without a history of coronary artery disease. CONCLUSION Evaluating TAB of BRAs might provide a new link between atherosclerosis of brain- and heart-supplying arteries, connected partially by BP circadian rhythm. It might facilitate identifying patients with ICVD with heavy coronary AB and comprehensively managing vascular risk.
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Affiliation(s)
- Qi Kong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Disorders, Beijing, China
- Clinical Center for Cardio-cerebrovascular Disease of Capital Medical University, Beijing, China
| | - Luguang Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chen Wang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiangying Du
- National Clinical Research Center for Geriatric Disorders, Beijing, China
- Clinical Center for Cardio-cerebrovascular Disease of Capital Medical University, Beijing, China
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yungao Wan
- Clinical Center for Cardio-cerebrovascular Disease of Capital Medical University, Beijing, China
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Akcelik A, Minakata K, Sunagawa G, Mangukia C, Boova R, Toyoda Y. Surgical management of primary aortic thrombus in thoracic aorta. JTCVS OPEN 2023; 16:84-92. [PMID: 38204638 PMCID: PMC10775053 DOI: 10.1016/j.xjon.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 01/12/2024]
Abstract
Background Primary aortic thrombus (PAT) in the absence of underlying aortic pathology such as atherosclerosis or aneurysm is quite rare and presents with various symptoms related to distal embolization. Treatment options include anticoagulation alone, open surgical thrombectomy, endovascular repair, and a combination of these approaches. The optimal management strategy remains controversial. Methods Between 2016 and 2020, 10 patients (6 females; mean age, 49.1 years) presented to our institution with PAT in the thoracic aorta. All 10 patients were active tobacco users, and 6 patients were found to have an underlying hypercoagulable state. Locations of the PAT included the ascending aorta in 4 patients, the descending thoracic aorta in 3 patients, and the aortic root, aortic arch, and thoracoabdominal aorta in 1 patient each. At presentation, 2 patients had developed myocardial infarction, and 2 others had cerebral infarction. All patients but 1, who was managed medically for PAT, underwent open surgical thrombectomy via either sternotomy or left thoracotomy. Concomitant procedures included coronary artery bypass grafting in 2 patients and pulmonary thromboembolectomy in 1 patient. There were no operative deaths. During a median follow-up of 18 months, 2 patients developed recurrent PAT, owing primarily to poor compliance with anticoagulation. One patient required redo open thrombectomy. Two patients had mesenteric ischemia necessitating small bowel resection. Conclusions Open surgical thrombectomy of the thoracic aorta can be performed with low mortality and morbidity; however, PAT can recur, especially in patients who have difficulty managing anticoagulation.
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Affiliation(s)
- Andrew Akcelik
- Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Kenji Minakata
- Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Gengo Sunagawa
- Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Chirantan Mangukia
- Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Robert Boova
- Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
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Kong Q, Ma X, Li L, Wang C, Du X, Wan Y. Atherosclerosis Burden of Brain- and Heart-Supplying Arteries and the Relationship With Vascular Risk in Patients With Ischemic Stroke. J Am Heart Assoc 2023; 12:e029505. [PMID: 37581397 PMCID: PMC10492925 DOI: 10.1161/jaha.123.029505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/18/2023] [Indexed: 08/16/2023]
Abstract
Background Atherosclerosis of brain- and heart-supplying arteries (BHAs) are risk indicators for patients with ischemic stroke, but the atherosclerosis burden (AB) of intracranial, cervical, aortic, and coronary arteries in each and in total have not been simultaneously evaluated, and the associations with vascular risk remain unknown. Methods and Results With computed tomography angiography, single-territory AB was triple ranked on the basis of the number of arterial segments with a significant atherosclerotic lesion. The total AB (TAB) of BHAs was triple ranked on the basis of the number of arterial territories with a significant atherosclerotic lesion, or according to the sum of 4 single-territory AB rank-scores. After a 12-month follow-up of 395 patients with ischemic stroke, a composite outcome of ischemic stroke, myocardial infarction, and vascular death occurred in 10.9%. The single-territory AB of intracranial, cervical, aortic, and coronary arteries showed distinct strata patterns and different associations with vascular risk. The score-based TAB of BHAs predicted vascular risk (crude hazard ratios [95% CIs]: per level increase, 2.35 [1.54-3.58]; median versus low, 3.37 [1.45-7.82]; high versus low, 6.00 [2.36-15.24]) independently of vascular risk factors and single-territory AB, providing more prognostic information than the TAB of BHAs measured by the number of significantly atherosclerotic territories. Vascular events occurred in 3.0%, 13.6%, and 22.6% of patients in the low (41.8%), median (44.8%), and high (13.4%) strata of the score-based TAB of BHAs, respectively. Conclusions The single-territory AB of intracranial, cervical, aortic, or coronary arteries might be not reliable for vascular risk stratification in patients with ischemic stroke, and evaluating the TAB of BHAs by quantitatively integrating the single-territory AB is advisable.
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Affiliation(s)
- Qi Kong
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xin Ma
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- National Clinical Research Center for Geriatric DisordersBeijingChina
- Clinical Center for Cardio‐Cerebrovascular Disease of Capital Medical UniversityBeijingChina
| | - Luguang Li
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Wang
- Department of Radiology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xiangying Du
- National Clinical Research Center for Geriatric DisordersBeijingChina
- Clinical Center for Cardio‐Cerebrovascular Disease of Capital Medical UniversityBeijingChina
- Department of Radiology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Yungao Wan
- Clinical Center for Cardio‐Cerebrovascular Disease of Capital Medical UniversityBeijingChina
- Department of Cardiology, Xuanwu HospitalCapital Medical UniversityBeijingChina
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Loose S, Solou D, Strecker C, Hennemuth A, Hüllebrand M, Grundmann S, Asmussen A, Treppner M, Urbach H, Harloff A. Characterization of aortic aging using 3D multi-parametric MRI-long-term follow-up in a population study. Sci Rep 2023; 13:6285. [PMID: 37072440 PMCID: PMC10111081 DOI: 10.1038/s41598-023-33219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/10/2023] [Indexed: 05/03/2023] Open
Abstract
We comprehensively studied morphological and functional aortic aging in a population study using modern three-dimensional MR imaging to allow future comparison in patients with diseases of the aortic valve or aorta. We followed 80 of 126 subjects of a population study (20 to 80 years of age at baseline) using the identical methodology 6.0 ± 0.5 years later. All underwent 3 T MRI of the thoracic aorta including 3D T1 weighted MRI (spatial resolution 1 mm3) for measuring aortic diameter and plaque thickness and 4D flow MRI (spatial/temporal resolution = 2 mm3/20 ms) for calculating global and regional aortic pulse wave velocity (PWV) and helicity of aortic blood flow. Mean diameter of the ascending aorta (AAo) decreased and plaque thickness increased significantly in the aortic arch (AA) and descending aorta (DAo) in females. PWV of the thoracic aorta increased (6.4 ± 1.5 to 7.0 ± 1.7 m/s and 6.8 ± 1.5 to 7.3 ± 1.8 m/s in females and males, respectively) over time. Local normalized helicity volumes (LNHV) decreased significantly in the AAo and AA (0.33 to 0.31 and 0.34 to 0.32 in females and 0.34 to 0.32 and 0.32 to 0.28 in males). By contrast, helicity increased significantly in the DAo in both genders (0.28 to 0.29 and 0.29 to 0.30, respectively). 3D MRI was able to characterize changes in aortic diameter, plaque thickness, PWV and helicity during six years in our population. Aortic aging determined by 3D multi-parametric MRI is now available for future comparisons in patients with diseases of the aortic valve or aorta.
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Affiliation(s)
- Sophie Loose
- Department of Neurology and Neurophysiology, University Medical Center Freiburg, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Demetris Solou
- Department of Neurology and Neurophysiology, University Medical Center Freiburg, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Strecker
- Department of Neurology and Neurophysiology, University Medical Center Freiburg, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anja Hennemuth
- Fraunhofer MEVIS, Bremen, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Hüllebrand
- Fraunhofer MEVIS, Bremen, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Grundmann
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Alexander Asmussen
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Martin Treppner
- Institute of Medical Biometry and Statistics, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neuroradiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, University Medical Center Freiburg, University of Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Huellebrand M, Jarmatz L, Manini C, Laube A, Ivantsits M, Schulz-Menger J, Nordmeyer S, Harloff A, Hansmann J, Kelle S, Hennemuth A. Radiomics-based aortic flow profile characterization with 4D phase-contrast MRI. Front Cardiovasc Med 2023; 10:1102502. [PMID: 37077748 PMCID: PMC10106758 DOI: 10.3389/fcvm.2023.1102502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/06/2023] [Indexed: 04/05/2023] Open
Abstract
4D PC MRI of the aorta has become a routinely available examination, and a multitude of single parameters have been suggested for the quantitative assessment of relevant flow features for clinical studies and diagnosis. However, clinically applicable assessment of complex flow patterns is still challenging. We present a concept for applying radiomics for the quantitative characterization of flow patterns in the aorta. To this end, we derive cross-sectional scalar parameter maps related to parameters suggested in literature such as throughflow, flow direction, vorticity, and normalized helicity. Derived radiomics features are selected with regard to their inter-scanner and inter-observer reproducibility, as well as their performance in the differentiation of sex-, age- and disease-related flow properties. The reproducible features were tested on user-selected examples with respect to their suitability for characterizing flow profile types. In future work, such signatures could be applied for quantitative flow assessment in clinical studies or disease phenotyping.
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Affiliation(s)
- Markus Huellebrand
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Digital Medicine MEVIS, Berlin, Germany
- Correspondence: Markus Huellebrand
| | - Lina Jarmatz
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Chiara Manini
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Ann Laube
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Matthias Ivantsits
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Jeanette Schulz-Menger
- Charité Universitätsmedizin Berlin, Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a joint cooperation between the Charité Universitätsmedizin Berlin and the Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Helios Hospital Berlin-Buch, Department of Cardiology and Nephrology, Berlin, Germany
| | - Sarah Nordmeyer
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Andreas Harloff
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Hansmann
- Department of Radiology, Theresienkrankenhaus und St. Hedwig-Klinik, Mannheim, Germany
| | - Sebastian Kelle
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Anja Hennemuth
- Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Digital Medicine MEVIS, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Schafstedde M, Jarmatz L, Brüning J, Hüllebrand M, Nordmeyer S, Harloff A, Hennemuth A. Population-based reference values for 4D flow MRI derived aortic blood flow parameters. Physiol Meas 2023; 44. [PMID: 36735968 DOI: 10.1088/1361-6579/acb8fd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 02/03/2023] [Indexed: 02/05/2023]
Abstract
Objective. This study assesses age-related differences of thoracic aorta blood flow profiles and provides age- and sex-specific reference values using 4D flow cardiovascular magnetic resonance (CMR) data.Approach. 126 volunteers (age 20-80 years, female 51%) underwent 4D flow CMR and 12 perpendicular analysis planes in the thoracic aorta were specified. For these planes the following parameters were evaluated: body surface area-adjusted aortic area (A'), normalized flow displacement (NFD), the degree of wall parallelism (WPD), the minimal relative cross-sectional area through which 80% of the volume flow passes (A80) and the angle between flow direction and centerline (α).Main results. Age-related differences in blood flow parameters were seen in the ascending aorta with higher values for NFD and angle and lower values for WPD and A80 in older subjects. All parameters describing blood flow patterns correlated with the cross-sectional area in the ascending aorta. No relevant sex-differences regarding blood flow profiles were found.Significance. These age- and sex-specific reference values for quantitative parameters describing blood flow within the aorta might help to study the clinical relevance of flow profiles in the future.
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Affiliation(s)
- Marie Schafstedde
- Institute of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Partner Site Berlin, German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Lina Jarmatz
- Institute of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany
| | - Jan Brüning
- Institute of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany.,Partner Site Berlin, German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Markus Hüllebrand
- Institute of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany.,Fraunhofer MEVIS, Bremen, Germany
| | - Sarah Nordmeyer
- Institute of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany
| | - Andreas Harloff
- Department of Neurology, University Medical Center Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Germany
| | - Anja Hennemuth
- Institute of Congenital Heart Disease, German Heart Center Charité, Berlin, Germany.,Partner Site Berlin, German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,Fraunhofer MEVIS, Bremen, Germany
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9
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Retrograde aortic thrombosis with TEVAR for secondary stroke prevention: Case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Wehrum T, Dragonu I, Strecker C, Hennemuth A, Hennig J, Reinhard T, Harloff A. Influence of Pulse Wave Velocity on Atherosclerosis and Blood Flow Reversal in the Aorta: A 4-Dimensional Flow Magnetic Resonance Imaging Study in Acute Stroke Patients and Matched Controls. J Thorac Imaging 2022; 37:42-48. [PMID: 33492047 DOI: 10.1097/rti.0000000000000580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aortic stiffness is associated with a higher incidence of cardiovascular events including stroke. The primary aim of this study was to evaluate whether increased pulse wave velocity (PWV), a marker of stiffness, is an independent predictor of aortic atheroma. The secondary aim was to test whether increased PWV reinforces retrograde blood flow from the descending aorta (DAo), a mechanism of stroke. METHODS We performed a cross-sectional case-control study with prospective data acquisition. In all, 40 stroke and 60 ophthalmic patients matched for age and cardiovascular risk factors were included. Multicontrast magnetic resonance imaging (MRI) protocol of the aorta tailored to allow a detailed plaque analysis using 3-dimensional (D) T1-weighted bright blood, T2-weighted and proton density-weighted black blood, and hemodynamic assessment using 4D flow MRI was applied. Individual PWV was calculated based on 4D flow MRI data using the time-to-foot of the blood flow waveform. The extent of maximum retrograde blood flow from the proximal DAo into the arch was quantified. RESULTS PWV was higher in stroke patients compared with controls (7.62±2.59 vs. 5.96±2.49 m/s; P=0.005) and in patients with plaques (irrespective of thickness) compared with patients without plaques (7.47±2.89 vs. 5.62±1.89 m/s; P=0.002). Increased PWV was an independent predictor of plaque prevalence and contributed significantly to a predictor model explaining 36.5% (Nagelkerke R2) of the variance in plaque presence. Maximum retrograde flow extent from the proximal DAo was not correlated with PWV. CONCLUSIONS Aortic stiffness was higher in stroke patients and associated with a higher prevalence of plaques. Increased PWV was an independent predictor of plaque presence. Accordingly, regional PWV seems to be a valuable biomarker for the assessment and management of aortic atherosclerosis. However, no association was found for increased retrograde flow extent from the DAo.
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Affiliation(s)
| | - Iulius Dragonu
- Departments of Neurology
- Radiology-Medical Physics, Medical Center
| | | | - Anja Hennemuth
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Thomas Reinhard
- Eye Center, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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11
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Hashimoto M, Nakano Y, Tamura Y. Thoracic endovascular aortic repair for recurrent stroke due to atheromatic plaque in the proximal descending aorta: a case report. Surg Case Rep 2021; 7:106. [PMID: 33913037 PMCID: PMC8081776 DOI: 10.1186/s40792-021-01187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/18/2021] [Indexed: 12/03/2022] Open
Abstract
Background Diastolic retrograde flow in the descending aorta (DAo) may occur in the presence of atherosclerosis and may be overlooked as a mechanism of retrograde embolization in patients with stroke. We performed thoracic endovascular aortic repair (TEVAR) in a patient with recurrent cerebral infarctions for treatment of aortic aneurysm with atheromatic plaque, which was considered as the source of embolism. Case presentation A 56-year-old man with a history of idiopathic thrombocytopenia and hypertension was referred to our hospital with paralysis of the right upper and lower limbs. Multiple cerebral infarctions were found and treated; however, 1 month later, another cerebral infarction developed. A small saccular aortic aneurysm with plaque was found beyond the left subclavian artery, and this site was deemed as the source of embolism. We performed TEVAR to prevent further recurrence of cerebral infarctions. No cerebral infarctions were observed 6 months post-operation. Conclusions TEVAR is a useful treatment for not only aortic aneurysm and dissection, but also cerebral infarctions caused by an embolic source proximal to the DAo due to retrograde aortic blood flow.
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Affiliation(s)
- Masafumi Hashimoto
- Division of Cardiovascular Surgery, Chibaken Saiseikai Narashino Hospital, Social Welfare Organization Saiseikai, Imperial Gift Foundation Inc., 1-1-1 Izumi chou Narashino city, Chiba, 275-8580, Japan.
| | - Yoshikazu Nakano
- Division of Neurology Chibaken Saiseikai Narashino Hospital, Social Welfare Organization Saiseikai, Imperial Gift Foundation Inc., Chiba, Japan
| | - Yusaku Tamura
- Division of Cardiovascular Surgery, Chibaken Saiseikai Narashino Hospital, Social Welfare Organization Saiseikai, Imperial Gift Foundation Inc., 1-1-1 Izumi chou Narashino city, Chiba, 275-8580, Japan
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12
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Pathrose A, Ma L, Berhane H, Scott MB, Chow K, Forman C, Jin N, Serhal A, Avery R, Carr J, Markl M. Highly accelerated aortic 4D flow MRI using compressed sensing: Performance at different acceleration factors in patients with aortic disease. Magn Reson Med 2020; 85:2174-2187. [PMID: 33107141 DOI: 10.1002/mrm.28561] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To systematically assess the feasibility and performance of a highly accelerated compressed sensing (CS) 4D flow MRI framework at three different acceleration factors (R) for the quantification of aortic flow dynamics and wall shear stress (WSS) in patients with aortic disease. METHODS Twenty patients with aortic disease (58 ± 15 y old; 19 M) underwent four 4D flow scans: one conventional (GRAPPA, R = 2) and three CS 4D flows with R = 5.7, 7.7, and 10.2. All scans were acquired with otherwise equivalent imaging parameters on a 1.5T scanner. Peak-systolic velocity (Vmax ), peak flow (Qmax ), and net flow (Qnet ) were quantified at the ascending aorta (AAo), arch, and descending aorta (DAo). WSS was calculated at six regions within the AAo and arch. RESULTS Mean scan times for the conventional and CS 4D flows with R = 5.7, 7.7, and 10.2 were 9:58 ± 2:58 min, 3:40 ± 1:19 min, 2:50 ± 0:56 min, and 2:05 ± 0:42 min, respectively. Vmax , Qmax , and Qnet were significantly underestimated by all CS protocols (underestimation ≤ -7%, -9%, and -10% by CS, R = 5.7, 7.7, and 10.2, respectively). WSS measurements showed the highest underestimation by all CS protocols (underestimation ≤ -9%, -12%, and -14% by CS, R = 5.7, 7.7, and 10.2). CONCLUSIONS Highly accelerated aortic CS 4D flow at R = 5.7, 7.7, and 10.2 showed moderate agreement with the conventional 4D flow, despite systematically underestimating various hemodynamic parameters. The shortened scan time may enable the clinical translation of CS 4D flow, although potential hemodynamic underestimation should be considered when interpreting the results.
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Affiliation(s)
- Ashitha Pathrose
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Liliana Ma
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Haben Berhane
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Michael B Scott
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Kelvin Chow
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Cardiovascular MR R&D, Siemens Medical Solutions USA, Inc., Chicago, Illinois, USA
| | | | - Ning Jin
- Cardiovascular MR R&D, Siemens Medical Solutions USA, Inc., Chicago, Illinois, USA
| | - Ali Serhal
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ryan Avery
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - James Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
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13
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Holswilder G, Wermer MJ, Holman ER, Kruyt ND, Kroft LJ, van Walderveen MA. CT Angiography of the Heart and Aorta in TIA and Ischaemic Stroke: Cardioembolic Risk Sources and Clinical Implications. J Stroke Cerebrovasc Dis 2020; 29:105326. [PMID: 33010723 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Cardiac emboli are important causes of (recurrent) ischaemic stroke. Aorta atherosclerosis might also be associated with an increased risk of stroke recurrence. This study aimed to evaluate the yield and clinical implications of CT-angiography (CTA) of the heart and aorta in the diagnostic workup of transient ischaemic attack (TIA) or ischaemic stroke. METHODS CTA of the heart and aortic arch was performed in TIA/ischaemic stroke patients, in addition to routine diagnostic workup. Occurrence of cardioembolic (CE) risk sources and complex aortic plaques were assessed. Implications of cardiac CTA for therapeutic management were evaluated RESULTS: Sixty-seven patients were included (TIA n = 33, ischaemic stroke n = 34) with a mean age of 68 years (range 51-89) and median NIHSS of 0 (interquartile range 0-2). CE risk sources were detected in 29 (43%) patients. An intracardiac thrombus was present in 2 patients (3%; TIA 0%; ischaemic stroke 6%). Medium/low-risk CE sources included mitral annular calcification (9%), aortic valve calcification (18%) and patent foramen ovale (18%). Complex aortic plaque was identified in 16 patients (24%). In two patients with an intracardiac thrombus, therapeutic management changed from antiplatelet to oral anticoagulation. CONCLUSIONS CTA of the heart and aorta has a high yield for detection of embolic risk sources in TIA/ischaemic stroke, with clinical consequences for 6% of ischaemic stroke patients. Implementation of CTA of the heart and aorta in the acute stroke setting seems valuable, but cost-effectiveness of this approach remains to be determined.
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Affiliation(s)
- Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Eduard R Holman
- Department of Cardiology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Lucia Jm Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Marianne Aa van Walderveen
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
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14
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Soulat G, Jarvis K, Pathrose A, Vali A, Scott M, Syed AA, Kinno M, Prabhakaran S, Collins JD, Markl M. Renin Angiotensin System Inhibitors Reduce Aortic Stiffness and Flow Reversal After a Cryptogenic Stroke. J Magn Reson Imaging 2020; 53:213-221. [PMID: 32770637 DOI: 10.1002/jmri.27279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Blood flow reversal is a possible mechanism for retrograde embolism in the setting of high-risk atherosclerotic plaques in the descending aorta (DAo). Evidence suggests that pulse wave velocity (PWV) is a determinant of blood flow reversal and can be reduced by the destiffening effect of renin-angiotensin system inhibitors (RASI). PURPOSE To evaluate the impact of antihypertensive therapy on in vivo changes in PWV and flow reversal in patients with cryptogenic stroke. STUDY TYPE Prospective. POPULATION Sixteen patients (69 ± 9 years; 10 males) included after cryptogenic stroke. FIELD STRENGTH/SEQUENCE 3T. 4D flow sequence (temporal resolution = 19.6 msec) ASSESSMENT: Patients underwent aortic MRI at baseline and at 6-month follow-up. Patients received standard-of-care antihypertensive therapy that were classified as RASI vs. non-RASI medications (ie, destiffening vs. nondestiffening).We compared aortic PWV, flow reversal fraction (FRF), aortic measurements, cardiac function, and other aortic and cardiac measurements in the antihypertensive therapy groups. STATISTICAL TESTS Two-tailed paired or unpaired Student's t-tests (normal distributions) or Wilcoxon tests (nonnormal distribution). Univariate correlations using Pearson correlation coefficients. RESULTS There was a significant decrease in PWV in the RASI (n = 10) group (9.4 ± 1.6 m/s vs. 8.3 ± 1.9 m/s; P < 0.05), as well as FRF (18.6% ± 4.1% vs. 16.3% ± 4.0%; P < 0.05) between baseline and the 6-month MRI studies. There were no changes in PWV or FRF in the non-RASI (n = 6) group (P = 0.146 and P = 0.32). A decrease in FRF was significantly correlated with a decrease in PWV (r = 0.53; P < 0.05). DATA CONCLUSION The findings of our study suggest that RASI therapy after cryptogenic stroke resulted in a decrease of blood flow reversal and aortic stiffness. EVIDENCE LEVEL 1 TECHNICAL EFFICACY STAGE: 4.
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Affiliation(s)
- Gilles Soulat
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kelly Jarvis
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ashitha Pathrose
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alireza Vali
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael Scott
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Amer A Syed
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Menhel Kinno
- Loyola's Center for Heart & Vascular Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Neurology, The University of Chicago Biological Sciences, Chicago, Illinois, USA
| | | | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
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15
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Dabas A, Mohimen A, Goel J, Anadure R. Defining the factors leading to stroke due to retrograde embolism in arterial thoracic outlet syndrome by literature search and report of two cases. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_38_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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