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Guo Y, Canton G, Geleri DB, Balu N, Sun J, Kharaji M, Zanaty N, Wang X, Zhang K, Tirschwell D, Hatsukami TS, Yuan C, Mossa-Basha M. Plaque Evolution and Vessel Wall Remodeling of Intracranial Arteries: A Prospective, Longitudinal Vessel Wall MRI Study. J Magn Reson Imaging 2024; 60:889-899. [PMID: 38131254 PMCID: PMC11192854 DOI: 10.1002/jmri.29185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Progression of intracranial atherosclerotic disease (ICAD) is associated with ischemic stroke events and can be quantified with three-dimensional (3D) intracranial vessel wall (IVW) MRI. However, longitudinal 3D IVW studies are limited and ICAD evolution remains relatively unknown. PURPOSE To evaluate ICAD changes longitudinally and to characterize the imaging patterns of atherosclerotic plaque evolution. STUDY TYPE Prospective. POPULATION 37 patients (69 ± 12 years old, 12 females) with angiography confirmed ICAD. FIELD STRENGTH/SEQUENCE 3.0T/3D time-of-flight gradient echo sequence and T1- and proton density-weighted fast spin echo sequences. ASSESSMENT Each patient underwent baseline and 1-year follow-up IVW. Then, IVW data from both time points were jointly preprocessed using a multitime point, multicontrast, and multiplanar viewing workflow (known as MOCHA). Lumen and outer wall of plaques were traced and measured, and plaques were then categorized into progression, stable, and regression groups based on changes in plaque wall thickness. Patient demographic and clinical data were collected. Culprit plaques were identified based on cerebral ischemic infarcts. STATISTICAL TESTS Generalized estimating equations-based linear and logistic regressions were used to assess associations between vascular risk factors, medications, luminal stenosis, IVW plaque imaging features, and longitudinal changes. A two-sided P-value<0.05 was considered statistically significant. RESULTS Diabetes was significantly associated with ICAD progression, resulting in 6.6% decrease in lumen area and 6.7% increase in wall thickness at 1-year follow-up. After accounting for arterial segments, baseline contrast enhancement predicted plaque progression (odds ratio = 3.61). Culprit plaques experienced an average luminal expansion of 10.9% after 1 year. 74% of the plaques remained stable during follow-up. The regression group (18 plaques) showed significant increase in minimum lumen area (from 7.4 to 8.3 mm2), while the progression group (13 plaques) showed significant decrease in minimum lumen area (from 5.4 to 4.3 mm2). DATA CONCLUSION Longitudinal 3D IVW showed ICAD remodeling on the lumen side. Culprit plaques demonstrated longitudinal luminal expansion compared with their non-culprit counterparts. Baseline plaque contrast enhancement and diabetes mellitus were found to be significantly associated with ICAD changes. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Yin Guo
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Gador Canton
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Duygu Baylam Geleri
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Niranjan Balu
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jie Sun
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Mona Kharaji
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Nadin Zanaty
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Radiology, Zagazig University, Egypt
| | - Xin Wang
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, USA
| | - Kaiyu Zhang
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - David Tirschwell
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Thomas S. Hatsukami
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Chun Yuan
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Radiology and Imaging Science, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
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2
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Zhai S, Wang X. Advanced MR techniques for the vessel wall: towards a better assessment of intracranial aneurysm instability. Eur Radiol 2024; 34:5201-5203. [PMID: 38240807 PMCID: PMC11254957 DOI: 10.1007/s00330-024-10583-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/12/2023] [Accepted: 11/24/2023] [Indexed: 07/18/2024]
Affiliation(s)
- Shuang Zhai
- Department of Outpatient, General Hospital of Northern Theatre Command, No.83 Wenhua Road, Shenhe District, Shenyang, 110016, China
| | - Xinrui Wang
- Department of Radiology, General Hospital of Northern Theatre Command, No.83, Wenhua Road, Shenhe District, Shenyang, 110016, China.
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3
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Veeturi SS, Hall S, Fujimura S, Mossa-Basha M, Sagues E, Samaniego EA, Tutino VM. Imaging of Intracranial Aneurysms: A Review of Standard and Advanced Imaging Techniques. Transl Stroke Res 2024:10.1007/s12975-024-01261-w. [PMID: 38856829 DOI: 10.1007/s12975-024-01261-w] [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: 04/16/2024] [Revised: 04/16/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024]
Abstract
The treatment of intracranial aneurysms is dictated by its risk of rupture in the future. Several clinical and radiological risk factors for aneurysm rupture have been described and incorporated into prediction models. Despite the recent technological advancements in aneurysm imaging, linear length and visible irregularity with a bleb are the only radiological measure used in clinical prediction models. The purpose of this article is to summarize both the standard imaging techniques, including their limitations, and the advanced techniques being used experimentally to image aneurysms. It is expected that as our understanding of advanced techniques improves, and their ability to predict clinical events is demonstrated, they become an increasingly routine part of aneurysm assessment. It is important that neurovascular specialists understand the spectrum of imaging techniques available.
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Affiliation(s)
- Sricharan S Veeturi
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14214, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Samuel Hall
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Soichiro Fujimura
- Department of Mechanical Engineering, Tokyo University of Science, Tokyo, Japan
- Division of Innovation for Medical Information Technology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Elena Sagues
- Department of Neurology, University of Iowa, Iowa City, IA, USA
| | | | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14214, USA.
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY, USA.
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4
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Wagner F, Almeida GG, Willems EP, Weber J, Geiss J, Hundsberger T, Mordasini P, Wildermuth S, Leschka S, Waelti S, Dietrich TJ, Fischer TS. Temporal evolution of primary angiitis of the central nervous system (PACNS) on MRI following immunosuppressant treatment. Insights Imaging 2024; 15:140. [PMID: 38853223 PMCID: PMC11162979 DOI: 10.1186/s13244-024-01710-y] [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: 01/29/2024] [Accepted: 04/26/2024] [Indexed: 06/11/2024] Open
Abstract
PURPOSE To systematically analyse the time course of vessel wall enhancement and associated stenosis in patients with primary angiitis of the central nervous system (PACNS) following immunosuppressive therapy. MATERIAL AND METHODS Two neuroradiologists retrospectively analysed MRIs of patients with PACNS seen at the Bern University Hospital and the St. Gallen Cantonal Hospital between 2015 and 2020. MRIs were examined for the presence of vessel wall enhancement, length of vessel wall enhancement (mm), circumferential extent of enhancement (degree) and degree of stenosis (%). Descriptive statistics and measurements of interobserver reliability were obtained. To investigate the temporal profiles of the variables following the commencement of immunosuppressant treatment, four series of Bayesian generalised multi-level models were generated. RESULTS A total of 23 patients with 43 affected vessels identified from 209 MRI exams were evaluated (mean follow-up: 715 days, standard deviation ± 487 days), leading to a complete dataset of 402 entries. Vessel wall enhancement and circumferential extent of enhancement decreased for approximately 1 year after the initiation of immunosuppressant therapy. Changes were more pronounced in younger patients. Disappearance of vessel wall enhancement (in at least one vessel) was seen in about half of patients after a median of 172 days interquartile range 113-244, minimum 54 days, maximum 627 days. CONCLUSIONS This study evaluated the typical time course of vessel wall enhancement in patients with PACNS. Our results could be a useful reference for radiologists and clinicians interpreting follow-up imaging in patients with PACNS. CRITICAL RELEVANCE STATEMENT Routine clinical exams can be interpreted with more confidence when radiologists are aware of the typical temporal evolution of vessel wall enhancement in patients with primary angiitis of the central nervous system after initiation of immunosuppressive therapy. KEY POINTS Few data exist for vessel wall imaging of primary angiitis of the central nervous system. Following immunosuppressant therapy, vessel wall enhancement decreases for approximately one year. These results may serve as a reference for radiologists performing follow-up imaging.
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Affiliation(s)
- Franca Wagner
- Bern University Hospital, University of Bern, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Gonçalo G Almeida
- University of Bern, Bern, Switzerland
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Erik P Willems
- Clinical Trials Unit, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Johannes Weber
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Johannes Geiss
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Thomas Hundsberger
- Department of Neurology and Oncology, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Pasquale Mordasini
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Simon Wildermuth
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Sebastian Leschka
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Stephan Waelti
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Tobias Johannes Dietrich
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland
| | - Tim Steffen Fischer
- Division of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, Medical School St. Gallen, St. Gallen, Switzerland.
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Song JW, Frame MY, Sellers RT, Klahn C, Fitzgerald K, Pomponio B, Schnall MD, Kasner SE, Loevner LA. Implementation of a Clinical Vessel Wall MR Imaging Program at an Academic Medical Center. AJNR Am J Neuroradiol 2024; 45:554-561. [PMID: 38514091 PMCID: PMC11288535 DOI: 10.3174/ajnr.a8191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/12/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND AND PURPOSE The slow adoption of new advanced imaging techniques into clinical practice has been a long-standing challenge. Principles of implementation science and the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework were used to build a clinical vessel wall imaging program at an academic medical center. MATERIALS AND METHODS Six phases for implementing a clinical vessel wall MR imaging program were contextualized to the RE-AIM framework. Surveys were designed and distributed to MR imaging technologists and clinicians. Effectiveness was measured by surveying the perceived diagnostic value of vessel wall imaging among MR imaging technologists and clinicians, trends in case volumes in the clinical vessel wall imaging examination, and the number of coauthored vessel wall imaging-focused publications and abstracts. Adoption and implementation were measured by surveying stakeholders about workflow. Maintenance was measured by surveying MR imaging technologists on the value of teaching materials and online tip sheets. The Integration dimension was measured by the number of submitted research grants incorporating vessel wall imaging protocols. Feedback during the implementation phases and solicited through the survey is qualitatively summarized. Quantitative results are reported using descriptive statistics. RESULTS Six phases of the RE-AIM framework focused on the following: 1) determining patient and disease representation, 2) matching resource availability and patient access, 3) establishing vessel MR wall imaging (VWI) expertise, 4) forming interdisciplinary teams, 5) iteratively refining workflow, and 6) integrating for maintenance and scale. Survey response rates were 48.3% (MR imaging technologists) and 71.4% (clinicians). Survey results showed that 90% of the MR imaging technologists agreed that they understood how vessel wall MR imaging adds diagnostic value to patient care. Most clinicians (91.3%) reported that vessel wall MR imaging results changed their diagnostic confidence or patient management. Case volumes of clinical vessel wall MR imaging performed from 2019 to 2022 rose from 22 to 205 examinations. Workflow challenges reported by MR imaging technologists included protocoling examinations and scan length. Feedback from ordering clinicians included the need for education about VWI indications, limitations, and availability. During the 3-year implementation period of the program, the interdisciplinary teams coauthored 27 publications and abstracts and submitted 13 research grants. CONCLUSIONS Implementation of a clinical imaging program can be successful using the principles of the RE-AIM framework. Through iterative processes and the support of interdisciplinary teams, a vessel wall MR imaging program can be integrated through a dedicated clinical pipeline, add diagnostic value, support educational and research missions at an academic medical center, and become a center for excellence.
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Affiliation(s)
- Jae W Song
- From the Department of Radiology (J.W.S., M.Y.F., R.T.S., B.P., M.D.S., L.A.L.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Megan Y Frame
- From the Department of Radiology (J.W.S., M.Y.F., R.T.S., B.P., M.D.S., L.A.L.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rob T Sellers
- From the Department of Radiology (J.W.S., M.Y.F., R.T.S., B.P., M.D.S., L.A.L.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Connie Klahn
- Department of Radiology, (C.K.), Penn Presbyterian Hospital, Philadelphia, Pennsylvania
| | - Kevin Fitzgerald
- Department of Radiology (K.F.), Penn Radnor, Philadelphia, Pennsylvania
| | - Bridget Pomponio
- From the Department of Radiology (J.W.S., M.Y.F., R.T.S., B.P., M.D.S., L.A.L.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mitchell D Schnall
- From the Department of Radiology (J.W.S., M.Y.F., R.T.S., B.P., M.D.S., L.A.L.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott E Kasner
- Department of Neurology (S.E.K.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurie A Loevner
- From the Department of Radiology (J.W.S., M.Y.F., R.T.S., B.P., M.D.S., L.A.L.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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6
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Rhee RL, Rebello R, Tamhankar MA, Banerjee S, Liu F, Cao Q, Kurtz R, Baker JF, Fan Z, Bhatt V, Amudala N, Chou S, Liang R, Sanchez M, Burke M, Desiderio L, Loevner LA, Morris JS, Merkel PA, Song JW. Combined Orbital and Cranial Vessel Wall Magnetic Resonance Imaging for the Assessment of Disease Activity in Giant Cell Arteritis. ACR Open Rheumatol 2024; 6:189-200. [PMID: 38265177 PMCID: PMC11016572 DOI: 10.1002/acr2.11649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/05/2023] [Accepted: 11/20/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE Acute visual impairment is the most feared complication of giant cell arteritis (GCA) but is challenging to predict. Magnetic resonance imaging (MRI) evaluates orbital pathology not visualized by an ophthalmologic examination. This study combined orbital and cranial vessel wall MRI to assess both orbital and cranial disease activity in patients with GCA, including patients without visual symptoms. METHODS Patients with suspected active GCA who underwent orbital and cranial vessel wall MRI were included. In 14 patients, repeat imaging over 12 months assessed sensitivity to change. Clinical diagnosis of ocular or nonocular GCA was determined by a rheumatologist and/or ophthalmologist. A radiologist masked to clinical data scored MRI enhancement of structures. RESULTS Sixty-four patients with suspected GCA were included: 25 (39%) received a clinical diagnosis of GCA, including 12 (19%) with ocular GCA. Orbital MRI enhancement was observed in 83% of patients with ocular GCA, 38% of patients with nonocular GCA, and 5% of patients with non-GCA. MRI had strong diagnostic performance for both any GCA and ocular GCA. Combining MRI with a funduscopic examination reached 100% sensitivity for ocular GCA. MRI enhancement significantly decreased after treatment (P < 0.01). CONCLUSION In GCA, MRI is a sensitive tool that comprehensively evaluates multiple cranial structures, including the orbits, which are the most concerning site of pathology. Orbital enhancement in patients without visual symptoms suggests that MRI may detect at-risk subclinical ocular disease in GCA. MRI scores decreased following treatment, suggesting scores reflect inflammation. Future studies are needed to determine if MRI can identify patients at low risk for blindness who may receive less glucocorticoid therapy.
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Affiliation(s)
| | - Ryan Rebello
- St Joseph's Hospital and McMaster UniversityHamiltonOntarioCanada
| | | | | | - Fang Liu
- University of PennsylvaniaPhiladelphia
| | - Quy Cao
- University of PennsylvaniaPhiladelphia
| | | | | | | | | | | | | | - Rui Liang
- University of PennsylvaniaPhiladelphia
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Zamora CA, Mossa-Basha M, Castillo M. Usefulness of Different Imaging Methods in the Diagnosis of Cerebral Vasculopathy. Neuroimaging Clin N Am 2024; 34:39-52. [PMID: 37951704 DOI: 10.1016/j.nic.2023.07.001] [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] [Indexed: 11/14/2023]
Abstract
Assessment of cerebral vasculopathies is challenging and requires understanding the utility of different imaging methods. Various techniques are available to image the vessel lumen, each with unique advantages and disadvantages. Bolus-based CT and MR angiography requires careful timing of a contrast bolus to provide optimal luminal enhancement. Non-contrast MRA techniques do not require a contrast agent and can provide images with little venous contamination. Digital subtraction angiography remains the gold standard but is invasive, while VW-MRI provides a non-invasive way of assessing vessel wall pathology. Conventional brain MRI has high sensitivity in the diagnosis of vasculitis but findings are nonspecific.
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Affiliation(s)
- Carlos A Zamora
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, CB 7510, Old Infirmary Building, 101 Manning Drive, Chapel Hill, NC 27599-7510, USA.
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Mauricio Castillo
- Division of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, CB 7510, Old Infirmary Building, 101 Manning Drive, Chapel Hill, NC 27599-7510, USA
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8
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Romero-Sanchez G, Dabiri M, Mossa-Basha M. Primary Large Vessel Vasculitis: Takayasu Arteritis and Giant Cell Arteritis. Neuroimaging Clin N Am 2024; 34:53-65. [PMID: 37951705 DOI: 10.1016/j.nic.2023.07.002] [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] [Indexed: 11/14/2023]
Abstract
Takayasu arteritis (TA) and Giant cell arteritis (GCA) are large vessel vasculitides, with TA targeting the aorta and its branches, and GCA targeting both large and medium-sized arteries. Early diagnosis of TA and GCA are of great importance, since delayed, inappropriate or no treatment can result in severe and permanent complications. Imaging plays a central role in establishing diagnosis, targeting lesions for confirmational diagnostic biopsy, specifically for GCA, and longitudinal disease evolution. In this article, we discuss imaging diagnosis of large artery vasculitis and the value of different imaging modalities.
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Affiliation(s)
- Griselda Romero-Sanchez
- Department of Radiology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Textitlan 21 Casa 11, Santa Ursula Xitla, Tlalpan, Mexico City 14420, Mexico
| | - Mona Dabiri
- Department of Radiology, Children's Medical Center, Tehran University of Medical Sciences, Abi Avenue, Dolat St, Tehran 11369, Iran
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
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Tóth A. Wall enhancement in stable aneurysms needs to be understood first to be able to identify instable and culprit aneurysms. Eur Radiol 2023; 33:4915-4917. [PMID: 37212849 DOI: 10.1007/s00330-023-09741-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 05/23/2023]
Affiliation(s)
- Arnold Tóth
- Department of Medical Imaging, University of Pécs Medical School, Pécs, Hungary.
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10
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Abstract
Cryptogenic strokes are symptomatic cerebral ischemic infarcts without a clear etiology identified following standard diagnostic evaluation and currently account for 10% to 40% of stroke cases. Continued research is needed to identify and bridge gaps in knowledge of this stroke grouping. Vessel wall imaging has increasingly shown its utility in the diagnosis and characterization of various vasculopathies. Initial promising evidence suggests rational use of vessel wall imaging in stroke workup may unravel pathologies that otherwise would have been occult and further improve our understanding of underlying disease processes that can translate into improved patient outcomes and secondary stroke prevention.
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Affiliation(s)
- Bhagya Sannananja
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road Northeast Suite BG20, Atlanta, GA 30322, USA
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
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Nehme A, Lanthier S, Boulanger M, Aouba A, Cacoub P, Jayne D, Makhzoum JP, Pagnoux C, Rhéaume M, Terrier B, Touzé E, de Boysson H. Diagnosis and management of adult primary angiitis of the central nervous system: an international survey on current practices. J Neurol 2023; 270:1989-1998. [PMID: 36538155 DOI: 10.1007/s00415-022-11528-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Primary angiitis of the central nervous system (PACNS) is a rare disease, for which no validated guidelines exist. We report the findings of a survey on the clinical practice of physicians who manage adults with PACNS. METHODS An online survey was distributed through neurology, internal medicine, and rheumatology societies in Canada and Europe. Participants who were directly involved as treating physicians for at least two adult patients with PACNS were eligible for the survey. RESULTS Ninety-six physicians completed the survey. Most participants were neurologists (n = 38, 40%), internists (n = 34, 35%) or rheumatologists (n = 22, 23%). Participants obtained a CNS biopsy in a median of 25% (IQR: 5-50%) of suspected PACNS cases. When determining the degree to which eight scenarios justified a CNS biopsy, participants achieved fair inter-rater agreement (Gwet's AC2 0.30, 95% CI 0.23-0.41). For induction therapy, 81 (84%) participants reported using glucocorticoids and cyclophosphamide in > 50% of patients. After obtaining remission, 85 (89%) participants systematically introduced or maintained immunosuppressive therapy. Glucocorticoids were prescribed for a median of 12 months. Maintenance therapy with another immunosuppressant was continued for a median of 24 months. In patients who achieved remission, we explored how eight scenarios with different imaging and CSF results supported an increase in treatment. Inter-rater agreement was substantial if the patient was symptomatic (0.66, 95% CI 0.58-0.80) and moderate (0.50, 95% CI 0.45-0.60) if asymptomatic. CONCLUSION This survey illustrates current real-world management of PACNS and emphasizes several areas for which physicians still lack study-based evidence and/or clinical practice guidelines.
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Affiliation(s)
- Ahmad Nehme
- Caen Normandie University, Caen, France.
- Department of Neurology, Centre Hospitalier Universitaire de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France.
- INSERM UMR-S U1237 PhIND/BB@C, Caen, France.
| | - Sylvain Lanthier
- Department of Neurology, Hôpital du Sacré-cœur de Montréal, Université de Montréal, Montréal, Canada
| | - Marion Boulanger
- Caen Normandie University, Caen, France
- Department of Neurology, Centre Hospitalier Universitaire de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France
- INSERM UMR-S U1237 PhIND/BB@C, Caen, France
| | - Achille Aouba
- Caen Normandie University, Caen, France
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, UMR 6211, Paris, France
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), 75005, Paris, France
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jean-Paul Makhzoum
- Department of Internal Medicine, Hôpital du Sacré-cœur de Montréal, Université de Montréal, Montréal, Canada
| | - Christian Pagnoux
- Division of Rheumatology, Vasculitis Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Maxime Rhéaume
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris, Paris, France
| | - Emmanuel Touzé
- Caen Normandie University, Caen, France
- Department of Neurology, Centre Hospitalier Universitaire de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France
- INSERM UMR-S U1237 PhIND/BB@C, Caen, France
| | - Hubert de Boysson
- Caen Normandie University, Caen, France
- Department of Internal Medicine, Caen University Hospital, Caen, France
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12
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Diab R, Chang D, Zhu C, Levitt MR, Aksakal M, Zhao HL, Huynh TJ, Romero-Sanchez G, Mossa-Basha M. Advanced cross-sectional imaging of cerebral aneurysms. Br J Radiol 2023; 96:20220686. [PMID: 36400095 PMCID: PMC10997029 DOI: 10.1259/bjr.20220686] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 11/21/2022] Open
Abstract
While the rupture rate of cerebral aneurysms is only 1% per year, ruptured aneurysms are associated with significant morbidity and mortality, while aneurysm treatments have their own associated risk of morbidity and mortality. Conventional markers for aneurysm rupture include patient-specific and aneurysm-specific characteristics, with the development of scoring systems to better assess rupture risk. These scores, however, rely heavily on aneurysm size, and their accuracy in assessing risk in smaller aneurysms is limited. While the individual risk of rupture of small aneurysms is low, due to their sheer number, the largest proportion of ruptured aneurysms are small aneurysms. Conventional imaging techniques are valuable in characterizing aneurysm morphology; however, advanced imaging techniques assessing the presence of inflammatory changes within the aneurysm wall, hemodynamic characteristics of blood flow within aneurysm sacs, and imaging visualization of irregular aneurysm wall motion have been used to further determine aneurysm instability that otherwise cannot be characterized by conventional imaging techniques. The current manuscript reviews conventional imaging techniques and their value and limitations in cerebral aneurysm characterization, and evaluates the applications, value and limitations of advanced aneurysm imaging and post-processing techniques including intracranial vessel wall MRA, 4D-flow, 4D-CTA, and computational fluid dynamic simulations.
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Affiliation(s)
- Rawan Diab
- American University of Beirut School of
Medicine, Beirut, Lebanon
| | - Dandan Chang
- Department of Radiology, University of
Washington, Seattle, United States
| | - Chengcheng Zhu
- Department of Radiology, University of
Washington, Seattle, United States
| | | | - Mehmet Aksakal
- Department of Radiology, University of
Washington, Seattle, United States
| | - Hui-Lin Zhao
- Deparment of Radiology, Renji Hospital,
Shanghai, China
| | - Thien J. Huynh
- Department of Radiology, Mayo
Clinic-Jacksonville, Jacksonville, United States
| | - Griselda Romero-Sanchez
- Department of Radiology, Instituto Nacional de Ciencias
Medicas y Nutricion Salvador Zubiran, Mexico City,
Mexico
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13
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Mossa-Basha M, Yuan C, Wasserman BA, Mikulis DJ, Hatsukami TS, Balu N, Gupta A, Zhu C, Saba L, Li D, DeMarco JK, Lehman VT, Qiao Y, Jager HR, Wintermark M, Brinjikji W, Hess CP, Saloner DA. Survey of the American Society of Neuroradiology Membership on the Use and Value of Extracranial Carotid Vessel Wall MRI. AJNR Am J Neuroradiol 2022; 43:1756-1761. [PMID: 36423951 DOI: 10.3174/ajnr.a7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Extracranial vessel wall MRI (EC-VWI) contributes to vasculopathy characterization. This survey study investigated EC-VWI adoption by American Society of Neuroradiology (ASNR) members and indications and barriers to implementation. MATERIALS AND METHODS The ASNR Vessel Wall Imaging Study Group survey on EC-VWI use, frequency, applications, MR imaging systems and field strength used, protocol development approaches, vendor engagement, reasons for not using EC-VWI, ordering provider interest, and impact on clinical care was distributed to the ASNR membership between April 2, 2019, to August 30, 2019. RESULTS There were 532 responses; 79 were excluded due to minimal, incomplete response and 42 due to redundant institutional responses, leaving 411 responses. Twenty-six percent indicated that their institution performed EC-VWI, with 66.3% performing it ≤1-2 times per month, most frequently on 3T MR imaging, with most using combined 3D and 2D protocols. Protocols most commonly included pre- and postcontrast T1-weighted imaging, TOF-MRA, and contrast-enhanced MRA. Inflammatory vasculopathy (63.3%), plaque vulnerability assessments (61.1%), intraplaque hemorrhage (61.1%), and dissection-detection/characterization (51.1%) were the most frequent applications. For those not performing EC-VWI, the reasons were a lack of ordering provider interest (63.9%), lack of radiologist time/interest (47.5%) or technical support (41.4%) for protocol development, and limited interpretation experience (44.9%) and knowledge of clinical applications (43.7%). Reasons given by 46.9% were that no providers approached radiology with interest in EC-VWI. If barriers were overcome, 51.1% of those not performing EC-VWI indicated they would perform it, and 40.6% were unsure; 48.6% did not think that EC-VWI had impacted patient management at their institution. CONCLUSIONS Only 26% of neuroradiology groups performed EC-VWI, most commonly due to limited clinician interest. Improved provider and radiologist education, protocols, processing techniques, technical support, and validation trials could increase adoption.
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Affiliation(s)
- M Mossa-Basha
- From the Department of Radiology (M.M.-B.), University of North Carolina, Chapel Hill, North Carolina .,Departments of Radiology (M.M.-B., N.B., C.Z.)
| | - C Yuan
- Department of Radiology (C.Y.), University of Utah, Salt Lake City, Utah
| | - B A Wasserman
- Department of Radiology (B.A.W.), University of Maryland, Baltimore, Maryland.,Department of Radiology (B.A.W., Y.Q.), Johns Hopkins University, Baltimore, Maryland
| | - D J Mikulis
- Joint Department of Medical Imaging (D.J.M.), The University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - T S Hatsukami
- Surgery (T.S.H.), University of Washington, Seattle, Washington
| | - N Balu
- Departments of Radiology (M.M.-B., N.B., C.Z.)
| | - A Gupta
- Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - C Zhu
- Departments of Radiology (M.M.-B., N.B., C.Z.)
| | - L Saba
- Department of Radiology (L.S.), University of Cagliari, Cagliari, Sardinia, Italy
| | - D Li
- Biomedical Imaging Research Institute (D.L.), Cedars-Sinai Medical Center, Los Angeles, California
| | - J K DeMarco
- Department of Radiology (J.K.D.), Walter Reed National Military Medical Center, Bethesda, Maryland and Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - V T Lehman
- Department of Radiology (V.T.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Y Qiao
- Department of Radiology (B.A.W., Y.Q.), Johns Hopkins University, Baltimore, Maryland
| | - H R Jager
- Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, University College London, Queen Square Institute of Neurology, London, UK
| | - M Wintermark
- Department of Neuroradiology (M.W.), MD Anderson Cancer Institute, Houston, Texas
| | - W Brinjikji
- Department of Radiology (V.T.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - C P Hess
- Department of Radiology and Biomedical Imaging (C.P.H., D.A.S.), University of California, San Francisco, San Francisco, California
| | - D A Saloner
- Department of Radiology and Biomedical Imaging (C.P.H., D.A.S.), University of California, San Francisco, San Francisco, California
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14
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Zhu C, Tanter M, Fan Z, Hu S, Sadat U, Wang DJJ. Editorial: Cerebrovascular imaging-From micro- to macroscopic scales. Front Neurosci 2022; 16:1086022. [PMID: 36483181 PMCID: PMC9723370 DOI: 10.3389/fnins.2022.1086022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, United States,*Correspondence: Chengcheng Zhu
| | - Mickael Tanter
- INSERM U1273 Physics for Medicine Paris (ESPCI), Paris, France
| | - Zhaoyang Fan
- Department of Radiology, University of Southern California, Los Angeles, CA, United States
| | - Song Hu
- McKelvey School of Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Umar Sadat
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | - Danny J. J. Wang
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
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Baradaran H, Kamel H, Gupta A. The role of cross-sectional imaging of the extracranial and intracranial vasculature in embolic stroke of undetermined source. Front Neurol 2022; 13:982896. [PMID: 36090870 PMCID: PMC9459011 DOI: 10.3389/fneur.2022.982896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Despite an extensive workup, nearly one third of ischemic strokes are defined as Embolic Stroke of Undetermined Source (ESUS), indicating that no clear etiologic cause has been identified. Since large vessel atherosclerotic disease is a major cause of ischemic stroke, we focus on imaging of large vessel atherosclerosis to identify further sources of potential emboli which may be contributing to ESUS. For a stroke to be considered ESUS, both the extracranial and intracranial vessels must have <50% stenosis. Given the recent paradigm shift in our understanding of the role of plaque vulnerability in ischemic stroke risk, we evaluate the role of imaging specific high-risk extracranial plaque features in non-stenosing plaque and their potential contributions to ESUS. Further, intracranial vessel-wall MR is another potential tool to identify non-stenosing atherosclerotic plaques which may also contribute to ESUS. In this review, we discuss the role of cross-sectional imaging of the extracranial and intracranial arteries and how imaging may potentially uncover high risk plaque features which may be contributing to ischemic strokes.
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Affiliation(s)
- Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, United States
- *Correspondence: Hediyeh Baradaran
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, United States
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Ajay Gupta
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
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