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Vessel-selective 4D-MR angiography using super-selective pseudo-continuous arterial spin labeling may be a useful tool for assessing brain AVM hemodynamics

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Abstract

Objectives

To evaluate the usefulness of 4D-MR angiography based on super-selective pseudo-continuous ASL combined with keyhole and view-sharing (4D-S-PACK) for vessel-selective visualization and to examine the ability of this technique to visualize brain arteriovenous malformations (AVMs).

Methods

In this retrospective study, 15 patients (ten men and five women, mean age 44.0 ± 16.9 years) with brain AVMs were enrolled. All patients were imaged with 4D-PACK (non-selective), 4D-S-PACK, and digital subtraction angiography (DSA). Observers evaluated vessel selectivity, identification of feeding arteries and venous drainage patterns, visualization scores, and contrast-to-noise ratio (CNR) for each AVM component. Measurements were compared between the MR methods.

Results

Vessel selectivity was graded 4 in 43/45 (95.6%, observer 1) and 42/45 (93.3%, observer 2) territories and graded 3 in two (observer 1) and three (observer 2) territories. The sensitivity and specificity for identification of feeding arteries for both observers was 88.9% and 100% on 4D-PACK, and 100% and 100% on 4D-S-PACK, respectively. For venous drainage, the sensitivity and specificity was 100% on both methods for observer 1. The sensitivity and specificity for observer 2 was 94.4% and 83.3% on 4D-PACK, and 94.4% and 91.7% on 4D-S-PACK, respectively. The CNRs at the timepoint of 1600 ms were slightly lower in 4D-S-PACK than in 4D-PACK for all AVM components (Feeding artery, p = .02; nidus, p = .001; and draining artery, p = .02). The visualization scores for both observers were not significantly different between 4D-PACK and 4D-S-PACK for all components.

Conclusions

4D-S-PACK could be a useful non-invasive clinical tool for assessing hemodynamics in brain AVMs.

Key Points

• The 4D-MR angiography based on super-selective pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing (4D-S-PACK) enabled excellent vessel selectivity.

• The 4D-S-PACK enabled the perfect identification of feeding arteries of brain arteriovenous malformation (AVM).

• 4D-S-PACK could be a non-invasive clinical tool for assessing hemodynamics in brain AVMs.

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Abbreviations

4D-PACK:

4D-MR angiography based on pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing

4D-S-PACK:

4D-MR angiography based on super-selective pCASL with CENTRA-keyhole and view-sharing

AVM:

Arteriovenous malformation

CINEMA:

Contrast-inherent inflow-enhanced multi-phase angiography

CNR:

Contrast-to-noise ratio

DSA:

Digital subtraction angiography

ECA:

External carotid artery

ICA:

Internal carotid artery

MIP:

Maximum intensity projection

pCASL:

Pseudo-continuous arterial spin labeling

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Acknowledgements

This work was supported by JSPS KAKENHI Grant Number JP17K10410 and JP20K08111.

Funding

This work was supported by JSPS KAKENHI Grant Number JP17K10410 and JP20K08111.

Author information

Authors and Affiliations

  1. Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan

    Osamu Togao, Koji Yamashita, Kazufumi Kikuchi, Daichi Momosaka & Yoshitomo Kikuchi

  2. Philips Japan, 13-37, Kohnan 2-chome, Minato-ku, Tokyo, 108-8507, Japan

    Makoto Obara & Marc Van Cauteren

  3. Philips Research, Hamburg, Germany

    Michael Helle

  4. Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan

    Ataru Nishimura, Koichi Arimura & Koji Iihara

  5. Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan

    Tatsuhiro Wada & Hiroo Murazaki

  6. Department of Molecular Imaging & Diagnosis, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan

    Akio Hiwatashi

Authors
  1. Osamu Togao
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Corresponding author

Correspondence to Akio Hiwatashi.

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Guarantor

The scientific guarantor of this publication is Akio Hiwatashi.

Conflict of interest

Two authors (M.O., M.V.C.) were employees of Philips Healthcare and provided technical support for sequence development but were not involved in the study design or interpretation of the data. The institutional authors, who were not employees of Philips Healthcare, were in control of all the data.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

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Institutional review board approval was obtained

Methodology

• retrospective

• diagnostic study

• performed at one institution

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Electronic supplementary material

Supplementary Material 1

(Movies). A 60-year-old woman with brain AVM. Left internal carotid arteriograms (A. lateral view) shows that the AVM is supplied by multiple branches from the left middle cerebral artery. Vertebral arteriograms (AVI 526 kb)

330_2020_7057_MOESM2_ESM.avi

B. lateral view) show that this AVM is also supplied by the left posterior cerebral artery. The 4D-MR angiography based on super-selective pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing (4D-S-PACK) labelling the left internal carotid artery (AVI 550 kb)

330_2020_7057_MOESM3_ESM.avi

C. sagittal view) shows the AVM is supplied by the left middle cerebral artery as seen on the digital subtraction angiography. The 4D-S-PACK labelling the bilateral vertebral arteries (AVI 54 kb)

330_2020_7057_MOESM4_ESM.avi

D. sagittal view) shows the AVM is also supplied by the left posterior cerebral artery as seen on the digital subtraction angiography. On the nonselective 4D-MR angiography based on pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing (4D-PACK (AVI 48 kb)

330_2020_7057_MOESM5_ESM.avi

E. multiple arteries overlapped in the maximum intensity projection image, making it difficult to identify the feeding arteries. (AVI 83 kb)

Supplementary Material 2

(Movies). A 47-year-old woman with brain AVM. Left internal carotid arteriograms (A. anterior-posterior view (AVI 741 kb)

330_2020_7057_MOESM7_ESM.avi

B. lateral view) show that the AVM in the left cerebrum is supplied by the left middle cerebral artery. Contrast-enhanced 4D-CT angiography (AVI 649 kb)

C. coronal view (AVI 180 kb)

330_2020_7057_MOESM9_ESM.avi

D. sagittal view) clearly depicts all compartments of the AVM; however temporal resolution (1 sec) is limited, and it is difficult to distinguish feeding arteries because of the lack of vessel selectivity. The 4D-MR angiography based on super-selective pseudo-continuous arterial spin labeling combined with CENTRA-keyhole and view-sharing (4D-S-PACK) labelling the left internal carotid artery (AVI 195 kb)

E. coronal view (AVI 57 kb)

F. sagittal view (AVI 56 kb)

330_2020_7057_MOESM12_ESM.avi

G. axial view) shows the AVM is supplied by the left middle cerebral artery as seen on the digital subtraction angiography. (AVI 107 kb)

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Togao, O., Obara, M., Helle, M. et al. Vessel-selective 4D-MR angiography using super-selective pseudo-continuous arterial spin labeling may be a useful tool for assessing brain AVM hemodynamics. Eur Radiol 30, 6452–6463 (2020). https://doi.org/10.1007/s00330-020-07057-4

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