Federico C. von Samson-Himmelstjerna

Ultrahigh-field MRI in human ischemic stroke--a 7 tesla study.

Introduction Magnetic resonance imaging (MRI) using field strengths up to 3 Tesla (T) has proven to be a powerful tool for stroke diagnosis. Recently, ultrahigh-field (UHF) MRI at 7 T has shown relevant diagnostic benefits in imaging of neurological diseases, but its value for stroke imaging has not been investigated yet. We present the first evaluation of a clinically feasible stroke imaging protocol at 7 T. For comparison an established stroke imaging protocol was applied at 3 T. Methods In a prospective imaging study seven patients with subacute and chronic stroke were included. Imaging at 3 T was immediately followed by 7 T imaging. Both protocols included T1-weighted 3D Magnetization-Prepared Rapid-Acquired Gradient-Echo (3D-MPRAGE), T2-weighted 2D Fluid Attenuated Inversion Recovery (2D-FLAIR), T2-weighted 2D Fluid Attenuated Inversion Recovery (2D-T2-TSE), T2* weighted 2D Fast Low Angle Shot Gradient Echo (2D-HemoFLASH) and 3D Time-of-Flight angiography (3D-TOF). Results The diagnostic information relevant for clinical stroke imaging obtained at 3 T was equally available at 7 T. Higher spatial resolution at 7 T revealed more anatomical details precisely depicting ischemic lesions and periinfarct alterations. A clear benefit in anatomical resolution was also demonstrated for vessel imaging at 7 T. RF power deposition constraints induced scan time prolongation and reduced brain coverage for 2D-FLAIR, 2D-T2-TSE and 3D-TOF at 7 T versus 3 T. Conclusions The potential of 7 T MRI for human stroke imaging is shown. Our pilot study encourages a further evaluation of the diagnostic benefit of stroke imaging at 7 T in a larger study.

Crossed cerebellar diaschisis after stroke: can perfusion-weighted MRI show functional inactivation?

In this study, we aimed to assess the detection of crossed cerebellar diaschisis (CCD) following stroke by perfusion-weighted magnetic resonance imaging (PW-MRI) in comparison with positron emission tomography (PET). Both PW-MRI and 15O-water-PET were performed in acute and subacute hemispheric stroke patients. The degree of CCD was defined by regions of interest placed in the cerebellar hemispheres ipsilateral (I) and contralateral (C) to the supratentorial lesion. An asymmetry index (AI = C/I) was calculated for PET-cerebral blood flow (CBF) and MRI-based maps of CBF, cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP). The resulting AI values were compared by Bland-Altman (BA) plots and receiver operating characteristic analysis to detect the degree and presence of CCD. A total of 26 imaging procedures were performed (median age 57 years, 20/26 imaged within 48 hours after stroke). In BA plots, all four PW-MRI maps could not reliably reflect the degree of CCD. In receiver operating characteristic analysis for detection of CCD, PW-CBF performed poorly (accuracy 0.61), whereas CBV, MTT, and TTP failed (accuracy < 0.60). On the basis of our findings, PW-MRI at 1.5 T is not suited to depict CCD after stroke.

3D GRASE Pulsed Arterial Spin Labeling at Multiple Inflow Times in Patients with Long Arterial Transit Times: Comparison with Dynamic Susceptibility-Weighted Contrast-Enhanced MRI at 3 Tesla

Pulsed arterial spin labeling (PASL) at multiple inflow times (multi-TIs) is advantageous for the measurement of brain perfusion in patients with long arterial transit times (ATTs) as in steno-occlusive disease, because bolus-arrival-time can be measured and blood flow measurements can be corrected accordingly. Owing to its increased signal-to-noise ratio, a combination with a three-dimensional gradient and spin echo (GRASE) readout allows acquiring a sufficient number of multi-TIs within a clinically feasible acquisition time of 5 minutes. We compared this technique with the clinical standard dynamic susceptibility-weighted contrast-enhanced imaging—magnetic resonance imaging in patients with unilateral stenosis >70% of the internal carotid or middle cerebral artery (MCA) at 3 Tesla. We performed qualitative (assessment by three expert raters) and quantitative (region of interest (ROI)/volume of interest (VOI) based) comparisons. In 43 patients, multi-TI PASL-GRASE showed perfusion alterations with moderate accuracy in the qualitative analysis. Quantitatively, moderate correlation coefficients were found for the MCA territory (ROI based: r=0.52, VOI based: r=0.48). In the anterior cerebral artery (ACA) territory, a readout related right-sided susceptibility artifact impaired correlation (ROI based: r=0.29, VOI based: r=0.34). Arterial transit delay artifacts were found only in 12% of patients. In conclusion, multi-TI PASL-GRASE can correct for arterial transit delay in patients with long ATTs. These results are promising for the transfer of ASL to the clinical practice.

Clinical evaluation of an arterial-spin-labeling product sequence in steno-occlusive disease of the brain

Introduction In brain perfusion imaging, arterial spin labeling (ASL) is a noninvasive alternative to dynamic susceptibility contrast-magnetic resonance imaging (DSC-MRI). For clinical imaging, only product sequences can be used. We therefore analyzed the performance of a product sequence (PICORE-PASL) included in an MRI software-package compared with DSC-MRI in patients with steno-occlusion of the MCA or ICA >70%. Methods Images were acquired on a 3T MRI system and qualitatively analyzed by 3 raters. For a quantitative analysis, cortical ROIs were placed in co-registered ASL and DSC images. Pooled data for ASL-cerebral blood flow (CBF) and DSC-CBF were analyzed by Spearman’s correlation and the Bland-Altman (BA)-plot. Results In 28 patients, 11 ASL studies were uninterpretable due to patient motion. Of the remaining patients, 71% showed signs of delayed tracer arrival. A weak correlation for DSC-relCBF vs ASL-relCBF (r = 0.24) and a large spread of values in the BA-plot owing to unreliable CBF-measurement was found. Conclusion The PICORE ASL product sequence is sensitive for estimation of delayed tracer arrival, but cannot be recommended to measure CBF in steno-occlusive disease. ASL-sequences that are less sensitive to patient motion and correcting for delayed blood flow should be available in the clinical setting.

Characterization of Phase-Based Methods Used for Transmission Field Uniformity Mapping: A Magnetic Resonance Study at 3.0 T and 7.0 T

Knowledge of the transmission field (B1 +) of radio-frequency coils is crucial for high field (B0 = 3.0 T) and ultrahigh field (B0≥7.0 T) magnetic resonance applications to overcome constraints dictated by electrodynamics in the short wavelength regime with the ultimate goal to improve the image quality. For this purpose B1 + mapping methods are used, which are commonly magnitude-based. In this study an analysis of five phase-based methods for three-dimensional mapping of the B1 + field is presented. The five methods are implemented in a 3D gradient-echo technique. Each method makes use of different RF-pulses (composite or off-resonance pulses) to encode the effective intensity of the B1 + field into the phase of the magnetization. The different RF-pulses result in different trajectories of the magnetization, different use of the transverse magnetization and different sensitivities to B1 + inhomogeneities and frequency offsets, as demonstrated by numerical simulations. The characterization of the five methods also includes phantom experiments and in vivo studies of the human brain at 3.0 T and at 7.0 T. It is shown how the characteristics of each method affect the quality of the B1 + maps. Implications for in vivo B1 + mapping at 3.0 T and 7.0 T are discussed.

Walsh-ordered hadamard time-encoded pseudocontinuous ASL (WH pCASL)

Walsh ordering of Hadamard encoding‐matrices and an additional averaging strategy are proposed for Hadamard‐encoded pseudocontinuous arterial spin labeling (H‐pCASL). In contrast to conventional H‐pCASL the proposed method generates more perfusion‐weighted images which are accessible already during a running experiment and even from incomplete sets of encoded images.

Moyamoya Vessel Pathology Imaged by Ultra-High-Field Magnetic Resonance Imaging at 7.0 T

BACKGROUND Prompt diagnosis of vessel pathology and appropriate treatment of moyamoya vasculopathy (MMV) are essential to improve long-term prognosis. The aims of our study were to explore the diagnostic value of ultra-high-field (UHF) magnetic resonance imaging at 7.0 T in MMV patients and to compare the applicability of two different 7.0 T vessel imaging modalities to 3.0 T magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). METHODS In a World Health Organization-registered and prospective imaging trial, patients were investigated at 7.0 T magnetization-prepared rapid-acquisition gradient echo (MPRAGE)-MRA and time-of-flight (TOF)-MRA, 3.0 T TOF-MRA, and by DSA. RESULTS Six patients were included in our study and evaluated for MMV. 3.0 T TOF-MRA and 7.0 T MPRAGE-MRA were able to depict the complete major vascular tree and confirmed MMV-specific steno-occlusions of major intracranial arteries, as previously identified by DSA. 7.0 T TOF-MRA was limited to visualization of the circle of Willis as well as the internal carotid artery only. Donor vessels for bypass surgery (i.e., branches of superficial temporal artery) could be sufficiently visualized with all magnetic resonance modalities. CONCLUSIONS Our results indicate that a specific 7.0 T vascular imaging protocol yields diagnostic information about vessel pathology in MMV that approximates conventional DSA. 7.0 T MPRAGE was superior to 7.0 T TOF-MRA due to shorter scanning times and better brain coverage. To date, however, limited availability of 7.0 T technology in medical facilities as well as technical and procedural constraints excludes a fair amount of patients from the clinical 7.0 T imaging process.

Correction for Susceptibility Distortions Increases the Performance of Arterial Spin Labeling in Patients with Cerebrovascular Disease

Arterial spin labeling (ASL) is an MRI technique to measure cerebral blood flow (CBF) without the need of exogenous contrast agents and is thus a promising alternative to the clinical standard dynamic susceptibility‐weighted contrast‐enhanced (DSC) perfusion imaging. Latest international guidelines encourage its application in the clinical setting. However, susceptibility‐induced image distortions impair ASL with fast readout modules (eg Echo Planar Imaging, EPI; gradient and spin echo, GRASE). In the present study, we investigated the benefit of a distortion correction for ASL compared to DSC.

Clinical-Radiological Parameters Improve the Prediction of the Thrombolysis Time Window by Both MRI Signal Intensities and DWI-FLAIR Mismatch

Background: With regard to acute stroke, patients with unknown time from stroke onset are not eligible for thrombolysis. Quantitative diffusion weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) MRI relative signal intensity (rSI) biomarkers have been introduced to predict eligibility for thrombolysis, but have shown heterogeneous results in the past. In the present work, we investigated whether the inclusion of easily obtainable clinical-radiological parameters would improve the prediction of the thrombolysis time window by rSIs and compared their performance to the visual DWI-FLAIR mismatch. Methods: In a retrospective study, patients from 2 centers with proven stroke with onset <12 h were included. The DWI lesion was segmented and overlaid on ADC and FLAIR images. rSI mean and SD, were calculated as follows: (mean ROI value/mean value of the unaffected hemisphere). Additionally, the visual DWI-FLAIR mismatch was evaluated. Prediction of the thrombolysis time window was evaluated by the area-under-the-curve (AUC) derived from receiver operating characteristic (ROC) curve analysis. Factors such as the association of age, National Institutes of Health Stroke Scale, MRI field strength, lesion size, vessel occlusion and Wahlund-Score with rSI were investigated and the models were adjusted and stratified accordingly. Results: In 82 patients, the unadjusted rSI measures DWI-mean and -SD showed the highest AUCs (AUC 0.86-0.87). Adjustment for clinical-radiological covariates significantly improved the performance of FLAIR-mean (0.91) and DWI-SD (0.91). The best prediction results based on the AUC were found for the final stratified and adjusted models of DWI-SD (0.94) and FLAIR-mean (0.96) and a multivariable DWI-FLAIR model (0.95). The adjusted visual DWI-FLAIR mismatch did not perform in a significantly worse manner (0.89). ADC-rSIs showed fair performance in all models. Conclusions: Quantitative DWI and FLAIR MRI biomarkers as well as the visual DWI-FLAIR mismatch provide excellent prediction of eligibility for thrombolysis in acute stroke, when easily obtainable clinical-radiological parameters are included in the prediction models.

Improving perfusion quantification in arterial spin labeling for delayed arrival times by using optimized acquisition schemes

OBJECTIVE The improvement in Arterial Spin Labeling (ASL) perfusion quantification, especially for delayed bolus arrival times (BAT), with an acquisition redistribution scheme mitigating the T1 decay of the label in multi-TI ASL measurements is investigated. A multi inflow time (TI) 3D-GRASE sequence is presented which adapts the distribution of acquisitions accordingly, by keeping the scan time constant. MATERIAL AND METHODS The MR sequence increases the number of averages at long TIs and decreases their number at short TIs and thus compensating the T1 decay of the label. The improvement of perfusion quantification is evaluated in simulations as well as in-vivo in healthy volunteers and patients with prolonged BATs due to age or steno-occlusive disease. RESULTS The improvement in perfusion quantification depends on BAT. At healthy BATs the differences are small, but become larger for longer BATs typically found in certain diseases. The relative error of perfusion is improved up to 30% at BATs>1500ms in comparison to the standard acquisition scheme. CONCLUSION This adapted acquisition scheme improves the perfusion measurement in comparison to standard multi-TI ASL implementations. It provides relevant benefit in clinical conditions that cause prolonged BATs and is therefore of high clinical relevance for neuroimaging of steno-occlusive diseases.