I van der Bom

Reduction of Coil Mass Artifacts in High-Resolution Flat Detector Conebeam CT of Cerebral Stent-Assisted Coiling

BACKGROUND AND PURPOSE: Developments in flat panel angiographic C-arm systems have enabled visualization of both the neurovascular stents and host arteries in great detail, providing complementary spatial information in addition to conventional DSA. However, the visibility of these structures may be impeded by artifacts generated by adjacent radio-attenuating objects. We report on the use of a metal artifact reduction algorithm for high-resolution contrast-enhanced conebeam CT for follow-up imaging of stent-assisted coil embolization. MATERIALS AND METHODS: Contrast-enhanced conebeam CT data were acquired in 25 patients who underwent stent-assisted coiling. Reconstructions were generated with and without metal artifact reduction and were reviewed by 3 experienced neuroradiologists by use of a 3-point scale. RESULTS: With metal artifact reduction, the observers agreed that the visibility had improved by at least 1 point on the scoring scale in >40% of the cases (κ = 0.6) and that the streak artifact was not obscuring surrounding structures in 64% of all cases (κ = 0.6). Metal artifact reduction improved the image quality, which allowed for visibility sufficient for evaluation in 65% of the cases, and was preferred over no metal artifact reduction in 92% (κ = 0.9). Significantly higher scores were given with metal artifact reduction (P < .0001). CONCLUSIONS: Although metal artifact reduction is not capable of fully removing artifacts caused by implants with high x-ray absorption, we have shown that the image quality of contrast-enhanced conebeam CT data are improved drastically. The impact of the artifacts on the visibility varied between cases, and yet the overall visibility of the contrast-enhanced conebeam CT with metal artifact reduction improved in most the cases.

Quantitative evaluation of C-arm CT cerebral blood volume in a canine model of ischemic stroke

BACKGROUND AND PURPOSE: Previous studies have shown the feasibility of assessing qualitative CBV measurements in the angiography suite by using FPD-CBCT systems. We have investigated the correlation of FPD-CBCT CBV lesion volumes to the infarct volume. MATERIALS AND METHODS: Unilateral strokes were created in 7 adult dogs. MR imaging and FPD-CBCT data were obtained after MCA occlusion. FPD-CBCT CBV and ADC maps were generated for all subjects. The animals were sacrificed immediately following the last imaging study to measure infarct volume on histology. The reliability of FPD-CBCT-based lesion volume measurements was compared with those measured histologically by using regression and Bland-Altman analysis. RESULTS: The best correlation (R2 = 0.72) between lesion volumes assessed with FPD-CBCT and histology was established with a threshold of mean healthy CBV − 2.5 × SD. These results were inferior to the correlation of lesion volumes measured with ADC and histology (R2 = 0.99). Bland-Altman analysis showed that the agreement of ADC-derived lesion volumes with histology was superior to the agreement of FPD-CBCT-derived lesion volumes with histology. CONCLUSIONS: We correlated FPD-CBCT measurements of CBV and MR ADC lesion volumes with histologically assessed infarct volume. As expected, ADC is a very accurate and precise method for determining the extent of infarction. FPD-CBCT CBV lesion volumes are correlated to the size of the infarct. Improvement of FPD-CBCT image quality provides an opportunity to establish quantitative CBV measurement in the angiography suite.

Evaluation of optimization methods for intensity-based 2D-3D registration in x-ray guided interventions

The advantage of 2D-3D image registration methods versus direct image-to-patient registration, is that these methods generally do not require user interaction (such as manual annotations), additional machinery or additional acquisition of 3D data. A variety of intensity-based similarity measures has been proposed and evaluated for different applications. These studies showed that the registration accuracy and capture range are influenced by the choice of similarity measure. However, the influence of the optimization method on intensity-based 2D-3D image registration has not been investigated. We have compared the registration performance of seven optimization methods in combination with three similarity measures: gradient difference, gradient correlation, and pattern intensity. Optimization methods included in this study were: regular step gradient descent, Nelder-Mead, Powell-Brent, Quasi-Newton, nonlinear conjugate gradient, simultaneous perturbation stochastic approximation, and evolution strategy. Registration experiments were performed on multiple patient data sets that were obtained during cerebral interventions. Various component combinations were evaluated on registration accuracy, capture range, and registration time. The results showed that for the same similarity measure, different registration accuracies and capture ranges were obtained when different optimization methods were used. For gradient difference, largest capture ranges were obtained with Powell-Brent and simultaneous perturbation stochastic approximation. Gradient correlation and pattern intensity had the largest capture ranges in combination with Powell-Brent, Nelder-Mead, nonlinear conjugate gradient, and Quasi-Newton. Average registration time, expressed in the number of DRRs required for convergence, was the lowest for Powell-Brent. Based on these results, we conclude that Powell-Brent is a reliable optimization method for intensity-based 2D-3D registration of x-ray images to CBCT, regardless of the similarity measure used.

The Effect of Intracranial Stent Implantation on the Curvature of the Cerebrovasculature

BACKGROUND AND PURPOSE: Recently, the use of stents to assist in the coiling and repair of wide-neck aneurysms has been shown to be highly effective; however, the effect of these stents on the RC of the parent vessel has not been quantified. The purpose of this study was to quantify the effect of intracranial stenting on the RC of the implanted artery using 3D datasets. MATERIALS AND METHODS: Twenty-four patients receiving FDA-approved neurovascular stents to support coil embolization of brain aneurysms were chosen for this study. The stents were located in the ICA, ACA, or MCA. We analyzed C-arm rotational angiography and contrast-enhanced cone beam CT datasets before and after stent implantation, respectively, to ascertain changes in vessel curvature. The images were reconstructed, and the vessel centerline was extracted. From the centerline, the RC was calculated. RESULTS: The average implanted stent length was 25.4 ± 5.8 mm, with a pre-implantation RC of 7.1 ± 2.1 mm and a postimplantation RC of 10.7 ± 3.5 mm. This resulted in a 3.6 ± 2.7 mm change in the RC due to implantation (P < .0001), more than a 50% increase from the pre-implantation value. There was no difference in the change of RC for the different locations studied. The change in RC was not impacted by the extent of coil packing within the aneurysm. CONCLUSIONS: The implantation of neurovascular stents can be shown to have a large impact on the RC of the vessel. This will lead to a change in the local hemodynamics and flow pattern within the aneurysm.

Temporal Evolution of Susceptibility Artifacts from Coiled Aneurysms on MR Angiography: An In Vivo Canine Study

BACKGROUND AND PURPOSE: Intracranial aneurysms treated by coiling have a risk for recurrence, requiring surveillance imaging. MRA has emerged as an attractive technique for postcoiling aneurysm imaging. Previous research has evaluated MR imaging artifacts of the coil mass in vitro. Our aim in this study was to evaluate MR imaging artifacts of coiled aneurysms in vivo with time. MATERIALS AND METHODS: Four sidewall aneurysms were created in each of 4 dogs. Aneurysms were embolized receiving only 1 type of coils. After embolization, the animals were transferred to MR imaging, which included axial 3D TOF MRA (TEs, 3.5, 5, and 6.9 ms), phase-contrast MRA, and coronal CE-MRA. MR imaging studies were repeated at 1, 4, 6, 8, 14, and 28 weeks. We calculated an OEF: OEF = VA/VCM, where the numerator represents the volume of the MR imaging artifacts and the denominator is the true volume of the coil mass measured by 3D RA. RESULTS: OEFs were largest immediately after embolization and showed a gradual decay until approximately 4 weeks, when there was stabilization of the size of the artifacts. By 4 weeks, there was mild coil compaction (average coil mass volume decrease of 7.8%); however, the OEFs decreased by 25% after 4 weeks (P < .001). CONCLUSIONS: MR imaging susceptibility artifacts change with time, being maximal in the postembolization setting and decaying until 4 weeks. The clinical implications of this study are that baseline MRA for comparison with future imaging should be acquired at a minimum of 1 week after the procedure.

MR Imaging of Myeloperoxidase Activity in a Model of the Inflamed Aneurysm Wall

BACKGROUND AND PURPOSE: Although myeloperoxidase activity in vivo can be visualized by using noninvasive imaging, successful clinical translation requires further optimization of the imaging approach. We report a motion-sensitized driven-equilibrium MR imaging approach for the detection of a myeloperoxidase activity–specific gadolinium-containing imaging agent in experimental aneurysm models, which compensates for irregular blood flow, enabling vascular wall imaging in the aneurysm. MATERIALS AND METHODS: A phantom was built from rotational angiography of a rabbit elastase aneurysm model and was connected to a cardiac pulse duplicator mimicking rabbit-specific flow conditions. A T1-weighted turbo spin-echo–based motion-sensitized driven-equilibrium pulse sequence was optimized in vitro, including the addition of fat suppression and the selection of the velocity-encoding gradient parameter. The optimized sequence was applied in vivo to rabbit aneurysm models with and without inflammation in the aneurysmal wall. Under each condition, the aneurysms were imaged before and after intravenous administration of the imaging agent. The signal-to-noise ratio of each MR imaging section through the aneurysm was calculated. RESULTS: The motion-sensitized driven-equilibrium sequence was optimized to reduce flow signal, enabling detection of the myeloperoxidase imaging agent in the phantom. The optimized imaging protocol in the rabbit model of saccular aneurysms revealed a significant increase in the change of SNR from pre- to post-contrast MR imaging in the inflamed aneurysms compared with naïve aneurysms and the adjacent carotid artery (P < .0001). CONCLUSIONS: A diagnostic MR imaging protocol was optimized for molecular imaging of a myeloperoxidase-specific molecular imaging agent in an animal model of inflamed brain aneurysms.

Finding the Striatum in Sheep: Use of a Multi-Modal Guided Approach for Convection Enhanced Delivery

Our goal is delivery of a long-term treatment for Huntingtons disease. We administer intracerebrally in sheep adeno-associated virus (AAV) to establish optimal safety, spread and neuronal uptake of AAV based therapeutics. Sheep have large gyrencephalic brains and offer the opportunity to study a transgenic Huntingtons disease model. However, lack of a relevant brain stereotactic atlas and the difficulty of skull fixation make conventional stereotaxy unreliable. We describe a multi-modal image-guidance technique to achieve accurate placement of therapeutics into the sheep striatum.

Reduced Patient Radiation Exposure during Neurodiagnostic and Interventional X-Ray Angiography with a New Imaging Platform

BACKGROUND AND PURPOSE: Advancements in medical device and imaging technology as well as accruing clinical evidence have accelerated the growth of the endovascular treatment of cerebrovascular diseases. However, the augmented role of these procedures raises concerns about the radiation dose to patients and operators. We evaluated patient doses from an x-ray imaging platform with radiation dose–reduction technology, which combined image noise reduction, motion correction, and contrast-dependent temporal averaging with optimized x-ray exposure settings. MATERIALS AND METHODS: In this single-center, retrospective study, cumulative dose-area product inclusive of fluoroscopy, angiography, and 3D acquisitions for all neurovascular procedures performed during a 2-year period on the dose-reduction platform were compared with a reference platform. Key study features were the following: The neurointerventional radiologist could select the targeted dose reduction for each patient with the dose-reduction platform, and the statistical analyses included patient characteristics and the neurointerventional radiologist as covariates. The analyzed outcome measures were cumulative dose (kerma)-area product, fluoroscopy duration, and administered contrast volume. RESULTS: A total of 1238 neurointerventional cases were included, of which 914 and 324 were performed on the reference and dose-reduction platforms, respectively. Over all diagnostic and neurointerventional procedures, the cumulative dose-area product was significantly reduced by 53.2% (mean reduction, 160.3 Gy × cm2; P < .0001), fluoroscopy duration was marginally significantly increased (mean increase, 5.2 minutes; P = .0491), and contrast volume was nonsignificantly increased (mean increase, 15.3 mL; P = .1616) with the dose-reduction platform. CONCLUSIONS: A significant reduction in patient radiation dose is achievable during neurovascular procedures by using dose-reduction technology with a minimal impact on workflow.

Projection-Slice Theorem Based 2D-3D Registration

In X-ray guided procedures, the surgeon or interventionalist is dependent on his or her knowledge of the patients specific anatomy and the projection images acquired during the procedure by a rotational X-ray source. Unfortunately, these X-ray projections fail to give information on the patients anatomy in the dimension along the projection axis. It would be very profitable to provide the surgeon or interventionalist with a 3D insight of the patients anatomy that is directly linked to the X-ray images acquired during the procedure. In this paper we present a new robust 2D-3D registration method based on the Projection-Slice Theorem. This theorem gives us a relation between the pre-operative 3D data set and the interventional projection images. Registration is performed by minimizing a translation invariant similarity measure that is applied to the Fourier transforms of the images. The method was tested by performing multiple exhaustive searches on phantom data of the Circle of Willis and on a post-mortem human skull. Validation was performed visually by comparing the test projections to the ones that corresponded to the minimal value of the similarity measure. The Projection-Slice Theorem Based method was shown to be very effective and robust, and provides capture ranges up to 62 degrees. Experiments have shown that the method is capable of retrieving similar results when translations are applied to the projection images.

O-012 Emergent Endovascular Management of Long-segment Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents

Background and purpose Cervical dissections are a significant cause of acute ischemic stroke, especially in young and middle aged adults. Although medical management of cervical dissections is standard treatment, emergent endovascular treatment may become necessary in the presence of acute intracranial large vessel occlusions, flow limiting and long segment lesions with impending occlusion, and/or ischemia at risk for cerebral infarction. We report our experience with the endovascular reconstruction of long segment carotid dissections using multiple tandem stents in acute ischemic stroke intervention. Materials and methods We retrospectively studied patients with carotid artery dissections requiring stent reconstruction at our institutions between January 2011 and January 2015, presenting with acute (<12 hours), severe ischemic stroke symptoms (NIHSS >4), and requiring carotid reconstruction with multiple tandem stents (≥3 stents). We analyzed patients’ demographics, vascular risk factors, presentations, imaging and angiographic findings, technical efficacy and safety, and clinical outcomes. Results We identified 15 patients presenting with acute ischemic stroke that underwent endovascular stent reconstruction of carotid dissections for vessel and/or ischemic tissue salvage. Mean patient age was 51.5 years with a mean presenting NIHSS of 15 and discharge NIHSS of 6. All carotid dissections presented with >70% stenosis and severe flow limitation, nearly all 14/15 involving the distal cervical segment of the ICA with a minimum length of 3.5 cm. Technical success of carotid stent reconstruction was achieved in all patients (100%) with no significant residual stenosis or flow limitation. Nine patients (60%) harbored simultaneous intracranial occlusions, and 6 patients (40%) required IA thrombolysis/thrombectomy achieving TICI 2 b-3 reperfusion in all 15 patients. There were no symptomatic intracranial hemorrhages. Procedural complications were limited to distal thromboemboli and multifocal infarcts in a single patient due to suspected in-stent thrombus, resulting in 7% procedural morbidity and 0% mortality. Follow-up 3–6 month angiographic and ultrasound imaging evaluations confirmed normalization of carotid artery caliber and stent patency in 12/14 patients, with 2 cases of only mild persistent vessel irregularity and <20% in-stent stenosis. On clinical follow-up, 9/15 (60%) of patients achieved mRS ≤ 2 at 90 days, with no interval recurrent TIAs or strokes. Conclusion Tandem stent reconstruction for the treatment of long segment and flow limiting carotid dissections is technically safe and effective with favorable clinical outcomes in acute ischemic stroke intervention, allowing for successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and prevention of recurrent thromboembolic stroke. Disclosures S. Ansari: None. A. Kuhn: None. A. Honarmand: None. S. Hou: None. M. Khan: None. J. Chueh: None. I. van der Bom: None. M. Hurley: None. A. Shaibani: None. M. Gounis: None. M. Potts: None. B. Jahromi: None. A. Wakhloo: None. A. Puri: None.