| PartⅠ Comparison of 3D volume isotropic spin-echo sequence with digital subtraction angiography and 3D time-of-flight magnetic resonance angiography in intracranial arterial stenotic diseases.ObjectiveReferring DSA as golden standard, to explore the diagnostic value of 3D-VISTA combined with 3D-TOF MRA.Materials and Methods1. Subjects69 consecutive patients to the neurology department of our hospital, who met the two inclusion criterions, underwent the 3D-VISTA examination from January 2014 to December 2015.The inclusion criterions were as following:(1)adult patients who had TIA or stroke;(2)existed intracranial large arteries(middle cerebral artery or vertebrobasilar artery of intracranial section) stenosis or occlusion, which were diagnosed by DSA、CTA or MRA. The study procedures and consent forms were reviewed and approved by institutional review board before study initiation. All patients had been checked the ethics committee agreed and signed consent.2. Equipments, scanning sequence and parameters3D-VISTA examination:All exams were performed on a 3.0T MRI scanner(Achieva 3.0T, Netherlands Philips Healthcare) using 16-channel quadrature head coil.3D-TOF MRA was first acquired to localize the intracranial arteries.3D-VISTA images were then acquired in a coronal plane to cover the major intracranial vessels as identified on the MRA.A axial plane were then performed to obtain the vertical images of the lesion vessels as identified on the coronal plane. Adjusting scan angles, according to the lesion location, in order to present the target vessel in multi-angle and multi-dimensional view. Imaging parameters were as following:(1)3D-TOF MRA repetition time/echo time(TR/TE)20ms/3.5ms,FOV 140mm×140mm,slice thickness 1.4mm;(2)3D-VISTA:T1WI SPAIR VISTA,TR/TE 350 ms/18 ms,FOV130mm×130mm,slice thickness 1.2mm, ETL 25,matrix 256x256;(3)T2WI VISTA,TR/TE 2000 ms/135 ms,FOV130mm×130mm,slice thickness 1.2mm,ETL 25,matrix 256×256.The T1WI enhancement scan was performed in coronal and axial plane. Gd-DTPA was injected into the vein, the dosage of which is 0.2 milliters per kilogram. Before scanning,50ml normal saline was used to wash the catheter after injection.DSA examination:Seldinger technology was used to conduct femoral artery cannulation. Systemic heparinization, though the way of vein injection, was necessary after placement of artery sheath. For the first time, the aortic arch and above angiography was operated by using pigtail catheter. Then,5F Sigel bend catheter was used to conduct subclavian artery and common carotid artery angiography. Performing the internal carotid and vertebral artery angiography continue. The processing of intubation was fluoroscopically guided. Heparin was neutralized at the end of angiography. We pressed the punctured site locally for 15 minutes and bandaged up.3.3D-VISTA image quality analysisEach scan was interpreted by 2 reviewers, who engaged in MRI diagnosis for at least 5 years, reaching a consensus opinion. The interpretation was according to the signal-to-noise ratio, the display of luminal contour and wall structure Reviewers were blinded to subject information and clinical information. An ImQ was divided into 4 degree. Imaging with an average ImQ≤2 was excluded from the study. 4. Image date process and measurementThe lumen stenosis degree in DSA,3D-VISTA and 3D-TOF MRA were according to Samuels’ standards.Stenosis Degree(%)=[1-(Dstenosis/Dnormal)]×100%The 3D-VISTA images and the MIP images of 3D-TOF MRA were enlarged to 2.5 times. The lumen stenosis degree was measured 3 times by electric ruler, the accuracy of which is up to 0.1 millimeter. We took their average representing as the degree of lumen stenosis.5. Statistical methodsSPSS 19.0 software package was applied to deal with the data of the study. The items for analysis were as following:(1) analyzed the Spearman correlation between DSA,3D-VISTA and 3D-TOF MRA, then computed the rank correlation coefficient; (2) referring DSA as gold standard, analyzed the consistency of 3D-VISTA,3D-TOF MRA and DSA. The Kappa value was also computed;(3) referring DSA as standard, evaluated the diagnostic efficacy of 3D-VISTA, computed the sensitivity, specificity, position predictive value, negative predictive value, diagnose accordance rate, youden index of four grades(mild, moderate, severe stenosis and occlusion) of lumen stenosis in middle cerebral artery group and intracranial vertebrobasilar artery group respectively.Results1、There were 47 branches of MCA and 22 branches of V-BA in total,the 3D-VISTA images quality of which satisfied the requirements of measurement.2、The difference of 3D-VISTA,3D-TOF MRA and DSA in evaluating middle cerebral artery/vertebrobasilar artery stenosis were of significant. The rank correlation coefficient between 3D-VISTA and DSA in evaluating middle cerebral artery stenosis was 0.93, while in evaluating vertebrobasilar artery stenosis was 0.90. The rank correlation coefficient between 3D-TOF MRA and DSA in evaluating middle cerebral artery stenosis was 0.72, while in evaluating vertebrobasilar artery stenosis was 0.67.3、Referring DSA as gold standard, the Kappa value of 3D-VISTA in evaluating middle cerebral artery stenosis was 0.87, while in evaluating vertebrobasilar artery stenosis was 0.90. The Kappa value of 3D-TOF MRA in evaluating middle cerebral artery stenosis was 0.52, while in evaluating vertebrobasilar artery stenosis was 0.51.4、In middle cerebral artery group,the sensitivity, specificity, positive predictive value, negative predictive value, diagnose accordance rate of 3D-VISTA in evaluating mild stenosis were 80%,100%,100%,97.7%,97.9% respectively, while in evaluating moderate stenosis were 100%,90%,63.6%,100%,91.5% respectively. The sensitivity, specificity, positive predictive value, negative predictive value, diagnose accordance rate for evaluating severe stenosis were 88.9%,100%,100%, 87%,93.6% separately and for evaluating occlusion were all 100%. The Youden index in mild, moderate, severe stenosis and occlusion were 80%,90%,88.9%, 100% respectively. In intracranial vertebrobasilar artery group, the sensitivity, specificity, positive predictive value, negative predictive value, diagnose accordance rate of 3D-VISTA in evaluating moderate stenosis were 80%,100%,100%,94.4%, 95.5%respectively, while in evaluating severe stenosis were 100%、85.7%% 93.8%% 100%、95.5% respectively. The sensitivity, specificity, positive predictive value, negative predictive value, diagnose accordance rate for evaluating occlusion were all 100%. The Youden index in moderate, severe stenosis and occlusion were 80%%、 85.7%% 100% respectively.Conclusions1% 3D-VISTA can clearly display the stenotic lesion of intracranial artery and accurately evaluate the lumen stenosis degree;2% In evaluating intracranial artery stenosis or occlusion,3D-VISTA is well consistent with DSA. The diagnosis accuracy of 3D-VISTA is comparable with golden standard;3% The diagnosis accuracy of 3D-VISTA in severe stenosis and occlusion are superior to mild and moderate stenosis;4% 3D-VISTA can replace DSA in a way and being the normal screening method of intracranial artery stenosis.Partll The preliminary study of the wall imaging character in middle cerebral artery stenostic diseases in 3D-VISTAObjectiveUse 3D-VISTA to perform the vessel wall imaging on patients with middle cerebral artery stenotic diseases. Analyze signal, morphology and ambient conditions changes. Distinguish the cause of lumen stenosis and decide the plaque vulnerability.Materials and Methods1. Subjects47 consecutive patients to the neurology department of our hospital, who met the two inclusion criterions, underwent the 3D-VISTA examination from January 2014 to December 2015.The inclusion criterion were as following:(1)adult patients who had TIA or stroke;(2)existed middle cerebral artery stenosis or occlusion, which were diagnosed by DSA, CTA or MRA. Divided the study objects into atherosclerotic group and non-atherosclerotic group,and then divided patients in atherosclerotic group into symptomatic group and non-symptomatic group, divided patients in non-atherosclerotic group into moyamoya disease group and intracranial artertis group. The study procedures and consent forms were reviewed and approved by institutional review board before study initiation. All patients had been checked the ethics committee agreed and signed consent.2. Equipments, scanning sequence and parametersThe equipments,3D-VISTA examination and imaging parameters were the same as part I.3. Image quality and quantity analysis3.1 The image quality analysisThe image quality analysis was the same as part I.3.2The image quantity analysisThe T1 weighted image signal, T2 weighted image signal and enhanced T1 weighted image signal were both regard near brain parenchyma as reference. Image quality analysis includes:(1)identified the signal, morphology and location of plaque on each sequences in atherosclerotic group; (2) identified the lumen morphology, signal intensity of enhanced T1 weighted image and formation of the collateral circulation around the lesion in non-atherosclerotic group.Results1、41 cases were involved in this study with excellent image quality, (except for 2 cases with motion artifact,4 cases of poor image quality). All patients’ age ranged from 25 to 76 years, and average age of 50±10 years,28 cases of male,13 cases of female,19 patients with hypertension,15 patients with hyperlipidemia,16 patients diabetes mellitus,16 patients with smoking. TC 4.16±1.08mmol/L, TG1.63±1.47mmol/L, HDL 1.17±0.29mmol/L, LDL 2.58、0.96mmol/L.2、There were 35 cases in atherosclerotic group, including 24 cases of symptomatic and 11 cases of non-symptomatic. The numbers in non-atherosclerotic group were 6, including 4 cases of moyamoya disease and 2 cases of intracranial arteritis.3、Symptomatic patients in atherosclerotic group:20 branches showed plaque (17 branches of eccentricity plaque and 3 branches of centrality plaque),2 branches showed non-plaque and 3 branches blocked.17 branches of plaque showed iso-intensity and 3 branches showed hyper-intensity in T1WI.6 branches of plaque showed hypo-intensity,9 branches showed iso-intensity,2 branches showed slightly hyper-intensity and 3 branches showed hyper-intensity in T2WI.Among them 9 branches showed hyper-intensity on plaque surface, including 5 branches with discontinuous signal and 6 branches with continuous signal.1 branch showed non-enhancement,1 branch showed slight enhancement,3 branches showed moderate enhancement,12 branches showed marked enhancement and the other 3 branches did not perform enhancement scan. Locations of 17 eccentricity plaques were as following:7 branches in the anterior wall,3 branches in the back wall,6 branches in the superior wall and 1 branch in the inferior wall.4、Non-symptomatic patients in atherosclerotic group:10 branches showed eccentricity plaque,1 branch showed non-plaque and 2 branches blocked.8 branches of plaque showed iso-intensity and 2 branches showed hyper-intensity in T1WI.3 branches of plaque showed hypo-intensity,6 branches showed iso-intensity and 1 branch showed hyper-intensity in T2WI.Among them 5 branches showed hyper-intensity on plaque surface, including 1 branch with discontinuous signal and 4 branches with continuous signal.1 branch showed non-enhancement,2 branches showed slight enhancement,1 branch showed moderate enhancement,3 branches showed marked enhancement and the other 3 branches did not perform enhancement scan. Locations of the 10 eccentricity plaques were as following:7 branches in the anterior wall,3 branches in the back wall,6 branches in the superior wall and 1 branch in the inferior wall.5、The wall imaging of non-atherosclerotic group:4 patients were diagnosed with moyamoya disease,3 patients had bilateral middle cerebral artery involved. One side of middle cerebral artery presented block with plenty of collateral vessels and the other side of middle cerebral artery presented stenosis on 3D-VISTA.The artery wall of the stenotic side showed centrality construction without wall thickness or plaque and did not enhanced after enhancement.2 patients were diagnosed with intracranial arteritis. The wall of arteritis patients presents centrality thickness.1 patient diagnosed with active arteritis presented diffuse enhanced of the wall after enhancement.The other patient who diagnosed with inactive arteritis only presented centrality thickness of wall. The outer wall showed irregular without enhancement.Conclusions1-.3D-VIST A can well present the wall morphology, the morphology,signal, location and enhancement degree of plaque in middle cerebral artery;2、The occurrence rate of intraplaque hemorrhage is low. There is no significant difference between symptomatic group and non-symptomatic group;3、There are significant difference in fibrous cap rupture and plaque enhancement between symptomatic group and non-symptomatic group. Thus fibrous cap rupture and plaque enhancement can be regarded as burden index to evaluate plaque vulnerability;4、There has close relate between plaque location and clinical symptom. Plaque in superior and anterior wall always indicate the occurrence of short-term symptom;5、3D-VISTA can differentiate atherosclerotic stenosis and non-atherosclerotic stenosis effectively and identify the cause of lumen stenosis. |
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