Korean J Radiol.  2017 Apr;18(2):383-391. 10.3348/kjr.2017.18.2.383.

Assessment of Arterial Wall Enhancement for Differentiation of Parent Artery Disease from Small Artery Disease: Comparison between Histogram Analysis and Visual Analysis on 3-Dimensional Contrast-Enhanced T1-Weighted Turbo Spin Echo MR Images at 3T

• Jang J
• Kim TW
• Hwang EJ
• Choi HS
• Koo J
• Shin YS
• Jung SL
• Ahn KJ
• Kim BS

• KMID: 2427951
• DOI: http://doi.org/10.3348/kjr.2017.18.2.383

Abstract

OBJECTIVE
The purpose of this study was to compare the histogram analysis and visual scores in 3T MRI assessment of middle cerebral arterial wall enhancement in patients with acute stroke, for the differentiation of parent artery disease (PAD) from small artery disease (SAD).
MATERIALS AND METHODS
Among the 82 consecutive patients in a tertiary hospital for one year, 25 patients with acute infarcts in middle cerebral artery (MCA) territory were included in this study including 15 patients with PAD and 10 patients with SAD. Three-dimensional contrast-enhanced T1-weighted turbo spin echo MR images with black-blood preparation at 3T were analyzed both qualitatively and quantitatively. The degree of MCA stenosis, and visual and histogram assessments on MCA wall enhancement were evaluated. A statistical analysis was performed to compare diagnostic accuracy between qualitative and quantitative metrics.
RESULTS
The degree of stenosis, visual enhancement score, geometric mean (GM), and the 90th percentile (90P) value from the histogram analysis were significantly higher in PAD than in SAD (p = 0.006 for stenosis, < 0.001 for others). The receiver operating characteristic curve area of GM and 90P were 1 (95% confidence interval [CI], 0.86-1.00).
CONCLUSION
A histogram analysis of a relevant arterial wall enhancement allows differentiation between PAD and SAD in patients with acute stroke within the MCA territory.

Keyword

Middle cerebral artery; Vessel wall imaging; Enhancement; Histogram analysis; Acute ischemic stroke; Parent artery disease; Small vessel disease; 3T MRI

MeSH Terms

Aged
Aged, 80 and over
Area Under Curve
Constriction, Pathologic/pathology
Female
Humans
Image Enhancement
Imaging, Three-Dimensional
Magnetic Resonance Imaging/*methods
Male
Middle Aged
Middle Cerebral Artery/diagnostic imaging/physiology
Myocardial Infarction/*diagnosis
ROC Curve
Retrospective Studies
Tertiary Care Centers

Figure

• 

  Fig. 1 Example of histogram analysis of MCA wall enhancement. Case with eccentric enhancement in source image (A) of 3D CE T1-TSE and corresponding region-of-interest (yellow circle in A) for enhancing middle cerebral artery including wall and its lumen. Left side of scheme (B) is scheme of sagittal M1 segment and matching voxel of 3D CE T1-TSE. Enhancing wall with variable degrees of thickness is presented in gray, and lumen of MCA and surrounding tissues are presented in black. Voxel intensity was decided from mean values of internal tissues, and depended on ratio of vessel wall, lumen and surrounding tissues. Voxel has mixed contents of enhancing wall and lumen with variable degrees (blue box). As result, voxels had variable degrees of signals from those of enhancing walls only (red box) to those of lumen only (green box). Example of histogram of normalized signal of VOI is located on right side of scheme. Shaded area under histogram represents relative signal intensities. Two histogram parameters, 90th percentile (solid arrow) and geometric mean (empty arrow) are marked. MCA = middle cerebral artery, VOI = volume of interest, 3D CE T1-TSE = 3-dimensional contrast-enhanced T1-weighted turbo spin echo image

• 

  Fig. 2 Box and whisker plot of 90P and GM for lesion and contralateral side of M1 in both groups. Lesion side 90P was significantly higher in PAD group than in SAD group. Contralateral side 90P showed no significant difference between two groups. Lesion side 90P and GM of PAD group was significantly higher than that of SAD group. In PAD group, lesion side GM and 90P was significantly higher than contralateral side GM. GM = geometric means, PAD = parent artery disease, SAD = small artery disease, 90P = 90th percentile

• 

  Fig. 3 Case of PAD. 82-year-old woman visited emergency room for tendency to fall to right side. DWI showed patchy area of hyperintensity (arrow on A) of left frontal white matter and centrum semiovale. Mild stenosis (44%) was noted in distal M1 segment of left MCA (arrowheads on B). Note long segmental enhancement (arrowheads on C and D) along stenotic segment of left MCA on multiplanar reformatted image (C) and sagittal image (D) of 3D CE T1-TSE. On histogram analysis of lesion side (E), 90P (solid arrow on E) was 1.015, which was higher than our cut-off value of 0.73. Lesion side GM (empty arrow on E) was 0.738. Cut-off of GM was 0.346. DWI = diffusion-weighted images, GM = geometric means, MCA = middle cerebral artery, PAD = parent artery disease, 3D CE T1-TSE = 3-dimensional contrast-enhanced T1-weighted turbo spin echo image, 90P = 90th percentile

• 

  Fig. 4 Case of SAD. 86-year-old woman visited emergency room for dysarthria. DWI showed small acute ischemic stroke lesion in left periventricular white matter (arrow on A). Minimal irregular contour (arrowheads) of M1 segment of left MCA was visible (B), and degree of stenosis was 20%. On sagittal image (C), enhancement score was 0. Histogram analysis of lesion side M1 (D) showed low 90P (solid arrow, 0.568) and low GM (empty arrow, 0.256) in lesion side M1. DWI = diffusion-weighted image, GM = geometric means, MCA = middle cerebral artery, SAD = small artery disease, 90P = 90th percentile

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