MRA image production and display.

Magnetic resonance angiography (MRA) refers to a collection of imaging techniques which accentuate the signal intensity of flowing blood and suppress the signal intensity of stationary tissues. The resulting images are processed to resemble conventional catheter angiograms but carry fundamentally different information which is derived from flow rather than anatomy. All MRA techniques are subject to a variety of artifacts can stimulate pathology. A knowledge of the techniques used to produce and display MR angiographic images is essential for their accurate interpretation.

Cerebral ischemia and infarction.

Cerebral infarction is most commonly related to atherosclerotic disease in the carotid and vertebrobasilar circulations. TIAs are manifestations of this same disease process and may occur before a complete infarction. The transformation of pale to hemorrhagic infarction may result from reperfusion of an infarct or from migration of an embolus. CT is often the primary imaging study to exclude frank hemorrhage. The use of MR is increasing, in both the acute and the subacute phases of stroke. The combination of MR imaging and MR angiography is gradually replacing CT, particularly in patients with TIAs. In addition, the depiction of minute alterations in contrast and subtle mass effect is visualized with MR more often than with CT. The precise localization of brain stem and posterior fossa infarctions is improved by the ability of MR to view complex structures in two or more orthogonal planes. Vascular structures are readily identified both on the spin echo images and with MR angiography. Slow or obstructed flow in the venous channels may be recognized, which makes MR the ideal examination for the evaluation of cerebral ischemia and infarction.

Hyperventilation-induced cerebral ischemia in patients with acute brain lesions: demonstration by xenon-enhanced CT.

PURPOSE: To examine the possibility that hyperventilation, commonly used to prevent or treat increased intracranial pressure in patients with acute brain lesions, may induce significant cerebral ischemia. METHODS: Local cerebral blood flow and vascular reactivity were measured before and after hyperventilation using xenon-enhanced CT in 12 patients with acute brain lesions. RESULTS: Five patients showed "paradoxical" reactivity (increased cerebral blood flow during hyperventilation) within the lesions. In five patients, hyperventilation induced ischemia in apparently normal regions of brain. In three patients, areas of luxury perfusion became ischemic during hyperventilation, while in three patients, lesions with moderate ischemia became more ischemic. Most patients showed more than one type of reactivity. CONCLUSIONS: These findings document hyperventilation-induced ischemia in acute brain lesions, and demonstrate that this phenomenon affects both injured and apparently intact areas of the brain. Further studies are required to determine the clinical significance of these pathophysiologic changes.

Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenon-enhanced computerized tomography.

The role of cerebral ischemia in the pathophysiology of traumatic brain injury is unclear. Cerebral blood flow (CBF) measurements with 133Xe have thus far revealed ischemia in a substantial number of patients only when performed between 4 and 12 hours postinjury. But these studies cannot be performed sooner after injury, they cannot be done in patients with intracranial hematomas still in place, and they cannot detect focal ischemia. Therefore, the authors performed CBF measurements in 35 comatose head-injured patients using stable xenon-enhanced computerized tomography (CT), simultaneously with the initial CT scan (at a mean (+/- standard error of the mean) interval of 3.1 +/- 2.1 hours after injury). Seven patients with diffuse cerebral swelling had significantly lower flows in all brain regions measured as compared to patients without swelling or with focal contusions; in four of the seven, cerebral ischemia (CBF less than or equal to 18 ml/100 gm.min-1) was present. Acute intracranial hematomas were associated with decreased CBF and regional ischemia in the ipsilateral hemisphere, but did not disproportionately impair brain-stem blood flow. Overall, global or regional ischemia was found in 11 patients (31.4%). There was no correlation between the presence of hypoxia or hypertension before resuscitation and the occurrence of ischemia, neither could ischemia be attributed to low pCO2. Ischemia was significantly associated with early mortality (p less than 0.02), whereas normal or high CBF values were not predictive of favorable short-term outcome. These data support the hypothesis that ischemia is an important secondary injury mechanism after traumatic brain injury, and that trauma may share pathophysiological mechanisms with stroke in a large number of cases; this may have important implications for the use of hyperventilation and antihypertensive drugs in the acute management of severely head-injured patients, and may lead to testing of drugs that are effective or have shown promise in the treatment of ischemic stroke.

Stable xenon CT cerebral blood flow imaging: rationale for and role in clinical decision making.

The stable xenon CT method of measuring cerebral blood flow has been investigated in research studies for over 10 years. Recently, it has been gaining clinical acceptance, primarily owing to a combination of several unique advantages it holds over other cerebral blood flow measurement techniques. The accuracy of this technique in quantifying low cerebral blood flow gives it a unique application in cases of brain death and acute stroke and it can be repeated after an interval of 20 min. making it possible to evaluate autoregulation and cerebrovascular reserve. Furthermore, cerebral blood flow information is directly coupled to CT anatomy. Although it is more difficult to administer than a standard CT scan, careful monitoring can ensure patient safety during the examination. In this article we review the physiologic and technical bases for the clinical application of xenon CT-derived quantitative cerebral blood flow information and discuss the advantages and disadvantages of the technique. We also describe its current clinical applications, including its usefulness in the evaluation of acute stroke, occlusive vascular disease, carotid occlusion testing, vasospasm, arteriovenous malformations, and head trauma management.

Xenon-CT cerebral blood flow evaluation of cerebral ischemia in children and young adults.

Xenon-CT cerebral blood flow determinations in 20 children and young adults (age less than 40) who presented with cerebral ischemia were retrospectively reviewed for evidence of unifocal or multifocal ischemic disease. These results were compared with the findings of conventional CT and magnetic resonance (MR) examinations in the same patients. Xenon-CT revealed additional lesions or added significant pathophysiological information in 80% of patients scanned by noncontrast CT, 89% scanned by postcontrast CT, and 58% scanned by MR. Xenon-CT is a useful adjunct to MR and conventional CT in the evaluation of cerebral ischemia in children and young adults.