Transcript P-MRI & stdTTP: PerfusionEventImaging

Global Change of Cerebral Hemodynamics
in Patients with Chronic Heart Failure
Našel C., Stift E., Sykora T., Kirchner T., Filka B., Reiter G., Frank H.
Center of Clinical Neurosciences
Department of Clinical & Preventive Medicine
Danube University Krems
Departments of Radiology & Internal Medicine
State Clinical Center - Danube District / Tulln
©2010 c.nasel
Background:
Cardiovascular risk factors were found to be
associated with a higher incidence of structural
brain lesions
Number and extent of white matter lesions are
higher in patients with heart failure (HF) than in
populations with comparable risk factors
Breteler MM, van Swieten JC, Bots ML, et al. Cerebral white matter lesions, vascular risk factors,
and cognitive function in a populationbased study: the Rotterdam Study. Neurology 1994;44:1246–52
de Leeuw FE, de Groot JC, Oudkerk M, et al. Hypertension and cerebral white matter lesions
in a prospective cohort study. Brain 2002;125:765–72.
Almeida JR, Alves TC,Wajngarten M, et al. Late-life depression, heart failure and frontal white matter
hyperintensity: a structural magnetic resonance imaging study. Braz J Med Biol Res 2005;38:431–6.
......
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Background:
Cerebral affections with relation to HF:
periventricular WM lesions
subcortical WM lesions
temporo-mesial atrophy
lacunar lesions in basal ganglia
Cardiac diseases with relation to cerebral affection:
idiopathic dilated cardiomyopathy
cardiac valve pathologies
arrhythmias (bradycard atrial fibrillation, sick sinus syndrome, ...)
dyskinetic disorders of heart wall
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Methodical Considerations:
One of the strongest predictors for cerebral structural
affections associated with chronic HF is left ventricular
ejection fraction (LVEF)
Vogels RLC et al. Brain magnetic resonance imaging abnormalities
in patients with heart failure. Eur J Heart Fail, 2007, 9: 1003-1009
The only available perfusion-MRI based parameter so
far, which automatically, quantitatively, reproducibly
describes regional bolus delay and global bolus
distribution over time within one map is the
standardized time-to-peak parameter (stdTTP).
Nasel C. et al. Standardized time to peak in ischemic and regular cerebral tissue measured
with perfusion MR imaging. AJNR Am J Neuroradiol. 2004; 25:945-50
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P-MRI & stdTTP: PerfusionEventImaging - jPerfModule
Perfusion Event Imaging
30
% [rel. global signal]
25
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mean signal
10
5
0
0
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-5
seconds [time after injection; 10s delay]
cerebral bolus passage of contrast agent may be seen as
the sum of the cardial pulse wave (target related to LVEF)
and its transformation by cerebral vessels (constant). . .
©2010 c.nasel
P-MRI & stdTTP: PerfusionEventImaging - jPerfModule
Perfusion Event Imaging
30
% [rel. global signal]
25
20
15
mean signal
vox(stdTTP)
10
vox(fit)
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seconds [time after injection; 10s delay]
the full automatic analysis of stdTTP-values frequency of
an examination reveals that individual stdTTP-values do
occur in relation to arterial input and venous wash out. . .
©2010 c.nasel
P-MRI & stdTTP: PerfusionEventImaging - jPerfModule
Perfusion Event Imaging
30
% [rel. global signal]
25
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mean signal
vox(stdTTP)
15
vox(fit)
PE_prop
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sig.mean(fit)
art.rise time
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seconds [time after injection; 10s delay]
automatic calculation of first pass duration, statistical
adjustment of stdTTP-offset and detection of zero point of
the first differential gives the arterial rise time (ART). . .
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P-MRI & stdTTP: PerfusionEventImaging - jPerfModule
packing the complete image information into a
characteristic number, which estimates the
cerebrovascular preload. . .
©2010 c.nasel
P-MRI & stdTTP: PerfusionEventImaging - jPerfModule
Perfusion Event Imaging
25
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mean signal
vox(stdTTP)
vox(fit)
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PE_prop
sig.mean(fit)
art.rise time
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% [rel. global signal]
% [rel. global signal]
Perfusion Event Imaging
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mean signal
vox(stdTTP)
vox(fit)
10
PE_prop
sig.mean(fit)
art.rise time
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seconds [time after injection; 10s delay]
LVEFUS: 63% [GrAl]
seconds [time after injection; 10s delay]
LVEFUS: 44% [WiJo]
correlation of cardial restriction and cerebral perfusion
signs of prolongated venous pooling (...)
©2010 c.nasel
Methods:
Multimodal MRI (1.5T- Avanto, Siemens Medical Systems, Germany)
- dual echo advanced flair imaging (protoneus) -/+ CE
- dynamic susceptibility contrast enhanced MRI (P-MRI)
- diffusion wheighted MRI (DWI) with b=1000 s/mm2
- dyn-CE-MR angiography: range: aortic arc – circle of Willis
Image postprocessing
- calculation of regional cerebral blood flow (rCBF)and regional mean transit time (rMTT)-maps
- calculation of standardised time-to-peak (stdTTP)-maps
with stdTTP-based arterial rise time
- ROI-based analysis (native MRI), voxel-wise analysis (SPM)
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Methods:
Analysis
- estimation of microvascualar disease (grading 0-4)
rang scaled data; Wilcoxon test;
- global CBF, MTT and stdTTP
rationally scaled data; t-Test
- arterial rise time (stdTTP-ART)
rationally scaled data; t-Test
- voxel-wise analysis
t-Tests [vectors: -1,1 & 1,-1]
Hypothesis: H0: no difference between reduced and regular LVEF
Limitation: small sample size
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Subjects:
Observation (19 mo) Analysis of 18 matched patients:
- indication for routine scans: TIA, vertigo, etc. (no exam. for study reasons )
- NIH-SS score: 0
- no MR-DWI alteration indicating recent / acute ischemia
- no stenotic/occlusive cerebrovascular disease
- electrocardiography: no myocardial infarction
- continous O2-pulse oxymetry: 94- 99% O2-saturation
- vascular risk factors equaly distributed in both groups
(hypertonia; mild hypercholesterolaemia; no diabetes; no smokers)
Group 1 (n=9; f=3/ m=6; age: 66-85 y): US-LVEF: 41 ± 16%
Group 2 (n=9; f=4/ m=5; age: 62-86 y): US-LVEF: 58 ± 2%
(Group2 changed, since age is covariate for LVEF and microangipathy)
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Results:
Group 1 (n=9; f=3/ m=6; age: 66-85 y): US-LVEF: 41 ± 16%
Group 2 (n=9; f=4/ m=5; age: 62-86 y): US-LVEF: 58 ± 2%
(orig. Grp2. replaced by matched group for covariates)
extent of microvascular disease [median]:
- grp.1 worse than grp.2: group 1 vs 2 = grade 0 vs 3.
perfusion restriction [mean +/- SD: grp.1 vs grp.2]:
- global CBF: grp.1 comparable grp.2 = 31.4 ± 14.5 vs 32.4 ± 6.8 ml/100g/min
t-test (grp.1<>2; lev.sig.: 0.05); p> 0.05 n.s.
- global MTT: grp.1 slightly worse than grp. 2 = 6.3± 2.5 vs 4.1 ± 1.1 s
t-test (grp.1>2; lev.sig.: 0.025); p> 0.05 n.s.
stdTTP-based arterial rise time [mean +/- SD: grp.1 vs grp.2]:
- stdTTP-ART: grp.1 worse than grp.2 = 9.2 ± 2.2 vs 5.9 ± 0.8 s
t-test (grp.1>2; lev.sig.: 0.025); p= 0.021 sig.
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P-MRI & stdTTP: PerfusionEventImaging - jPerfModule
Cerebral Microangiopathy
Perfusion
EventMRI
Imaging
Perfusion
12,0
100,0
100,0
seconds [stdTTP - art.rise time]
90,0
90,0
80,0
80,0
% [LVEF-US]
70,0
70,0
60,0
60,0
50,0
50,0
40,0
40,0
30,0
30,0
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20,0
10,0
8,0
control (n=9)
6,0
cardial (n=9)
4,0
2,0
10,0
10,0
0,0
0,0
3,5
0,00
0,0
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1,00
5,5
2,00
6,5
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7,5
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8,5
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9,5
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10,5
7,00
seconds
[stdTTP
- art.rise
time]
seconds
[mean transit
time]
11,5
8,00
12,5
9,00
13,5
10,00
30
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% [LVEF-US]
- reduction of LVEF relates to higher stdTTP-ARTs and MTT
- LVEF and stdTTP-art.rise time both seem to predicted a
higher extent of microangiopathy
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Conclusion:
- according to earlier studies reduced LVEF was found
more frequentlyin patients with larger extent of
cerebrovascular disease
- LVEF restriction occurs more often in patients with
increased cerebral transit time (stdTTP-ART)
- stdTTP-ART could potential become useful in
identification of patiens with unspecific neurological
symptoms due to occult chronic HF
larger number of cases needed
different cerebrovascular conditions have to be analysed
©2010 c.nasel
Global Change of Cerebral Hemodynamics
in Patients with Chronic Heart Failure
Našel C., Stift E., Sykora T., Kirchner T., Filka B., Reiter G., Frank H.
Center of Clinical Neurosciences
Department of Clinical & Preventive Medicine
Danube University Krems
Departments of Radiology & Internal Medicine
State Clinical Center - Danube District / Tulln
©2010 c.nasel