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Symptomatic Carotid Artery Occlusion: Flow Territories of Major Brain-Feeding Arteries¹

¹ From the Departments of Radiology (P.J.v.L., J.H.) and Neurology (C.J.M.K., L.J.K.), University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; and Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands (M.J.P.v.O., J.v.d.G.). Received January 30, 2006; revision requested March 28; revision received April 3; accepted April 19; final version accepted June 15. C.J.M.K. is supported by a clinical fellowship from the Netherlands Organization for Health Research and Development and by the Netherlands Heart Foundation. Address correspondence to P.J.v.L. (e-mail: p.j.vanlaar{at}azu.nl).

View larger version (46K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: The oblique sagittal labeling slab for selective labeling of the left ICA (2) was planned by using (a) coronal phase-contrast survey (14/7, 20° flip angle) and (b) transverse maximum intensity projection of the time-of-flight MR angiograms of the circle of Willis (30/6.9, 20° flip angle). The coronal labeling slab for selective labeling of the vertebrobasilar arteries was planned by using (c) sagittal phase-contrast survey (14/7, 20° flip angle) and (d) transverse maximum intensity projection of the time-of-flight of the circle of Willis (30/6.9, 20° flip angle). 1 = basilar artery.

View larger version (73K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: The oblique sagittal labeling slab for selective labeling of the left ICA (2) was planned by using (a) coronal phase-contrast survey (14/7, 20° flip angle) and (b) transverse maximum intensity projection of the time-of-flight MR angiograms of the circle of Willis (30/6.9, 20° flip angle). The coronal labeling slab for selective labeling of the vertebrobasilar arteries was planned by using (c) sagittal phase-contrast survey (14/7, 20° flip angle) and (d) transverse maximum intensity projection of the time-of-flight of the circle of Willis (30/6.9, 20° flip angle). 1 = basilar artery.

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: The oblique sagittal labeling slab for selective labeling of the left ICA (2) was planned by using (a) coronal phase-contrast survey (14/7, 20° flip angle) and (b) transverse maximum intensity projection of the time-of-flight MR angiograms of the circle of Willis (30/6.9, 20° flip angle). The coronal labeling slab for selective labeling of the vertebrobasilar arteries was planned by using (c) sagittal phase-contrast survey (14/7, 20° flip angle) and (d) transverse maximum intensity projection of the time-of-flight of the circle of Willis (30/6.9, 20° flip angle). 1 = basilar artery.

View larger version (66K): [in this window] [in a new window] [Download PPT slide]   Figure 1d: The oblique sagittal labeling slab for selective labeling of the left ICA (2) was planned by using (a) coronal phase-contrast survey (14/7, 20° flip angle) and (b) transverse maximum intensity projection of the time-of-flight MR angiograms of the circle of Willis (30/6.9, 20° flip angle). The coronal labeling slab for selective labeling of the vertebrobasilar arteries was planned by using (c) sagittal phase-contrast survey (14/7, 20° flip angle) and (d) transverse maximum intensity projection of the time-of-flight of the circle of Willis (30/6.9, 20° flip angle). 1 = basilar artery.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Pictorial description of postprocessing method (based on one set of transverse images in patient with symptomatic right-sided ICA occlusion) resulting from selective labeling of left ICA with regional perfusion imaging (3000/5.6/1600 [repetition time msec/echo time msec/inversion time msec], 90° flip angle). By subtracting labeled images from control images, perfusion-weighted images of the left ICA flow territory were obtained. Subtracted images were manually outlined, filled, and registered on a standard brain template. Bottom row shows combined flow territory maps of individual subjects (n = 18), expressed as a probability map. Colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain.

View larger version (39K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: Transverse flow territory maps projected onto a standard brain template in (a) patients with unilateral ICA occlusion (n = 18) of the contralateral ICA and vertebrobasilar arteries (VBA) and (b) control subjects (n = 68). In a, the side with symptomatic occlusion was standardized to the right ICA. Colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain. (c) Significant differences are seen in the left ICA and vertebrobasilar artery flow territories between patients with unilateral symptomatic ICA occlusion and control subjects. Colors correspond to the color bar, which uses a logarithmic scale to indicate significant P  values. In all regions with significant differences, the percentage of individuals who demonstrated flow territories was higher for patients than for control subjects.

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: Transverse flow territory maps projected onto a standard brain template in (a) patients with unilateral ICA occlusion (n = 18) of the contralateral ICA and vertebrobasilar arteries (VBA) and (b) control subjects (n = 68). In a, the side with symptomatic occlusion was standardized to the right ICA. Colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain. (c) Significant differences are seen in the left ICA and vertebrobasilar artery flow territories between patients with unilateral symptomatic ICA occlusion and control subjects. Colors correspond to the color bar, which uses a logarithmic scale to indicate significant P  values. In all regions with significant differences, the percentage of individuals who demonstrated flow territories was higher for patients than for control subjects.

View larger version (37K): [in this window] [in a new window] [Download PPT slide]   Figure 3c: Transverse flow territory maps projected onto a standard brain template in (a) patients with unilateral ICA occlusion (n = 18) of the contralateral ICA and vertebrobasilar arteries (VBA) and (b) control subjects (n = 68). In a, the side with symptomatic occlusion was standardized to the right ICA. Colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain. (c) Significant differences are seen in the left ICA and vertebrobasilar artery flow territories between patients with unilateral symptomatic ICA occlusion and control subjects. Colors correspond to the color bar, which uses a logarithmic scale to indicate significant P  values. In all regions with significant differences, the percentage of individuals who demonstrated flow territories was higher for patients than for control subjects.

View larger version (42K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Transverse flow territory maps of patients who had unilateral ICA occlusion with (a) anterior and posterior collateral flow (n = 12) or (b) posterior collateral flow (n = 5). In a, the side with symptomatic occlusion was standardized to the right ICA. Anterior collateral flow indicates retrograde flow in ipsilateral A1 segment, and posterior collateral flow indicates flow in posterior communicating artery or leptomeningeal anastomoses. Colors correspond to the color bar, which indicates the percentage of patients who demonstrated perfusion in that region of the brain. VBA = vertebrobasilar arteries.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Transverse flow territory maps of patients who had unilateral ICA occlusion with (a) anterior and posterior collateral flow (n = 12) or (b) posterior collateral flow (n = 5). In a, the side with symptomatic occlusion was standardized to the right ICA. Anterior collateral flow indicates retrograde flow in ipsilateral A1 segment, and posterior collateral flow indicates flow in posterior communicating artery or leptomeningeal anastomoses. Colors correspond to the color bar, which indicates the percentage of patients who demonstrated perfusion in that region of the brain. VBA = vertebrobasilar arteries.

View larger version (22K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: Transverse flow territory maps of the vertebrobasilar arteries (VBA) in (a) patients with symptomatic bilateral ICA occlusion (n = 5) and (b) control subjects (n = 68); colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain. Note that b corresponds to the bottom row of Figure 3b. (c) Significant differences in the vertebrobasilar artery flow territories are seen between patients with symptomatic bilateral ICA occlusion and control subjects. Colors correspond to the color bar, which uses a logarithmic scale to indicate significant P  values. In all regions with significant differences, the percentage of individuals who demonstrated a flow territory was higher for patients than for control subjects.

View larger version (19K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: Transverse flow territory maps of the vertebrobasilar arteries (VBA) in (a) patients with symptomatic bilateral ICA occlusion (n = 5) and (b) control subjects (n = 68); colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain. Note that b corresponds to the bottom row of Figure 3b. (c) Significant differences in the vertebrobasilar artery flow territories are seen between patients with symptomatic bilateral ICA occlusion and control subjects. Colors correspond to the color bar, which uses a logarithmic scale to indicate significant P  values. In all regions with significant differences, the percentage of individuals who demonstrated a flow territory was higher for patients than for control subjects.

View larger version (23K): [in this window] [in a new window] [Download PPT slide]   Figure 5c: Transverse flow territory maps of the vertebrobasilar arteries (VBA) in (a) patients with symptomatic bilateral ICA occlusion (n = 5) and (b) control subjects (n = 68); colors correspond to the color bar, which indicates the percentage of individuals who demonstrated perfusion in that region of the brain. Note that b corresponds to the bottom row of Figure 3b. (c) Significant differences in the vertebrobasilar artery flow territories are seen between patients with symptomatic bilateral ICA occlusion and control subjects. Colors correspond to the color bar, which uses a logarithmic scale to indicate significant P  values. In all regions with significant differences, the percentage of individuals who demonstrated a flow territory was higher for patients than for control subjects.