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Gadolinium 3D MRA, intracranial pathology, case 2

Comparison of Gd 3D MRA with 3D TOF and 3DPC angiography techniques.
Right anterior clinoid meningioma: evaluation of the associated right carotid artery stenosis.

Clinical history
This 40-year-old female complains at the end of pregnancy from progressive visual loss. She experienced a similar episode at the end of a previous pregnancy 4 years ago but symptomatology resolved after delivery.
Vision dropped recently from 10/10 in July 98 to 1/10 in mid September on the right eye, reason why the patient was urged to have a prematurely delivery and emergency surgery was planned as a large right sphenoid meningioma was diagnosed.

First, a conventional MRI study is performed in order to identify the meningioma and evaluate full extension of the lesion:

Image 1: sagittal T1 weighted images. The large meningioma is isointense to grey matter covering a normal pituitary gland which presents a slightly hyperintense aspect (arrow).

Image 2: axial T2 weighted images show a right sphenoid large meningioma involving more specifically the right anterior clinoid process. Hyperostosis of the right anterior clinoid process is well seen (red arrow). Associated vascular displacements are already noticed: the upper basilar artery is pushed backwards. The right artery carotid artery is totally surrounded by the tumor and focal stenosis of the carotid may be suspected. The right middle cerebral artery is equally involved in the pathologic process (blue arrow).

Image 3: Axial proton density images are, according to our experience optimal in demonstrating the relationship between tumor and vascular elements. Those cuts are used for the planing of the subsequent MR angiographic acquisitions.

Images 4 - 5 - 6: First a 3D TOF technique was chosen for the MRA work up in this patient. The three standard MIP automatically generated images are shown here. The coronal view (image 6) shows narrowing of the right carotid siphon especially in his supra-clinoidal segment (image 6 - arrow). The right middle cerebral artery is included in the tumor growth and irregular lumen clearly seen (image 4 - arrow). The right posterior communicating artery is large (image 4 - arrow). The circumpedicular segment of the right posterior cerebral is displaced posteriorly. On the contrary, the first horizontal segment of the right anterior cerebral artery is not shown in a satisfactory manner on this coronal standard reconstructed image (image 6 - red arrow).

Image 7: 3DTOF: additional reconstructions from the axial plane.

Image 8: reconstructions from sagittal to the coronal plane according to a foot-head direction.
This series of images processed from the 3D TOF acquisition allows excellent evaluation of the multiple vascular stenosis due to the meningeal intracranial growth. Still some in-plane saturation effects are observed at the level of the carotid siphon, the carotid artery in the carotid canal and at the level of the initial segment of the anterior cerebral artery.

Image 9: Gd 3D MRA: 3D reconstructions acquired from the arterial phase (first 18 seconds of 3D coronal acquisition).

Image 10: compared to the 3D TOF, there are less saturation effects and a better delineation of the carotid artery, not only within the carotid canal (red arrow) but also in its supraclinoidal segment (blue arrow). The true extent of the secondary tumoral stenosis of the carotid siphon is better demonstrated on this MRA sequence. The first, horizontal segment of the anterior cerebral artery is now well identified on this Gadolinium-enhanced T1 weighted image.

Image 11: This coronal 3DPC standard MIP image is shown for comparison. It shows equally well the vascular irregularities of the carotid siphon and right sylvian artery. Still, acquisition time is much longer (6 mm) compared to the 3D MRA, Gd 3D MRA.

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- Gd 3D MRA: intracranial pathology

 

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Fig. 1

Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 1
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 2
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 3
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 4
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 5
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 6
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 7
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 8
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 9
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 10
Gadolinium 3D MRA, intracranial pathology, case 2, Fig. 11