Utility of Arterial Spin Labeling (ASL) Perfusion as a Prognostic Factor for Cerebral Ischemia in Tumors which Encase and Stenose the Internal Carotid Artery (ICA) at the level of the Cavernous Sinus.

AUTHORS:A MAS-BONET, M PICADO VALLES, D QUINONES TAPIA, M GASSENT, A MARIN QUILES, B RODRIGUEZ FISAC, P JIMENEZ ARRIBAS.NEURORADIOLOGY. HOSPITAL SON ESPASES.PALMA DE MALLORCA. SPAIN.

Control #: 637.Poster # : EP-52.

THE AUTHORS HAVE NO DISCLOSURES TO MAKE.

PURPOSE

• Evaluation of the risk of cerebral ischemia using arterial spin labeling (ASL) in asymptomatic patients with tumors invading the cavernous sinus and causing encasement and stenosis of the ICA. We hypothesized that reduced cerebral perfusion associated with stenosis of ICA evaluated with Angio-RM 3D TOF and ASL could be a prognostic risk factor for cerebral ischemia.

MATERIAL and METHODS.• We performed arterial spin labeling CBF and Angio 3D TOF of the ICA

complementing the standard MRI protocol in 14 patients with tumors that invade the cavernous sinus (9 Meningiomas and 5 Macroadenomas).

• None of the patients had symptomatic ischemia. • The evaluation of the stenosis grade was performed by using Angio-

RM 3D TOF and comparing the affected ICA with the contralateral side. In all the cases stenosis was greater than 15%.

• Quantitative mean cerebral CBF was measured and averaged at three consecutive images just above the centrum semiovale by using region of interest analysis (size 6000 mm2) comparing both hemispheres.

• Significant difference was considered when the medium value was higher than 10% from one hemisphere to another.

ASL I.(ARTERIAL SPIN LABELING).

• Arterial spin-labeling (ASL) perfusion imaging can be implemented successfully into a routine clinical neuroimaging protocol and can accurately demonstrate alterations in brain perfusion. ASL requires no contrast, the complication of nephrogenic systemic fibrosis can be avoided.

• Other cerebral perfusion methods that rely on dynamic bolus techniques require large bore intravenous access devices and adequate renal function.

• We have observed patterns of focal hyperperfusion in case of tumors.

• Focal High-flow states on ASL could be associated with meningioma.

ASL II .(ARTERIAL SPIN LABELING).

• Arterial spin-labeling (ASL), when applied in a diverse clinical population, is capable of accurately depicting various states of hypo and hyperperfusion.

• Much of the value of ASL or any other brain perfusion technique is derived from its ability to image tissue at risk for ischemia or infarction and regions that are potentially salvageable with timely intervention.

• ASL can also evaluate asymptomatic carotid stenosis by showing asymmetric regions of modestly reduced blood flow.

Fig 1. A) Coronal T2 W. B) Axial T2 W. Meningioma situated to the right cavernous sinus that encases the ICA at this level.

Fig 2. Axial T1 W-post-Gd.Avidly enhancing cavernous sinus meningioma is demonstrated on the post gadolinium image (T1W).

CASE 1.48 year old man with paresis of cranial nerves III, IV, and VI .

Fig 1.Meningioma situated to the right Cavernous sinus with focal hyperperfusion pattern.

Fig 2. Focal decrease in signal intensity of compromised CBF in right hemisphere.

Fig 3. Angio 3D-TOF with 3D reconstruction. Stenosis and displacement of the Cavernous segment of the ICA.

CASE 1.48 year old man with paresis of cranial nerves III, IV, and VI.

ASL III .(Chronic Cerebrovascular Occlusive Disease)

• In patients with carotid or other proximal arterial stenosis, tissue at risk for subsequent ischemia and infarction can be identified with spin-tag perfusion, though a current limitation of most versions of ASL is the inability to assess CBV, a sensitive metric for at-risk tissue.

• If CBF is relatively decreased with a compensatory increase in CBV, a side-to-side flow asymmetry can be appreciated representing at-risk tissue that may benefit from stent placement or surgery. A focal decrease in signal intensity of compromised CBF can be seen most commonly in the anterior or posterior watershed zones.

Fig 1.A) Coronal T2W. B) Axial T2 W. Huge intraselar and paraselar mass (Macroadenoma) that invade boths cavernous sinus and encases both ICA at the level of cavernous and supraclinoid segment.

Fig 2. Axial T1 post-Gd. The ICA is situated in the center of the mass.

CASE 2.76 year old woman with Hypogonadotropic hypogonadism and bilateral

visual deficit . Macroadenoma.

Fig 1. Sagital T1W. A) Right Side. B) Left side.The intracavernous mass involve both segments of ICA at the Cavernous sinus.

Fig 2. Angio 3D-TOF with 3D reconstruction. Both ICA are displaced and the left side are more stenosed.

CASE 2.76 year old woman with Hypogonadotropic hypogonadism and bilateral

visual deficit

CASE 3.44 year old man with incidental brain tumor

Fig 1. Axial and Coronal T2 W. Right Cavernous mass that spreads upwards and involves the Supraclinoid segment of the ICA.

CASE 3.44 year old man with incidental brain tumor

Fig 1. A) Angio 3D-TOF with 3D reconstruction. Minimal displacement of the right supraclinoid portion of the ICA. B) ASL. No significant differences are seen in the perfusion pattern.

CASE 4.60 year old woman with weakness on the left side of the body and visual

deficit

Fig 1. A) Axial T1 W post-Gd. B) Axial T2W. C) Coronal T2 W. Meningioma. The Meningioma extends to Cavernous sinus, supraselar cistern and prepontine cistern.Streching the ICA at the level of the supraselar cistern.

CASE 4.60 year old woman with weakness on the left side of the body

Fig 1. Angio 3D-TOF with 3D reconstruction. Stenosis of the cavernous portion and stretching at the level supraselar portion of the right ICA.

Fig 2. ASL. Focal hyperperfusion pattern corresponding to the tumor and extensive hypoperfusion of the right hemisphere secondary to the compromise of the right ICA.

CASE 5.57 year old woman with diplopia

Fig 1. A) Axial T2W B) Coronal T2 W. Cavernous sinus Meningioma that encases the right ICA at this level.

CASE 5.57 year old woman with diplopia

Fig 1. Angio 3D-TOF with 3D reconstruction. Stenosis and stretching of the carvenous segment.

Fig 2. ASL. A) Focal hyperpefusion pattern corresponding to the mass. B) Minimum focal hypoperfusion at the level of the right insular region.

Fig 1. Multiple Meningiomatosis. A) Axial T2 W B) Axial T1 W. One of the Meningioma involve the left cavernous sinus.

Fig 2. Focal hypoperfusion pattern secundary to previous surgery. No significant differences between the perfusion patterns of both hemispheres.

CASE 6.73 year old woman with left oculomotor nerve palsy

Results

• Differences in the values of CBF between the two hemispheres was observed in all the patients with stenosis superior to 30% (six patients). In patients with stenosis between 15% to 30% a significant difference was observed in three patients and none in five patients.

Conclusions

• Arterial spin labeling CBF could be a useful tool combined with Angio-RM 3D TOF as a prognostic factor for cerebral ischemia in patients with tumors invading the cavernous sinus that cause asymptomatic ICA encasement and stenosis.

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