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\title{\huge Perioperative Assessment Of Cerebral Perfusion Territories Through Arterial Spin Labeling Magnetic Resonance Imaging In Carotid Stenosis}
\author[taipapa et al.]{taipapa, taimama, taison, taidaughter, other person1,
other person2, other person3, other person 4, other person 5}
\institute[HogeFuga University]{Department of HogeFuga, HogeFuga Medical Center Japan}
\date[Feb. 23, 2017]{Feb. 17, 2017}
% abbreviations
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\def\@onedot{\ifx\@let@token.\else.\null\fi\xspace}
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\def\etal{{et al}\onedot}
\makeatother%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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\begin{document}
\begin{frame}{}
\begin{columns}[t]
\begin{column}{.32\linewidth}
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\vspace*{-2.35cm}
\begin{block}{Introduction}
% \begin{columns}[t]
% \begin{column}{.75\linewidth}
\begin{itemize}
% \item Arterial spin labeling (ASL) is a magnetic resonance
% imaging (MRI) technique that uses the protons of arterial
% blood water molecules as endogenous tracers to evaluate
% CBF noninvasively.
\item Territorial arterial spin labeling (TASL), a modified
ASL technique, allows for the independent labeling of
major individual feeding vessels and, consequently,
visualization of their perfusion territories.
\item Perfusion territories can change substantially during
the perioperative periods of carotid endarterectomy (CEA)
and carotid artery stenting (CAS). Perioperative changes
in the perfusion territories of major arteries are
important because these changes can influence the
perioperative management of hyperperfusion and other
conditions.
\end{itemize}
\vspace{0.5cm}
\small{
$\bigstar$\textbf{Financial Disclosures:} This study was
supported, in part, by a Grants-in-Aid for Scientific
Research (C) KAKENHI Number 15K10302 from the Japan
Society for the Promotion of Science.
}
\end{block}
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\begin{block}{Objective}
The objective of this study was to use TASL to assess the
relationships between perioperative changes in the perfusion
territories of the ICA and the CBF increase after carotid
revascularization in patients with carotid stenosis.
\end{block}
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\begin{block}{Subjects and Methods}
\begin{columns}[t]
\begin{column}{.5\linewidth}
\centering\includegraphics[width=1\linewidth]{Figures/ISC2017-subjects-left_Kohmura_opt.pdf}\\%[1ex]
\end{column}
\begin{column}{.5\linewidth}
\centering\vspace{-44cm}
\includegraphics[width=0.85\linewidth]{Figures/ISC2017-subjects-right_opt.pdf}\\[1ex]\begin{itemize}
\item TASL images were fused with T1 weighed
images(T1WI) on the software (Osirix) to match with
anatomical images. Perfusion volume of each ICA was
calculated from perfusion area and thickness of
slices.
\item Asymmetry Index (AI) was also calculated
from perfused volume of ICA on each side.
% \item The patients were divided into 2 groups on the
% basis of the preoperative perfusion volume of the
% stenotic ICA, that is, \textbf{normal PV} (n = 13)
% or \textbf{reduced PV} (n = 19) groups.
% \item \textbf{Normal PV} was defined as $\geq$ -2SD of the
% healthy volunteer group, that is, 312.4 cm3.
% \item \textbf{Reduced PV} was defined as $\textless$
% -2SD.
\end{itemize}
\end{column}
\end{columns}
\end{block}
\end{column}
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\begin{column}{.32\linewidth}
\vspace*{-2.35cm}
\begin{block}{Results}
\textbf{General postoperative changes in PV of ICA}\\\begin{columns}
\begin{column}{.4\linewidth}
\vspace*{-17cm}
\begin{itemize}
\item The preoperative perfusion volume (\textbf{PV}) of the
stenotic ICA in the carotid stenosis group was significantly
smaller than that in the control group. Revascularization
increased the PV of the stenotic ICA and equalized the PV of
the ICAs bilaterally.
\end{itemize}
\end{column}
\begin{column}{.6\linewidth}
\centering\includegraphics[width=1\linewidth]{Figures/Figure-2-WNS.pdf}\\\end{column}
\end{columns}
\vspace*{-0.5cm}
\begin{itemize}
\item The patients were divided into 2 groups on the basis of
the preoperative PV of the stenotic ICA, that is,
\textbf{normal PV} (n = 13) or \textbf{reduced PV} (n = 19)
groups.
\item\textbf{Normal PV} was defined as $\geq$ -2SD of the
healthy volunteer group, that is, 312.4 cm3.
\item\textbf{Reduced PV} was defined as $\textless$ -2SD.
\end{itemize}
\vspace{0.5cm}
\textbf{Differential postoperative changes in PV \& CBF }
\begin{columns}
\begin{column}{.4\linewidth}
\vspace*{-18cm}
\begin{itemize}
\item\textbf{A:} The changes in the PV of the stenotic ICA
before and after CEA or CAS in the normal PV group and the
reduced PV group. After treatment, the PV increases
significantly in the two groups, while the postoperative
increase was much larger in the reduced PV group.
\end{itemize}
\end{column}
\begin{column}{.6\linewidth}
\includegraphics[width=1\linewidth]{Figures/Figure-3-WNS.pdf}\\\end{column}
\end{columns}
\begin{itemize}
\item\textbf{B:} The changes in ipsilateral CBF before and
after CEA or CAS in the normal PV group and the reduced PV
group. The postoperative increase in the ipsilateral CBF was
larger in the reduced PV group than in the normal PV group.
\end{itemize}
\vspace{0.5cm}
\textbf{Relationships between postoperative changes in PV \& CBF}
\begin{columns}
\begin{column}{.45\linewidth}
\vspace*{-24cm}
\begin{itemize}
\item\textbf{A:} The rate of PV increase is significantly
higher in the reduced PV group than in the normal PV
group.
\item\textbf{B:} The rate of CBF increase is significantly
higher in the reduced PV group than in the normal PV
group.
\item\alert{Red circles} represent 4 patients whose
postoperative increase in perfusion volume are less
than lower quartile, and whose increase in CBF is more
than upper quartile.
\end{itemize}
\end{column}
\begin{column}{.55\linewidth}
\vspace*{-1.75cm}
\includegraphics[width=0.96\linewidth]{Figures/Figure-4-WNS.pdf}\\[2ex]\end{column}
\end{columns}
\end{block}
\end{column}
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\begin{column}{.32\linewidth}
\vspace*{-3cm}
\begin{block}{}
\textbf{Differential postoperative ICA flow changes}
\begin{columns}[t]
\begin{column}{.6\linewidth}
\begin{itemize}
\item The preoperative ICA flow was significantly lower in the
reduced PV group than in the normal PV group.
\item After treatment, the perfusion volume increases
significantly in the two groups, while the postoperative
increase was much larger in the reduced PV group.
\end{itemize}
\end{column}
\begin{column}{.4\linewidth}
\vspace*{-4cm}
\centering\includegraphics[width=0.8\linewidth]{Figures/Figure-5-WNS.pdf}\\[2ex]\end{column}
\end{columns}
\textbf{Illustrative cases}
\begin{itemize}
\item\underline{Case 6 (normal PV group)}: PV markedly increased 1 day
after CEA and was nearly unchanged between 1 and 7 days
after CEA. ICA flow markedly increased after arterial
reconstruction during CEA. Regional CBF was stable
throughout the perioperative period.
\item\underline{Case 8 (reduced PV group)}: PV 1 day after CEA was not
significantly different from that before surgery, and then,
it significantly increased between 1 and 7 days after CEA,
resulting in equalization of the perfusion volumes of the
left and right ICAs. ICA flow markedly increased after
arterial reconstruction during CEA. Regional CBF increased
significantly at 1 day after CEA (CBF increase $\geq$ 100\%),
representing typical hyperperfusion. Regional CBF decreased
significantly at 7 days after CEA compared with the first
postoperative day and returned to its normal range.
\end{itemize}
% \vspace{1cm}
\centering\includegraphics[width=0.8\linewidth]{Figures/UsualCase_legend_v2_opt.pdf}\\\end{block}
\vspace*{-0.95cm}
\begin{block}{Conclusion}
\vspace*{-1cm}
\begin{itemize}
\item TASL demonstrated that CEA and CAS elicited increases in the
PV of stenotic ICAs, which resulted in equalization of the
PV of the left and right ICAs.
\item Patients with reduced PV tended to increase the PV
more markedly than patients with PV within normal ranges.
\item In some patients with a reduced PV, the PV increased
slightly, while the ICA flow markedly increased, which
resulted in a large increase in CBF or hyperperfusion.
\item These findings suggested that an imbalance between
increases in the PV and ICA flow could play an important
role in the pathophysiology of hyperperfusion.
\end{itemize}
\vspace{-1ex}
\end{block}
\vspace*{-0.5cm}
\begin{block}{References}
\vspace*{-0.75cm}
\begin{enumerate}
\scriptsize{
\item Uchihashi et al. Clinical application of arterial
spin-labeling MR imaging in patients with carotid
stenosis: quantitative comparative study with
single-photon emission CT. AJNR Am J Neuroradiol 32,
1545--51, 2011
\item Hartkamp et al. Mapping of cerebral
perfusion territories using territorial arterial spin
labeling: techniques and clinical application. NMR Biomed
26, 901--12, 2013}
\end{enumerate}
\end{block}
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\end{document}
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