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Background and purpose <p>Internal carotid artery stenosis (ICS) is a major cause of ischemic stroke, requiring accurate evaluation of stenosis severity and cerebral hemodynamics to guide treatment strategies. This study aimed to assess the clinical utility of a novel four-dimensional carotid blood flow laterality (4D-CBL) scale, derived from four-dimensional pseudo-continuous arterial spin labeling MRA with Keyhole and View-sharing (4D-PACK), in evaluating the severity of ICS compared with DSA and SPECT.</p> Materials and methods <p>Forty patients with unilateral cervical ICS were prospectively enrolled. Patients were classified into three stages according to the 4D-CBL scale: stage 0 (no blood-flow delay), stage 1 (delayed ipsilateral perfusion), and stage 2 (collateral-dependent circulation). The severity of stenosis was determined by NASCET criteria on DSA and compared with 4D-CBL scale. Hemodynamic status was assessed by interhemispheric CBF ratios derived from SPECT. Interobserver agreement for 4D-CBL scale was evaluated using weighted Cohen’s κ statistics.</p> Results <p>Among the 40 patients, 10 were stage 0, 23 stage 1, and 7 stage 2. The median degree of stenosis significantly increased with higher 4D-CBL stages (58.3% in stage 0, 71.0% in stage 1, and 95% in stage 2; <i>p</i> &lt; 0.001). The median CBF ratios decreased significantly across stages (0.98, 0.97, and 0.93; <i>p</i> = 0.037). Interobserver agreement was excellent (concordance rate = 0.85, κ = 0.82; 95% CI 0.68–0.96).</p> Conclusions <p>The 4D-CBL scale derived from 4D-PACK enables noninvasive and reliable assessment of ICS severity and hemodynamic compromise without the need for contrast medium or radiation exposure. It demonstrates correlation with DSA and SPECT findings, suggesting its potential role as a practical alternative or adjunct for evaluating ICS severity.</p>

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Four-dimensional carotid blood flow laterality (4D-CBL) scale using four-dimensional magnetic resonance angiography for the assessment of severity of internal carotid artery stenosis

  • 期刊论文

  • 发表日期：

    2026年1月6日

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  • Koki Mitani,
  • Takeshi Miyata,
  • Takeru Umemura,
  • Yu Abekura,
  • Yuji Agawa,
  • Tomoya Ogawa,
  • Hiroshi Miyaji,
  • Hiroki Sakamoto,
  • Daisuke Abe,
  • Ryo Hamamoto,
  • Takashi Nagahori,
  • Jun Hashimoto,
  • Kan Sumita,
  • Wataru Shiraishi,
  • Yusuke Nakazawa,
  • Yuta Honkawa,
  • Makoto Obara,
  • Tatsunori Saho,
  • Taketo Hatano

摘要

Background and purpose

Internal carotid artery stenosis (ICS) is a major cause of ischemic stroke, requiring accurate evaluation of stenosis severity and cerebral hemodynamics to guide treatment strategies. This study aimed to assess the clinical utility of a novel four-dimensional carotid blood flow laterality (4D-CBL) scale, derived from four-dimensional pseudo-continuous arterial spin labeling MRA with Keyhole and View-sharing (4D-PACK), in evaluating the severity of ICS compared with DSA and SPECT.

Materials and methods

Forty patients with unilateral cervical ICS were prospectively enrolled. Patients were classified into three stages according to the 4D-CBL scale: stage 0 (no blood-flow delay), stage 1 (delayed ipsilateral perfusion), and stage 2 (collateral-dependent circulation). The severity of stenosis was determined by NASCET criteria on DSA and compared with 4D-CBL scale. Hemodynamic status was assessed by interhemispheric CBF ratios derived from SPECT. Interobserver agreement for 4D-CBL scale was evaluated using weighted Cohen’s κ statistics.

Results

Among the 40 patients, 10 were stage 0, 23 stage 1, and 7 stage 2. The median degree of stenosis significantly increased with higher 4D-CBL stages (58.3% in stage 0, 71.0% in stage 1, and 95% in stage 2; p < 0.001). The median CBF ratios decreased significantly across stages (0.98, 0.97, and 0.93; p = 0.037). Interobserver agreement was excellent (concordance rate = 0.85, κ = 0.82; 95% CI 0.68–0.96).

Conclusions

The 4D-CBL scale derived from 4D-PACK enables noninvasive and reliable assessment of ICS severity and hemodynamic compromise without the need for contrast medium or radiation exposure. It demonstrates correlation with DSA and SPECT findings, suggesting its potential role as a practical alternative or adjunct for evaluating ICS severity.