Introdução: O acesso lombar transpsoas extremo lateral (LLIF) é uma abordagem retroperitoneal para artrodese intersomática que constitui num implante (cage) o qual se sustenta nas duas margens laterais do anel epifisário, maximizando o apoio na placa terminal. Há também a descompressão indireta das estruturas nervosas através da discectomia e restauro da altura discal pelo cage. Objetivo: Avaliar a eficácia clínica e radiológica da descompressão indireta após o LLIF para estenose do canal lombar. Métodos: Estudo prospectivo clínico e radiológico em único centro, com 20 pacientes portadores de estenose do canal lombar, sem resposta ao tratamento clínico, submetidos à cirurgia de artrodese por via lateral transpsoas minimamente invasiva. Foram coletados dados clínicos e radiológicos no período pré-operatório, em 6 semanas, em três meses, seis e doze meses após a cirurgia. Dados radiológicos medidos em RNM incluíram área e altura dos forâmens, área do canal, diâmetro do canal e altura anterior e posterior do disco intervertebral. Questionários clínicos incluíram EVA e ODI. A incidência de complicações e re-operações foram descritas. Resultados: A idade média do grupo foi de 57,8 anos. Foram tratados ao todo 25 níveis. As cirurgias decorreram sem complicações intra-operatórias. Um caso (5%) recebeu re-operação. A área do canal aumentou de 109 mm para 149mm (p < 0,001) e de 9,3mm para 12,2mm (p < 0,001) em diâmetro anteroposterior. Os valores de área dos forâmens também demonstraram o efeito da descompressão indireta em ambos lados (p < 0,001). A altura do forâmen mostrou ganhos significativos, de 2,8mm de média (p < 0,001). A altura discal foi aumentada em média 25% (p < 0,001). Os resultados de questionários EVA e ODI respondidos pelos pacientes confirmaram o efeito clínico da descompressão indireta demonstrada radiologicamente. Conclusão: Observamos que a descompressão indireta pelo método de LLIF apresenta resultados que comprovam a melhora tanto radiológica quanto clínica com baixa taxa de complicações e re-operações / Background: Lateral transpsoas lateral access (LLIF) is a retroperitoneal approach for intersomatic arthrodesis that constitutes an implant, which is supported on the two lateral margins of the epiphyseal ring, maximizing the support in the terminal plate. There is also indirect decompression of nerve structures through discectomy and restoration of disc height by cage. Aim: Evaluate the clinical and radiological improvement of the indirect decompression after LLIF for lumbar canal stenosis. Methods: Prospective clinical and radiological study in a single center, with 20 patients with lumbar canal stenosis, without response to clinical treatment, submitted to minimally invasive transpsoas lateral lumbar interbody fusion (LLIF) surgery. Clinical and radiological data were collected in the preoperative period, at 6 weeks, at three, six and twelve months after surgery. Radiological data measured on MRI included area and height of foramen, canal area, canal diameter and anterior and posterior height of the intervertebral disc. Clinical questionnaires included VAS and ODI. Complications and re-operations were described. Results: The mean age of the group was 57.8 years. A total of 25 levels were treated. Surgeries were performed without intraoperative complications. One case (5%) received reoperation. The canal area increased from 109 mm to 149 mm (p < 0.001) and from 9.3 mm to 12.2 mm (p < 0.001) in the anteroposterior diameter. The values of the foramen area also demonstrated the effect of indirect decompression on both sides (p < 0.001). The height of the foramen showed significant gains, of 2.8 mm of mean (p < 0.001). Disc height was increased by an average of 25% (p < 0.001). The results of VAS and ODI questionnaires answered by the patients confirmed the clinical effect radiologically demonstrated of indirect decompression. Conclusion: We observed that indirect decompression by the LLIF method is feasible radiologically and clinically with a low rate of complications and reoperations

In patients with aortic stenosis, accurate assessment of severity with echocardiography is central to surgical decision making. But, when image quality is poor or equivocal results obtained, another robust non-invasive technique would be invaluable. Cardiac magnetic resonance (CMR) may be a useful alternative. Phase contrast CMR can measure ow and velocity, therefore it is theoretically possible to estimate the main determinant of severity aortic valve area, using the continuity approach. However, it was found that the phase contrast estimate of stroke volume, sampled in the stenotic jet, systematically underestimated left ventricular stroke volume. This underestimation was greater with increasing aortic stenosis severity. Critical clinical treatment decisions depend on the ability to reliably differentiate between patients with moderate and severe aortic stenosis. To achieve accurate estimation of aortic valve areas the velocity and ow data obtained in these turbulent, high velocity jets must be accurate. In this thesis, non-stenotic and stenotic phantoms were designed and constructed to experimentally interrogate the error. It was determined that signal loss, due to intravoxel dephasing, decreased the reliability of the measured forward ow jet velocities. Extreme signal loss in the jet eventuated in salt and pepper noise, which, with a mean velocity of zero, resulted in the underestimation. Intravoxel dephasing signal loss due to higher order motions, turbulence and spin mixing could all be mitigated by reducing the duration of the velocity sensitivity gradients and shortening the overall echo time (TE). However, improvements in an optimised PC sequence (TE 1:5ms) were not satisfactory. Flow estimates remained variable and were underestimated beyond the aortic valve. To reduce the TE further, a new phase contrast pulse sequence based on an ultrashort TE readout trajectory and velocity dependent slice excitation with gradient inversion was designed and implemented. The new sequence's TE is approximately 25% (0:65ms) of what is currently clinically available (TE 2:8ms). Good agreement in the phantom was maintained up to very high ow rates with improved signal characteristics shown in-vivo. This new phase contrast pulse sequence is worthy of further investigation as an accurate evaluation of patients with aortic stenosis. / This work in this thesis was conducted at The Auckland Bioengineering Institute, The Centre for Advanced MRI and The Oxford Centre for Clinical Magnetic Resonance in collaboration with Siemens Health care.

La sténose valvulaire aortique (SVA) est une pathologie associée au vieillissement et aux facteurs de risque cardiovasculaire. Afin d’étudier la SVA et d’explorer de nouvelles thérapies, plusieurs modèles animaux ont été récemment développés, mais la plupart de ces modèles ciblent les mécanismes de développement de la SVA reliés à l’hypercholestérolémie. Le syndrome de Werner (WS) est une maladie caractérisée par un vieillissement prématuré. Récemment, il a été découvert que des souris mutantes ayant une délétion du domaine hélicase du gène Werner, responsable du WS, démontraient un profile hémodynamique typique de la SVA. De ce fait, nous avons émis l’hypothèse que ces souris pourraient développer une SVA plus rapidement que des souris de type sauvage. Nous avons donc étudié les effets cette mutation chez des souris WrnΔhel/Δhel, en comparant le taux de progression d’une SVA entre des souris WrnΔhel/Δhel (WrnΔhel) et des souris de type sauvage comme groupe contrôle. À la suite d’une diète riche en sucre et en gras sur une période de 24 semaines, les souris WrnΔhel ont démontré une diminution plus prononcée de leur aire de valve aortique (mesures échocardiographiques) que les souris contrôles, supportée par les analyses histologiques concernant la fibrose des valves aortiques. Les souris n’ont toutefois développé aucun signe évident d’athérosclérose comme l’infiltration de lipides ou l’inflammation, bien que certaines caractéristiques liées à la dysfonction endothéliale semblent être augmentées chez les souris WrnΔhel. D’autres mesures échocardiographiques indiquant une SVA, comme une hypertrophie du ventricule gauche dans le groupe WrnΔhel, ont été obtenues. Nous avons aussi observé des indices de vieillissement plus marqués quant aux analyses sanguines et de la moelle osseuse des souris WrnΔhel en comparaison avec les souris contrôles. Par conséquent, ce modèle expérimental de vieillissement pourrait être utilisé pour les études futures sur la SVA sans les principaux effets athérogéniques des autres modèles expérimentaux. / Aortic valve stenosis (AVS) is associated with aging and classical cardiovascular risk factors. Different animal models were recently developed to study AVS and explore new therapies, however, most of these models rely almost exclusively on hypercholesterolemia-related mechanisms for AVS development. Werner syndrome (WS) is a disorder characterized by premature aging. It was recently demonstrated that mutant mice with a deletion of the helicase domain of the Werner gene, the gene responsible for WS, showed hemodynamic profile typical of AVS. We therefore hypothesized that mice with the WrnΔhel deletion could develop AVS earlier than wild-type (WT) mice. We studied the effect of the WrnΔhel mutation by comparing the rate of progression of AVS in homozygous mutant versus WT mice. By twenty-four weeks on a high-fat/high-carbohydrate diet, WrnΔhel/Δhel (WrnΔhel) mice showed a stronger decrease of the aortic valve area measured by serial echocardiography than WT mice, supported by histological analyses of valve fibrosis but without developing major signs of atherosclerosis such as lipid infiltration or increased inflammation. Some features linked to endothelial dysfunction also appeared to be increased in WrnΔhel mice. Other echocardiographic measurements were typical of AVS, such as left ventricle hypertrophy in the WrnΔhel group. We also observed stronger aging properties from WrnΔhel mice bone marrow and blood analyses compared to the WT group. Consequently, this experimental aging model could be used for AVS research without the major confounding atherogenic effects of other experimental models.

We prospectively evaluated 30 consecutive patients with echo-enhanced transcranial color-coded duplexsonography (TCCD) and correlative transfemoral digital subtraction angiography to assess the diagnostic efficacy of echo-enhanced TCCD for evaluation of collateral pathways through the circle of Willis in patients with limited acoustic bone windows and critical symptomatic carotid disease. Echo-enhanced TCCD detected collateral blood flow through the anterior communicating artery in 16 of 18 patients (sensitivity 89%, 95% CI 65–99%) and was false positive in one out of 12 patients without collateral flow (specificity 92%, 95% CI 59–100%). For the posterior communicating artery, sensitivity was 11/14 (79%, 95% CI 49–95%) and specificity was 15/16 (94%, 95% CI 70–100%). Echo-enhanced TCCD enables to study collateral blood flow through the communicating arteries of the circle of Willis with high sensitivity and specificity in patients with obstructions of the internal carotid artery and limited acoustic bone windows. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background. Carotid stenosis is an important cause of stroke. Carotid endarterectomy is a means of reducing the burden of stroke but is of marginal benefit in individuals with asymptomatic carotid stenosis. The identification of factors associated with increased risk of cerebral ischemic events would help select individuals who may obtain a greater benefit. / Methods. A comprehensive search was performed to identify studies examining risk factors for cerebral ischemic events in patients with asymptomatic carotid stenosis. Inclusion criteria were defined a priori. Relevant studies were reviewed, assessed for quality, and data were extracted. / Results. Thirty-four studies met the inclusion criteria. There was a suggestion of increasing neurological events with increasing severity and progression of carotid stenosis. There was some evidence for an association with carotid plaque morphology. No consistent association was found with clinical factors, impaired cerebral vasoreactivity, or cerebral embolic signals. / Conclusions. The evidence is insufficient to reliably identify individuals with asymptomatic carotid stenosis who are at a higher risk of cerebral ischemic events.

To aid diagnosis, treatment planning, and patient education, clinicians require tools to anal- yse and explore the increasingly large three-dimensional (3-D) datasets generated by modern medical scanners. Direct volume rendering is one such tool finding favour with radiologists and surgeons for its photorealistic representation. More recently, volume illustration — or non-photorealistic rendering (NPR) — has begun to move beyond the mere depiction of data, borrowing concepts from illustrators to visually enhance desired information and suppress un- wanted clutter. Direct volume rendering generates images by accumulating pixel values along rays cast into a 3-D image. Transfer functions allow users to interactively assign material properties such as colour and opacity (a process known as classification). To achieve real-time framerates, the rendering must be accelerated using a technique such as 3-D texture mapping on commod- ity graphics processing units (GPUs). Unfortunately, current methods do not allow users to intuitively enhance regions of interest or suppress occluding structures. Furthermore, addi- tional scalar images describing clinically relevant measures have not been integrated into the direct rendering method. These tasks are essential for the effective exploration, analysis, and presentation of 3-D images. This body of work seeks to address the aforementioned limitations. First, to facilitate the research program, a flexible architecture for prototyping volume illustration methods is pro- posed. This program unifies a number of existing techniques into a single framework based on 3-D texture mapping, while also providing for the rapid experimentation of novel methods. Next, the prototyping environment is employed to improve an existing method—called tagged volume rendering — which restricts transfer functions to given spatial regions using a number of binary segmentations (tags). An efficient method for implementing binary tagged volume rendering is presented, along with various technical considerations for improving the classifi- cation. Finally, the concept of greyscale tags is proposed, leading to a number of novel volume visualisation techniques including position modulated classification and dynamic exploration. The novel methods proposed in this work are generic and can be employed to solve a wide range of problems. However, to demonstrate their usefulness, they are applied to a specific case study. Ischaemic heart disease, caused by narrowed coronary arteries, is a leading healthconcern in many countries including Australia. Computed tomography angiography (CTA) is an imaging modality which has the potential to allow clinicians to visualise diseased coronary arteries in their natural 3-D environment. To apply tagged volume rendering for this case study, an active contour method and minimal path extraction technique are proposed to segment the heart and arteries respectively. The resultant images provide new insight and possibilities for diagnosing and treating ischaemic heart disease.

In patients with aortic stenosis, accurate assessment of severity with echocardiography is central to surgical decision making. But, when image quality is poor or equivocal results obtained, another robust non-invasive technique would be invaluable. Cardiac magnetic resonance (CMR) may be a useful alternative. Phase contrast CMR can measure ow and velocity, therefore it is theoretically possible to estimate the main determinant of severity aortic valve area, using the continuity approach. However, it was found that the phase contrast estimate of stroke volume, sampled in the stenotic jet, systematically underestimated left ventricular stroke volume. This underestimation was greater with increasing aortic stenosis severity. Critical clinical treatment decisions depend on the ability to reliably differentiate between patients with moderate and severe aortic stenosis. To achieve accurate estimation of aortic valve areas the velocity and ow data obtained in these turbulent, high velocity jets must be accurate. In this thesis, non-stenotic and stenotic phantoms were designed and constructed to experimentally interrogate the error. It was determined that signal loss, due to intravoxel dephasing, decreased the reliability of the measured forward ow jet velocities. Extreme signal loss in the jet eventuated in salt and pepper noise, which, with a mean velocity of zero, resulted in the underestimation. Intravoxel dephasing signal loss due to higher order motions, turbulence and spin mixing could all be mitigated by reducing the duration of the velocity sensitivity gradients and shortening the overall echo time (TE). However, improvements in an optimised PC sequence (TE 1:5ms) were not satisfactory. Flow estimates remained variable and were underestimated beyond the aortic valve. To reduce the TE further, a new phase contrast pulse sequence based on an ultrashort TE readout trajectory and velocity dependent slice excitation with gradient inversion was designed and implemented. The new sequence's TE is approximately 25% (0:65ms) of what is currently clinically available (TE 2:8ms). Good agreement in the phantom was maintained up to very high ow rates with improved signal characteristics shown in-vivo. This new phase contrast pulse sequence is worthy of further investigation as an accurate evaluation of patients with aortic stenosis. / This work in this thesis was conducted at The Auckland Bioengineering Institute, The Centre for Advanced MRI and The Oxford Centre for Clinical Magnetic Resonance in collaboration with Siemens Health care.

In patients with aortic stenosis, accurate assessment of severity with echocardiography is central to surgical decision making. But, when image quality is poor or equivocal results obtained, another robust non-invasive technique would be invaluable. Cardiac magnetic resonance (CMR) may be a useful alternative. Phase contrast CMR can measure ow and velocity, therefore it is theoretically possible to estimate the main determinant of severity aortic valve area, using the continuity approach. However, it was found that the phase contrast estimate of stroke volume, sampled in the stenotic jet, systematically underestimated left ventricular stroke volume. This underestimation was greater with increasing aortic stenosis severity. Critical clinical treatment decisions depend on the ability to reliably differentiate between patients with moderate and severe aortic stenosis. To achieve accurate estimation of aortic valve areas the velocity and ow data obtained in these turbulent, high velocity jets must be accurate. In this thesis, non-stenotic and stenotic phantoms were designed and constructed to experimentally interrogate the error. It was determined that signal loss, due to intravoxel dephasing, decreased the reliability of the measured forward ow jet velocities. Extreme signal loss in the jet eventuated in salt and pepper noise, which, with a mean velocity of zero, resulted in the underestimation. Intravoxel dephasing signal loss due to higher order motions, turbulence and spin mixing could all be mitigated by reducing the duration of the velocity sensitivity gradients and shortening the overall echo time (TE). However, improvements in an optimised PC sequence (TE 1:5ms) were not satisfactory. Flow estimates remained variable and were underestimated beyond the aortic valve. To reduce the TE further, a new phase contrast pulse sequence based on an ultrashort TE readout trajectory and velocity dependent slice excitation with gradient inversion was designed and implemented. The new sequence's TE is approximately 25% (0:65ms) of what is currently clinically available (TE 2:8ms). Good agreement in the phantom was maintained up to very high ow rates with improved signal characteristics shown in-vivo. This new phase contrast pulse sequence is worthy of further investigation as an accurate evaluation of patients with aortic stenosis. / This work in this thesis was conducted at The Auckland Bioengineering Institute, The Centre for Advanced MRI and The Oxford Centre for Clinical Magnetic Resonance in collaboration with Siemens Health care.

In patients with aortic stenosis, accurate assessment of severity with echocardiography is central to surgical decision making. But, when image quality is poor or equivocal results obtained, another robust non-invasive technique would be invaluable. Cardiac magnetic resonance (CMR) may be a useful alternative. Phase contrast CMR can measure ow and velocity, therefore it is theoretically possible to estimate the main determinant of severity aortic valve area, using the continuity approach. However, it was found that the phase contrast estimate of stroke volume, sampled in the stenotic jet, systematically underestimated left ventricular stroke volume. This underestimation was greater with increasing aortic stenosis severity. Critical clinical treatment decisions depend on the ability to reliably differentiate between patients with moderate and severe aortic stenosis. To achieve accurate estimation of aortic valve areas the velocity and ow data obtained in these turbulent, high velocity jets must be accurate. In this thesis, non-stenotic and stenotic phantoms were designed and constructed to experimentally interrogate the error. It was determined that signal loss, due to intravoxel dephasing, decreased the reliability of the measured forward ow jet velocities. Extreme signal loss in the jet eventuated in salt and pepper noise, which, with a mean velocity of zero, resulted in the underestimation. Intravoxel dephasing signal loss due to higher order motions, turbulence and spin mixing could all be mitigated by reducing the duration of the velocity sensitivity gradients and shortening the overall echo time (TE). However, improvements in an optimised PC sequence (TE 1:5ms) were not satisfactory. Flow estimates remained variable and were underestimated beyond the aortic valve. To reduce the TE further, a new phase contrast pulse sequence based on an ultrashort TE readout trajectory and velocity dependent slice excitation with gradient inversion was designed and implemented. The new sequence's TE is approximately 25% (0:65ms) of what is currently clinically available (TE 2:8ms). Good agreement in the phantom was maintained up to very high ow rates with improved signal characteristics shown in-vivo. This new phase contrast pulse sequence is worthy of further investigation as an accurate evaluation of patients with aortic stenosis. / This work in this thesis was conducted at The Auckland Bioengineering Institute, The Centre for Advanced MRI and The Oxford Centre for Clinical Magnetic Resonance in collaboration with Siemens Health care.

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