European Journal of Radiology 85 (2016) 534539

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Cortical vessel sign on susceptibility weighted imaging reveals

clinically relevant hypoperfusion in internal carotid artery stenosis
Sibu Mundiyanapurath a, , Peter A. Ringleb a , Sascha Diatschuk b,c , Sina Burth b ,
Markus Mhlenbruch b , Ralf O. Floca c , Wolfgang Wick a,d , Martin Bendszus b ,
Alexander Radbruch b,c
a
Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
b
Department of Neuroradiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
c
German Cancer Research Center, Department of Radiology, INF 280, 69120 Heidelberg, Germany
d
CCU Neurooncology, German Cancer Consortium (DKTK) & German Cancer Research Center (DKFZ), INF 280, 69120 Heidelberg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background and purpose: Internal carotid artery (ICA) stenosis can lead to cerebral hypoperfusion and is a
Received 20 July 2015 common cause of stroke. As susceptibility weighted imaging (SWI) has been used for penumbra imaging
Received in revised form in acute ischemic stroke, we aimed at analyzing hypoperfusion using SWI in patients with ICA stenosis.
30 November 2015
Material and methods: Clinical characteristics, asymmetric cortical vessel sign (more and/or larger,
Accepted 24 December 2015
hypointense asymmetric cortical vessels) on SWI, Doppler sonography results and diffusion weighted
imaging (DWI) lesion volume were retrospectively analyzed in patients with ICA stenosis. In a subgroup
Keywords:
of patients, volume of prolonged time to peak and volume of prolonged time to peak of the residue
Susceptibility weighted imaging
Perfusion weighted imaging
curve (Tmax ) were measured as reference standard. Outcome was assessed as modied Rankin score at
Carotid artery stenosis discharge.
Hypoperfusion Results: 104 patients were included. Median age was 72 and median degree of stenosis 70% according to
MR NASCET. 13% had a asymmetric cortical vessel sign. These patients had a higher degree of stenosis (80% vs.
Ischemic stroke 70%, p = 0.004), were more often symptomatic (93% vs. 61%, p = 0.020) and had higher DWI volume (7.3 ml
vs. 0.2 ml, p = 0.011). Specicity for the prediction of DWI lesions was 86%. Also, patients with asymmetric
cortical vessel sign had lower rates of favorable outcome (mRS = 02; 57% vs. 82%, p = 0.033) and volumes
of Tmax 4 s, 6 s, 8 s, 10 s and TTP 2 s, 4 s, 6 s were signicantly higher. In multivariate analysis,
asymmetric cortical vessel sign was an independent negative predictor of favorable outcome (mRS 02;
OR 0.184; CI [0.039; 0.875] p = 0.033).
Conclusion: In patients with ICA stenosis, asymmetric cortical vessel sign is a sign of clinically relevant
hypoperfusion.
2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Internal carotid artery (ICA) stenosis is a frequent etiology of
ischemic stroke and is estimated to affect about 13% of adults [1].
Abbreviations: ACVS, asymmetric cortical vessel sign; ICA, internal carotid
artery; DWI, diffusion weighted imaging; MRI, magnetic resonance imaging; mRS,
modied Rankin scale; NASCET, north american symptomatic carotid endarterec-
tomy trial; NIHSS, National Institute of Health Stroke Scale; PWI, perfusion weighted
imaging; SWI, susceptibility weighted imaging; Tmax , time to the peak of the residue
curve; TTP, time to the peak of the tissue concentration time curve.
Corresponding author. Fax: +49 6221 56 7554.
E-mail address: sibu.mundiyanapurath@med.uni-heidelberg.de
(S. Mundiyanapurath).
While many strokes due to ICA stenosis are of embolic origin, high-
grade ICA stenosis can elicit hemodynamically caused strokes in the
watershed areas [2]. Perfusion weighted imaging (PWI) can be used
to examine the hemodynamic effects of ICA stenosis. In ICA steno-
sis, however, clinically irrelevant increases of time to peak (TTP) can
be found [3,4]. Clinicians have to deal with a considerable uncer-
tainty in how to interpret these increases. More recent parameters
of perfusion weighted imaging as time to the peak of the residue
curve (Tmax ) and TTP with thresholding and normalization demand
a postprocessing software and are still under evaluation in larger
randomized trials [5]. In addition, contrast agents cannot be applied
in all patients due to contraindications, such as allergies or renal
failure. Therefore, alternatives for MR perfusion are needed in the
evaluation of hypoperfusion in patients with carotid artery steno-

http://dx.doi.org/10.1016/j.ejrad.2015.12.020
0720-048X/ 2015 Elsevier Ireland Ltd. All rights reserved.
 S. Mundiyanapurath et al. / European Journal of Radiology 85 (2016) 534539
sis. Susceptibility weighted imaging (SWI) can be used without any
postprocessing, can be implemented at basically any MR-scanner
and does not require the application of contrast agents. SWI is an
MRI sequence that leads to an increased contrast and conspicuity
of T2*-lesions through the combination of the phase mask and the
gradient echo magnitude map [68]. It has been used for the detec-
tion of cerebral microbleeds or intracranial hemorrhage for many
years [8]. Recently, changes in cortical and deep medullary vessels
were described in patients with acute ischemic stroke [916]. Signs
for hypoperfusion have been described in T2*-weighted imaging
before, but due to the calculation of the SWI maps explained above,
the ndings are more prominent and therefore easier to exam-
ine on SWI [17]. In the recent studies with SWI, more prominent
hypointense asymmetric and partially enlarged vessels were found
in areas of hypoperfusion. The hypointense vessels were found to
be a correlate of increased deoxyhemoglobin in this area [18]. All
of these changes were shown to predict outcome and can be used
to calculate a tissue at risk [13,14]. One study found that the cal-
culation of the penumbra using SWI was more accurate than the
calculation using PWI [13] in patients with ischemic stroke of the
anterior circulation. The aim of the current study was to inves-
tigate whether SWI abnormalities, i.e. asymmetric cortical vessel
sign (ACVS), occur in patients with ICA stenosis, whether they are
clinically relevant and whether they correspond to PWI changes.
2. Methods
The study was approved by the local ethics committee (state-
ment S-330/2012). Due to the retrospective nature of this study,
the ethics committee did not require subsequent informed written
consent of the included patients.
2.1. Patient selection
Consecutive patients were retrospectively selected from the
hospital database. Only patients with at least 20% ICA stenosis
(according to NASCET, see below) without intracranial stenosis
or occlusion (in Doppler sonography or angiography, Fig. S1) that
received MRI including SWI were selected. 20% was used as cut
off value because it is the lowest degree of stenosis with hemo-
dynamic changes in the ICA in Doppler sonography. Patients with
bilateral carotid artery stenosis could be included if at least one
side had less than 50% stenosis (NASCET). This exclusion crite-
rion was implemented as the ACVS is based on asymmetry and a
bilateral hemodynamically relevant ICA stenosis could lead to dif-
culties in scoring ACVS. Carotid artery occlusions were excluded.
Age, side of stenosis, degree of stenosis, type of stenosis (symp-
tomatic/asymptomatic), additional therapy (thrombolysis, carotid
endarterectomy, carotid artery stenting), risk factors (atrial bril-
lation, peripheral artery disease, smoking, hyperlipoproteinemia,
hypertension, diabetes), National Institute of Health Stroke Scale
(NIHSS) score and modied Rankin scale (mRS) score on admission
and on discharge and medication were recorded from the dis-
charge letters and the hospital archive. Symptomatic carotid artery
stenosis was dened by clinical symptoms that could have been
caused by the stenosis. Ipsilateral lesions on diffusion weighted
imaging (DWI) alone without clinical symptoms were not counted
as symptomatic. Degree of stenosis was examined using Doppler
sonography (see below).
Supplementary material related to this article can be found
in the online version, at http://dx.doi.org/10.1016/j.ejrad.2015.12.
020.
Clinical outcome was assessed at discharge by an experienced
stroke neurologist not blinded to the clinical course of the patient
but to this analysis by clinical examination using the NIHSS and the
535
mRS. A mRS of 02 was dened as favorable outcome, reecting
the ability to live independently. This denition is commonly used
in stroke trials [19]. In large stroke trials, patients with a higher
premorbid mRS are usually excluded. We included 7 patients with
a premorbid mRS of 3. For these patients an unchanged mRS at dis-
charge was dened as favorable outcome as well. 2 patients with an
premorbid mRS 4 were excluded, because a signicant increase in
disability can go in hand with an unchanged mRS in these patients.
2.2. Image acquisition
Images were acquired during routine clinical diagnostics using
a 3 Tesla MR system (Magnetom Tim Trio or Verio with identi-
cal technical parameters, Siemens Healthcare, Erlangen, Germany)
with a 12-channel head-matrix coil. SWI data were recorded
with a 3D, fully ow-compensated gradient echo sequence using
the following parameters: TE 19.7 ms, TR 27 ms, ip angle 15 ,
FOV 230 230 mm, slice thickness 3 mm, pixel spacing 0.72 and
an acquisition time of 2:16 min. The GRE magnitude and phase
images were converted into SW images by the MR-scanner
software. For dynamic susceptibility contrast perfusion imaging
(PWI) 0.1 mmol/kg gadolinium based contrast medium (Dotarem ,
Guerbet) was administered and images were obtained with a
GRE echo planar imaging (EPI) sequence: TE 35 ms, TR 1920 ms,
FOV 240 240 mm, slice thickness 5 mm, 75 dynamic scans
(0.1 mmol/kg Dotarem 3.5 ml/s using a power injector, injection
after the third frame), resulting in an acquisition time of 2:31 min.
TTP and Tmax maps were calculated using the software supplied by
the manufacturer (Syngo Software, Leonardo, Siemens Medical Sys-
tems, Erlangen, Germany). DWI was performed using a single-shot
spin-echo echo-planar sequence with the following parameters:
TE = 90 ms, TR = 5300 ms, ip angle = 90 , slice thickness = 5 mm.
Diffusion sensitizing gradients were applied sequentially in the x,
y, and z directions with b-values of 0 and 1200 s/mm2 . Apparent
diffusion coefcient trace maps were created automatically using
the above mentioned software, supplied by the manufacturer.
2.3. Image analysis
Pathological hypointense cortical vessels were scored posi-
tive if they were clearly asymmetric, enlarged or more numerous
on SWI by visual inspection and dened as asymmetric corti-
cal vessel sign (ACVS). SWI was scored prior to DWI to avoid a
reading bias by two authors (SM, AR). Any case of disagreement
was solved by consensus reading. We avoided performing volu-
metric measurement on SWI as these can be highly subjective if
it is not performed with quantitative automated measurement.
Dichotomized visual scoring of ACVS was used as it is can be done
rapidly and does not require sophisticated postprocessing methods.
The presence of a rosary-like pattern of DWI lesions in the cen-
trum semiovale was used to classify a hemodynamic distribution of
these lesions. Volumetric measurements were done using an open-
source segmentation-software (ITK-SNAP, www.itksnap.org [20]).
TTP maps with thresholds and Tmax maps with thresholds were
calculated automatically using the Olea-Sphere software (Olea
Medical , La Ciotat, France). Automatic detection for the arterial
input function and block-circulant matrix without minimization of
oscillation single value decomposition deconvolution were used.
The maps were then grouped by values and the respective volumes
were computed using in-house software created with MATLAB
(MathWorks , Natick, MA, USA) by one of the authors (SD). For
TTP the groups were: 2 s, 4 s and 6 s. For Tmax the groups were:
4 s, 6 s, 8 s and 10 s. All images were manually checked and
corrected for artifacts using ITK-SNAP. PWI images were aligned
536 S. Mundiyanapurath et al. / European Journal of Radiology 85 (2016) 534539

with T2-images to facilitate artifact detection using an FSL-based Table 1

Baseline characteristics.
algorithm. Image reading was done blinded to outcome parameters.
n = 104

Age (years); median (IQR) 72 (63; 77)

2.4. Doppler sonography
Degree of stenosis (%); median (IQR) 70% (50; 80)
Left sided stenosis 63%
The degree of the stenosis was determined by routine
Cardiovascular risk factors
continuous-wave Doppler sonography using a 4 MHz extracranial
Atrial brillation 12%
Doppler probe (SONARA system, medilab , Estenfeld, Germany) Peripheral artery disease 14%
and a linear 510 Mhz duplex probe with color Doppler-assisted Coronary heart disease 21%
imaging according to the NASCET criteria based on criteria dened Current smoker 30%
Hypercholesterinemia 52%
by the German Society of Sonography in Medicine (DEGUM) [21].
Hypertension 82%
Transcranial Doppler sonography was performed in routine clinical Diabetes mellitus 29%
workup with a 2 MHz pulse-wave probe using the SONARA sys-
Medication
tem. The frequencies used in the study were collected by probing
ACE-inhibitor 36%
the MCA at 50 mm depth. The extent of ow distraction reduced Angiotensin-receptor blocker 20%
acceleration time in the MCA was assessed based on acoustic Beta blocker 42%
impression compared to the normal contralateral side. Ultrasound Calcium-channel blocker 24%
Diuretics 37%
was performed by a vascular neurologist (more than 20 years of
Statin 42%
experience) or one of two technicians (more than 20 years of expe- Aspirin 49%
rience and 7 years of experience). Clopidogrel 13%
Oral anticoagulation 5%
Insulin 4%
2.5. Statistical analysis Oral antidiabetic drugs 18%

Female gender 34%

Statistical analysis was carried out with Microsoft Excel Ver-
sion 2010 and IBM SPSS Version 21. Pretesting for normal
distribution was not performed to avoid error accumulation [22].
Inter-rater reliability was tested using Cohens Kappa coefcient.
Univariate analysis comparing the patients with ACVS and without
ACVS on the one hand and with favorable and unfavorable out-
come on the other hand was performed using MannWhitney-U
and chi-square test depending on the level of measurement. Multi-
variate analysis with favorable outcome as dependent variable was
done applying binary logistic regression models. Variable selection
was performed using the backward elimination method based on
likelihood-ratio tests where variables were removed if the related
p-value fell above 0.10. An -Level of 0.05 was chosen. Two-sided
p-values are reported throughout.
Length of stay in hospital 5 (4; 7)
ACE: angiotensin converting enzyme.
In the subgroup of patients with PWI, volume of prolonged
TTP 2 s/4 s/6 s and Tmax 4 s/6 s/8 s/10 s were substan-
tially different between patients with or without ACVS (Table 3).
Analyzing outcome, univariate analysis showed that besides
the incidence of ACVS (p = 0.033) and diabetes (p = 0.014) were
signicantly different between patients with favorable (mRS 02
or identical to admission) and unfavorable outcome (Table S1).
NIHSSS on admission (OR 0.699; [0.578; 0.844]; p < 0.001) and ACVS
(OR 0.184; CI [0.0390; 0.875]; p = 0.033) were the only indepen-
dent predictors of outcome in the multivariate logistic regression
that included all signicantly different parameters of the univariate
analysis (ACVS, diabetes, NIHSSS on admission, premorbid mRS).

3. Results
Table 2
Characteristics of patients with and without ACVS. Values are shown as median (IQR)
104 patients that were treated between 2009 and 2014 were or percentage.
retrieved from the hospital database. The baseline characteris-
tics are summarized in the rst table (Table 1). Out of the 104 ACVS No ACVS p-value
(n = 14) (n = 90)
selected patients, 39 (38%) also had a PWI sequence available
for evaluation. Intracranial stenosis was excluded in 70% using Age (years) 74 (68; 82) 71 (63; 75) 0.083
Degree of stenosis (%) 80 (70; 90) 70 (40; 80) 0.004
Doppler sonography, in 20% using contrast-enhanced MR angiog-
Symptomatic stenosis 93% 61% 0.020
raphy, in 5% using time-of-ight MR angiography and in another 5%
using CT-angiography. 25 patients (24%) had bilateral ICA stenosis. TCD
SF (kHz) 1.9 (1.7; 2.4) 2.2 (1.6; 2.6) 0.642
Inter-rater reliability analysis for scoring ACVS showed substantial
DF (kHz) 0.7(0.6; 1.0) 0.8 (0.6; 0.9) 0.612
agreement (Cohens kappa coefcient 0.75; p < 0.001). ACVS was Contralateral SF (kHz) 1.9 (1.8; 3.1) 2.0 (1.6; 2.9) 0.680
found in 13% of the patients (Fig. 1). Although it was less prominent Contralateral DF (kHz) 0.7 (0.6; 1.1) 0.8 (0.6; 1.0) 0.962
than in middle cerebral artery occlusion, ACVS could be effortlessly RI 0.64 (0.56; 0.67) 0.63 (0.56; 0.68) 0.786
Contralateral RI 0.65 (0.61; 0.72) 0.63 (0.59; 0.68) 0.456
scored in all patients (see Fig. S2 for further examples). Patients
Reduced acceleration at MCA 64%% 36% 0.145
with ACVS had a higher degree of stenosis according to NASCET
(80% vs. 70%, p = 0.004), larger volumes with restricted diffusion DWI lesion volume (ml) 7.3 (0.2; 16.3) 0.2 (0; 4.8) 0.011
DWI hemodynamic distribution 71% 26% 0.093
(7.3 ml vs. 0.2 ml, p = 0.011), and less frequently had a favorable
Favorable outcome 57% 82% 0.033
outcome (57% vs. 82%, p = 0.033) (Table 2). Although there was a
higher rate of hemodynamic distributions (rosary-like pattern) of Treatment
IV alteplase 7% 8% 0.925
the DWI lesions (71% vs. 26%), this did not reach statistical signi- CAS/CEA 64% 46% 0.205
cance (p = 0.093). Even though sensitivity for the detection of DWI
ACVS: asymmetric cortical vessel sign; TCD: transcranial doppler sonography;
lesions was very low (21%), the specicity of ACVS reached 86%.
SF/DF: systolic/diastolic frequency, RI: resistance index; MCA: middle cerebral
Supplementary material related to this article can be found artery; DWI: diffusion weighted imaging; NIHSSS: National Institute of Health
in the online version, at http://dx.doi.org/10.1016/j.ejrad.2015.12. Stroke Scale Score; mRS: modied Rankin Scale score; CAS: carotid artery stenting;
020. CEA: carotid endarterectomy.
 S. Mundiyanapurath et al. / European Journal of Radiology 85 (2016) 534539 537

Fig. 1. Asymmetric cortical vessel sign in patients with internal carotid artery stenosis.
First row shows images of a patient with 70% stenosis and unfavorable outcome. In SWI, asymmetric hypointense cortical vessels on the left side are prominent (A). PWI
shows a large hypoperfused region in this area (B). Additional intracranial MCA stenosis was ruled out in this patient by CTA (Fig. S1). Second row shows images of another
patient with 70% stenosis but favorable outcome. No asymmetric hypointense vessels were observed on SWI (C) and PWI was normal (D). Bar shows color-coded Tmax values
(in seconds) for PWI.

Supplementary material related to this article can be found increase in deoxyhemoglobin, that can be detected using SWI. We
in the online version, at http://dx.doi.org/10.1016/j.ejrad.2015.12. demonstrated that this hypoperfusion can be identied by simply
020. stating whether asymmetric cortical vessels were present or not.
This nding is conrmed by the subgroup of patients that showed
4. Discussion higher volumes of pathological Tmax and TTP values in patients with
ACVS. While hypoperfusion in stroke has been found to correlate
In our study, we present evidence that SWI is a new method to with SWI abnormalities in previous studies [16,17] the results of
judge hypoperfusion in patients with ICA stenosis. The hypoper- our study are new in that they show the clinical relevance of the
fusion found in carotid artery stenosis seems to cause a relevant ACVS in a homogenous population of patients with ICA stenosis.
Table 3
Risk factors and medication are comparable to previously described
Perfusion weighted imaging volumes for patients with or without ACVS. populations of patients with ICA stenosis [23].
DWI lesion volume is a well-known risk factor for unfavorable
ACVS (n = 8) No ACVS (n = 31) p-value
outcome in ischemic stroke and it is therefore of interest whether
Tmax imaging signs of hypoperfusion show a correlation to DWI lesions
4 s 42.2 (5.7; 110.6) 0 (0; 7.3) 0.007
[24]. While Tmax and TTP are sensitive for the detection of DWI
6 s 16.7 (2.3; 42.1) 0 (0; 0.8) 0.005
8 s 10.2 (1.7; 15.3) 0 (0; 0.4) 0.005 lesions, our study showed that SWI and ACVS had a rather low
10 s 6.6 (1.5; 9.4) 0 (0; 0.2) 0.007 sensitivity but a reasonable specicity for DWI lesions (86%). This
goes in hand with previously published studies. Lou et al. ana-
TTP
2 s 48.0 (29.5; 138.7) 12.6 (0; 30.0) 0.006 lyzed 54 patients and found that the SWIDWI mismatch is more
4 s 14.7 (2.8; 69.3) 0.7 (0; 2.9) 0.005 accurate than several denitions of PWIDWI mismatch [13]. They
6 s 10.8 (1.3; 26.3) 0.2 (0; 0.8) 0.003 also stated that while the sensitivity was lower compared to the
ACVS: asymmetric cortical vessel sign; Tmax : time to peak of the residue curve; TTP: PWIDWI mismatch, the specicity was markedly higher which is
time to peak of the tissue concentration curve. similar to our nding. Taken these ndings together, SWI changes
538 S. Mundiyanapurath et al. / European Journal of Radiology 85 (2016) 534539
only seem to occur in critical hypoperfusion and are clinically rel-
evant when they occur. The impact on short term outcome in
patients with ICA stenosis was evident in our study. ACVS was an
independent predictor of outcome in multivariate analysis. Other
studies have shown the effect of ACVS on outcome in patients
with middle cerebral artery infarction [14,25]. We suspect that
the reason for this increased rate of unfavorable outcome might
be caused by early infarct growth which was reported to occur
in areas with severe hypoperfusion [26]. This would have to be
proven in a prospective study using sequential MR imaging. Sun
et al. included patients with ICA stenosis as well. However, a com-
parison to our results is difcult as the degree of stenosis and the
number of patients with intracranial stenosis is not described in
detail. High-grade intracranial stenosis/occlusion can cause man-
ifest alteration of ACVS [25,27] and patients who exhibited these
were therefore excluded in our trial.
In comparison to another study that used more specic and
objective methods as voxel count and asymmetry index [13], ACVS
is a subjective parameter. Even though this is a disadvantage
regarding reproducibility, this simple method has the advantage
that it can be used all over the world, without the need for mostly
complicated and time consuming postprocessing methods. For
clinicians it is an important advantage if the result can be obtained
immediately. Due to these advantages ACVS has been used by other
groups before [14,25]. Although SWI and ACVS are therefore con-
venient methods, other non-invasive methods like arterial spin
labeling with the advantage of whole brain and selective perfusion
imaging are also available [2830].
Limitations of our study include the retrospective monocentric
design that might have led to a selection bias. Especially regarding
outcome analysis, we suspect that a higher percentage of severely
affected patients were admitted to the hospital and received MRI,
while MRI is rarely performed in asymptomatic patients. Further-
more, the outcome parameters only show short term outcome and
our results cannot be used to predict the risk for recurrent stroke.
The exclusion of intracranial stenosis was mainly based on Doppler
sonography whose accuracy is dependent on the examiner. This is
also true for the classication of the degree of stenosis. Although
our results were obtained by a vascular neurologist or a techni-
cian with exhaustive experience in Doppler sonography, we cannot
exclude that intracranial stenosis might have been missed or that
the degree of stenosis is incorrect in some patients. Especially for
patients with pseudoocclusions, Doppler sonography has its limita-
tions. In the future, prospective trials with larger patient numbers
should be carried out to conrm our ndings. Once conrmed, SWI
might be used to evaluate critical and clinically relevant hypoper-
fusion in patients with ICA stenosis and contraindications against
contrast agents.
5. Conclusion
Our study provides evidence that ACVS might be a new method
to evaluate critical and clinically relevant hypoperfusion in patients
with ICA stenosis. Prospective trials will have to examine whether
early infarct growth might be one of the reasons for a higher rate
of unfavorable outcome in patients with ACVS.
Conict of interests
None.
Contributions
In our manuscript, we present a new method to evaluate
hypoperfusion in patients with carotid artery stenosis. Using sus-
ceptibility weighted imaging and the asymmetric cortical vessel
sign, critical and clinically relevant hypoperfusion can be depicted
without the need for contrast agents or postprocessing methods.
The identication of relevant hypoperfusion might become impor-
tant in the selection of patients for revascularization procedures in
the future.
Susceptibility weighted imaging reveals clinically relevant
hypoperfusion in carotid artery stenosis.
Disclosures
None.
Funding
None.
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