Spinal infarcts.

Compared to cerebral ischaemia, the frequency of spinal cord ischaemia is rare. Spinal infarcts lead to various types of neurological deficits, usually consisting of an abrupt and complete tetra- or paraplegia. Magnetic resonance imaging is the most valuable tool to show the infarct and to rule out other causes of acute spinal cord syndromes., such as myelitis or acute compressions. Nowadays, in western countries, most spinal cord infarcts are due to aortic diseases (atherosclerosis, aneurysm, dissection) or are of iatrogenic origin (mainly aortic surgery and interventional radiology), while other causes are rare. There is no specific treatment, besides prevention of complications, treatment of the underlying cause and rehabilitation.

Access to mechanical thrombectomy for cerebral ischaemia: A population-based study in the North-of-France.

BACKGROUND AND PURPOSE: Hospitals admitting acute strokes should offer access to mechanical thrombectomy (MT), but local organisations are still based on facilities available before MT was proven effective. MT rates and outcomes at population levels are needed to adapt organisations. We evaluated rates of MT and outcomes in inhabitants from the North-of-France (NoF) area. METHOD: We prospectively evaluated rates of MT and outcomes of patients at 3 months, good outcomes being defined as a modified Rankin scale (mRS) 0 to 2 or like the pre-stroke mRS. RESULTS: During the study period (2016-2017), 666 patients underwent MT (454, 68.1% associated with intravenous thrombolysis [IVT]). Besides, 1595 other patients received IVT alone. The rate of MT was 81 (95% confidence interval [CI] 72-90) per million inhabitants-year, ranging from 36 to 108 between districts. The rate of IVT was 249 (95% CI 234-264) per million inhabitants-year, ranging from 155 to 268. After 3 months, 279 (41.9%) patients who underwent MT had good outcomes, and 167 (25.1%) had died. Patients living outside the district of Lille where the only MT centre is, were less likely to have good outcomes at 3 months, after adjustment on age, sex, baseline severity, and delay. CONCLUSION: The rate of MT is one of the highest reported up to now, even in low-rate districts, but outcomes were significantly worse in patients living outside the district of Lille, and this is not only explained by the delay.

Are the results of intravenous thrombolysis trials reproduced in clinical practice? Comparison of observed and expected outcomes with the stroke-thrombolytic predictive instrument (STPI).

AIM: In patients with cerebral ischemia, intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) increases survival without handicap or dependency despite an increased risk of bleeding. This study evaluated whether the results of randomized controlled trials are reproduced in clinical practice. METHOD: Data from a registry of consecutive patients treated by rt-PA at Lille University Hospital were retrospectively analyzed for outcomes, using modified Rankin Scale (mRS) scores, at 3 months. The observed outcomes were then compared with the probability of good (mRS 0-1) and of catastrophic (mRS 5-6) outcomes, as predicted by the stroke-thrombolytic predictive instrument (STPI). RESULTS: Of the 1000 consecutive patients (469 male, median age 74 years, median baseline National Institutes of Health Stroke Scale 11, median onset-to-needle time 143min), 438 (43.8%) had a good outcome, 565 (56.5%) had an mRS score 0-2 or similar to their pre-stroke mRS, 155 (15.5%) died within 3 months and 74 (7.4%) developed symptomatic intracerebral hemorrhage according to ECASS-II (Second European-Australasian Acute Stroke Study) criteria. Of the 613 patients (61.3%) eligible for evaluation by the s-TPI, the observed rate of good outcomes was 41.3% (95% CI: 37.5-45.3%), while expected rates with and without rt-PA were 48.8% (95% CI: 44.8-52.7%) and 32.5% (95% CI: 28.8-36.2%), respectively; the observed rate of catastrophic outcomes was 17.0% (95% CI: 14.0-19.9%), while the expected rate was 19.2% (95% CI: 16.1-22.4%) with or without rt-PA. CONCLUSION: In clinical practice, the rate of good outcomes is slightly lower than expected, according to the s-TPI, except for the most severe cases, whereas the rate of catastrophic outcomes is roughly similar. However, the rate of good outcomes is higher than predicted without treatment. This finding suggests that rt-PA is effective for improving outcomes in clinical practice.

Length of optic nerve double inversion recovery hypersignal is associated with retinal axonal loss.

OBJECTIVES: To assess the association between optic nerve double inversion recovery (DIR) hypersignal length and retinal axonal loss in neuroinflammatory diseases affecting optic nerves. METHODS: We recruited patients previously affected (> 6 months) by a clinical episode of optic neuritis (ON). We had 25 multiple sclerosis (MS) patients, eight neuromyelitis optica spectrum disorder (NMOSD) patients and two patients suffering from idiopathic caused ON undergo brain magnetic resonance imaging (MRI); including a 3-dimensional (3D) DIR sequence, optical coherence tomography (OCT) examination and visual disability evaluation. Evaluation criteria were retinal thickness/volume, optic nerve DIR hypersignal length and high/low contrast vision acuity. RESULTS: In the whole cohort, we found good associations (< 0.0001) between optic nerve DIR hypersignal length, peripapillary retinal nerve fiber layer thickness, inner macular layers volumes, and visual disability. We found subclinical radiological optic nerve involvement in 38.5% of non-ON MS eyes. CONCLUSIONS: Optic nerve DIR hypersignal length may be a biomarker for retinal axonal loss, easily applicable in routine and research on new anti-inflammatory or neuroprotective drug evaluation. Detection of subclinical ON with 3D-DIR in a non-negligible proportion of MS patients argues in favor of optic nerve imaging in future OCT MS studies, in order to achieve a better understanding of retinal axonal loss in non-ON eyes.

Reduced-dose CT protocol for the assessment of cerebral vasospasm.

INTRODUCTION: Despite the increased radiation dose, multimodal CT including noncontrast CT (NCT), CT angiography (CTA), and perfusion CT (PCT) remains a useful tool for the diagnosis of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess the radiation dose and the image quality between a standard-dose and a reduced-dose multimodal CT protocol. METHODS: The study group consisted of 26 aSAH patients with a suspicion of DCI on clinical examination and transcranial doppler. Two different CT protocols were used: a standard-dose protocol (NCT 120 kV, 350 mAs; CTA 100 kV, 250 mAs; PCT 80 kV, 200 mAs) from August 2011 to October 2013 (n = 13) and a reduced-dose protocol (NCT 100 kV, 400 mAs; CTA 100 kV, 220 mAs; PCT 80 kV, 180 mAs) from November 2013 to May 2014 (n = 13). Dose-length product (DLP), effective dose, volume CT dose index (CTDI), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and overall image quality were determined for each examination. RESULTS: The overall image quality was judged as good or excellent in all cases. The reduced-dose protocol allowed a 15 % decrease in both the median total DLP (2438 vs 2898 mGy cm, p < 0.0001) and the effective dose as well as a significant decrease in median CTDI of 23, 31, and 10 % for NCT, CTA, and CTP, respectively. This dose reduction did not result in significant alteration of SNR (except for NCT) or CNR between groups. CONCLUSION: The present study showed that the reduced-dose multimodal CT protocol enabled a significant reduction of radiation dose without image quality impairment.

Feasibility and usefulness of brain imaging in catatonia.

Catatonia is a well characterized psychomotor syndrome that has recognizable motor, affective, behavioural and vegetative manifestations. Despite recent demonstration that catatonia is often associated with brain imaging abnormalities, there is currently no consensus or guidelines about the role of brain imaging. In this study, we assessed the feasibility of brain imaging in a series of patients with catatonia in a routine clinical setting and estimated the prevalence of clinically relevant radiological abnormalities. Sixty patients with catatonia were evaluated against sixty non-healthy controls subjects with headache. The MRI reports were reviewed, and MRI scans were also interpreted by neuroradiologists using a standardised MRI assessment. In this cohort, more than 85% of brain scans of patients with catatonia revealed abnormalities. The most frequently reported abnormalities in the catatonic group were white matter abnormalities (n = 44), followed by brain atrophy (n = 27). There was no evidence for significant differences in the frequency of abnormalities found in radiology reports and standardised neuroradiological assessments. The frequency of abnormalities was similar to that found in a population of non-healthy controls subjects with headache. This study shows that MRI is feasible in patients with catatonia and that brain imaging abnormalities are common findings in these patients. Most frequently, white matter abnormalities and diffuse brain atrophy are observed.

Single-centre prospective comparison between contrast-enhanced ultrasound and computed tomography angiography after EVAR.

AIM: To evaluate contrast-enhanced ultrasound (CEUS) as an effective alternative to CT-angiography (CTA) for endoleak detection and aneurismal sac diameter measurement in the follow-up after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: From January 2006 to December 2010, 395 patients underwent EVAR follow-up with both CTA and CEUS. The diameter of the aneurismal sac and the presence of endoleaks were evaluated in all the 395 paired examinations. RESULTS: Bland-Altman plots showed a good agreement in aneurismal sac diameter evaluation between the two imaging modalities. The mean diameter was 54.93 mm (standard deviation (SD) ±12.57) with CEUS and 56.01 mm (SD ± 13.23) with CTA. The mean difference in aneurismal sac diameter was -1.08 mm ± 3.3543 (95% confidence interval (CI), -0.75 to -1.41), in favour of CTA. The number of observed agreement in endoleak detection was 359/395 (90.89%). The two modalities detected the same type I and type III endoleaks. McNemar's χ(2) test confirmed that CTA and CEUS are equivalent in endoleak detection. CONCLUSIONS: CEUS demonstrated to be as accurate as CTA in endoleak detection and abdominal aortic aneurysm diameter measurements during EVAR follow-up, without carrying the risks of radiation exposure or nephrotoxicity. Even if it cannot be proposed as the sole imaging modality during follow-up, our analysis suggests that it should have a major role.

[Paraclinoid region: descriptive anatomy and radiological correlations with MR imaging]. / La région paraclinoïdienne: anatomie descriptive et corrélations radiologiques en imagerie par résonance magnétique.

OBJECTIVE: The paraclinoid region has a complex anatomy. The purpose of this study was to depict in details its anatomical landmarks and their radiological translations with magnetic resonance imaging (MRI). MATERIAL AND METHOD: Ten anatomical specimens (20 paraclinoid regions) were prepared, then dissected and further analyzed with MRI in order to describe their important radio-anatomical structures (dural folds, osseous surfaces, arteries and nerves) along with their course and measurements, and the reference points of the carotid distal dural ring. The paraclinoid MR protocol consisted in a T2 high-resolution sequence with thin and contiguous slices acquired in a coronal (diaphragmatic) and sagittal oblique (carotid) plane. Reproducibility in living subjects was evaluated on 15 patients (30 paraclinoid regions). Statistical comparison was made between laboratory and MR measurements obtained on cadavers. RESULTS: A detailed description of paraclinoid anatomy and structures was provided. Its landmarks were satisfactorily identified with the dedicated MR protocol. Reproducibility in living subjects was obtained. No statistical difference was found between laboratory and MR measurements. CONCLUSION: This study provides a precise description of paraclinoid anatomical structures and their radiological correlations. This paraclinoid MR protocol allows locating paraclinoid lesions in comparison with the cavernous sinus roof, which is of paramount importance for the management of paraclinoid carotid artery aneurysms.

[Diffusion-weighted MR imaging of the brain]. / IRM de diffusion et encéphale.

Imaging of water diffusion or diffusion-weighted MR imaging provides physiological information about brain diseases that cannot be obtained from conventional sequences. This technique is very sensitive for the detection of cerebral ischemia from arterial origin and can distinguish cerebral ischemia from other non-vascular brain pathologies in patients presenting with abrupt onset of focal neurological deficit. Diffusion-weighted imaging is used for the evaluation of non-vascular diseases as well. Combined with conventional sequences, it is helpful to differentiate brain abscesses from necrotic tumors. Quantitative diffusion-weighted imaging provides additional information in the characterization of tumors or inflammatory, degenerative and metabolic lesions. Finally, diffusion-weighted imaging data also has prognostic value.

Structural Connectivity and Cortical Thickness Alterations in Transient Global Amnesia.

BACKGROUND AND PURPOSE: Transient global amnesia (TGA) is a sudden onset of anterograde and retrograde amnesia. We aimed to assess differences in terms of cortical thickness and structural brain connectome between patients with TGA (at acute and delayed postrecovery stages) and matched controls. MATERIALS AND METHODS: We report on 18 consecutive patients with TGA who underwent 3T MR imaging, including DTI and MPRAGE sequences, at the acute (mean delay postonset: 44 hours) and delayed post-recovery (mean delay: 35 days) stages. Structural connectome was assessed in patients with TGA and in 18 age- and sex-matched controls by using probabilistic fiber- tracking and segmentation of 164 cortical/subcortical structures ("nodes"). Connectivity graphs were computed and global network metrics were calculated. Network-based statistical analysis (NBS) was applied to compare patients with TGA at each stage with controls. We also compared cortical thickness between patients with TGA and healthy controls. RESULTS: Global network metrics were not altered in patients with TGA. NBS-analysis showed structural connectome alterations in patients with TGA compared with controls, in core regions involving the limbic network, with 113 nodes and 114 connections (33 left intrahemispheric, 31 right intrahemispheric, and 50 interhemispheric connections) showing significantly decreased structural connectivity (P < .05 NBS corrected, t-values ranging from 3.03 to 8.73). Lower cortical thickness compared with controls was associated with these structural alterations in patients with TGA, involving the orbitofrontal, cingulate, and inferior temporal cortices. All the abnormalities were visible at both acute and delayed postrecovery stages. CONCLUSIONS: Our preliminary study suggests there are structural abnormalities of the limbic network in patients with TGA compared with controls, including decreased structural connectivity and cortical thickness.

COVID-19 Neurologic Complication with CNS Vasculitis-Like Pattern.

Coronavirus disease 2019 (COVID-19) is a viral infection caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), which spreads rapidly from person to person and manifests in most symptomatic patients as a respiratory illness, similar to prior SARS viruses. Neurologic manifestations of COVID-19 are uncommon; those so far reported include encephalopathy, stroke from large-vessel occlusion, and polyneuropathy. We report a unique neurologic complication of COVID-19 in a patient who had extensive cerebral small-vessel ischemic lesions resembling cerebral vasculitis in a characteristic combined imaging pattern of ischemia, hemorrhage, and punctuate postcontrast enhancement. Also, a characteristic lower extremity skin rash was present in our patient. Our observation lends support to the increasingly suspected mechanism of "endotheliitis" associated with this novel coronavirus.

Follow-Up MRI for Small Brain AVMs Treated by Radiosurgery: Is Gadolinium Really Necessary?

BACKGROUND AND PURPOSE: Follow-up MR imaging of brain AVMs currently relies on contrast-enhanced sequences. Noncontrast techniques, including arterial spin-labeling and TOF, may have value in detecting a residual nidus after radiosurgery. The aim of this study was to compare noncontrast with contrast-enhanced MR imaging for the differentiation of residual-versus-obliterated brain AVMs in radiosurgically treated patients. MATERIALS AND METHODS: Twenty-eight consecutive patients with small brain AVMs (<20 mm) treated by radiosurgery were followed with the same MR imaging protocol. Three neuroradiologists, blinded to the results, independently reviewed the following: 1) postcontrast images alone (4D contrast-enhanced MRA and postcontrast 3D T1 gradient recalled-echo), 2) arterial spin-labeling and TOF images alone, and 3) all MR images combined. The primary end point was the detection of residual brain AVMs using a 5-point scale, with DSA as the reference standard. RESULTS: The highest interobserver agreement was for arterial spin-labeling/TOF (κ = 0.81; 95% confidence interval, 0.66-0.93). Regarding brain AVM detection, arterial spin-labeling/TOF had higher sensitivity (sensitivity, 85%; specificity, 100%; 95% CI, 62-97) than contrast-enhanced MR imaging (sensitivity, 55%; specificity, 100%; 95% CI, 27-73) and all MR images combined (sensitivity, 75%; specificity, 100%; 95% CI, 51-91) (P = .008). All nidus obliterations on DSA were detected on MR imaging. In 6 patients, a residual brain AVM present on DSA was only detected with arterial spin-labeling/TOF, including 3 based solely on arterial spin-labeling images. CONCLUSIONS: In this study of radiosurgically treated patients with small brain AVMs, arterial spin-labeling/TOF was found to be superior to gadolinium-enhanced MR imaging in detecting residual AVMs.

Spontaneous thrombosis of a recurrent clipped intracranial aneurysm.

Spontaneous thrombosis of an intracranial aneurysm is a rare event. It is predominantly observed with aneurysms that are large and have relatively narrow necks. We report here a case of a 48-year-old woman presenting with subarachnoid hemorrhage (SAH) due to rupture of a 2-mm aneurysm of the anterior cerebral artery treated by microsurgical clipping. Six months after treatment of the aneurysm, the patient presented with severe headache. SAH was excluded, but computed tomographic angiography (CTA) revealed the recurrence of a large aneurysm (7 mm) that was confirmed by cerebral angiography (DSA). Endovascular treatment was scheduled for several days later, but DSA also revealed spontaneous occlusion of the recurrent aneurysm. On the control CTA performed one week later, the recurrent aneurysm had again reappeared, again confirmed by DSA, and was subsequently treated by coil embolization.

[Management of intracranial dural arteriovenous fistulas with cortical venous drainage]. / Prise en charge des fistules artérioveineuses durales intracrâniennes à drainage veineux cortical.

BACKGROUND AND PURPOSE: Intracranial dural arteriovenous fistulas (DAVF) with cortical venous drainage are vascular malformations with high hemorrhagic risk. Their treatment may be complex and requires a multidisciplinary approach. METHODS: We retrospectively report 38 observations of dural arteriovenous fistulas with cortical venous drainage from 1990 to 2001. There were 28 men and 10 women with a mean age of 57 years. Hemorrhage revealed the malformation in 24 cases (63%). The other patients had headache, neurological deficit, seizure or pulsating mass of the scalp. One patient was asymptomatic. All the patients had DAVF with cortical venous drainage and decision of treatment was in each case multidisciplinary. RESULTS: Of the 38 patients, seven had no treatment for the following reasons: spontaneous occlusion of the malformation after hemorrhage, refusal of treatment, or poor neurological status at the admission. Thirty-one patients were treated and complete exclusion of the fistula was obtained in 30 cases. Endovascular occlusion of the fistula was performed in 14 patients, surgical clipping of the origin of the draining vein in 12 and combined treatment (surgical clipping after embolization of feeding arteries) in four. One patient had an untreated fistula despite several procedures. CONCLUSION: Complete exclusion of these malformations is mandatory because of the potential risk of hemorrhagic complications. The best treatment is the occlusion of the origin of the draining vein (endovascular or surgical) and requires multidisciplinary discussion.

Endovascular Stroke Therapy with a Novel 6-French Aspiration Catheter.

BACKGROUND AND PURPOSE: Direct thrombus aspiration is increasingly used as a first-line therapy in acute ischemic stroke with large vessel occlusion. We assessed the performance and safety of a novel aspiration catheter available: the 6-French AXS Catalyst catheter. MATERIALS AND METHODS: We conducted a cohort study from a prospective clinical registry of consecutive stroke patients treated by mechanical thrombectomy between March 2016 and July 2016. Baseline clinical and imaging characteristics, recanalization rates, complications, and clinical outcomes were analyzed. RESULTS: Among the 60 patients included, 30 were treated using aspiration alone, 14 were treated using aspiration and then stent retriever as a rescue therapy, and 16 were treated using aspiration combined with a stent retriever straightaway. Successful recanalization (mTICI2b/3) was achieved in 85% patients and functional independence in 48.3%. We observed one intracranial perforation and one vertebral artery dissection. Symptomatic intracranial hemorrhage occurred in 5% and mortality in 21.7%. CONCLUSION: Endovascular stroke therapy using the AXS Catalyst catheter seems safe and effective, with similar performance than other reperfusion catheters.

Biometry of the Cerebellar Vermis and Brain Stem in Children: MR Imaging Reference Data from Measurements in 718 Children.

BACKGROUND AND PURPOSE: Objective and quantitative data to define cerebellar vermis and/or brain stem hypoplasia in children are lacking. Our aim was to provide MR imaging biometric references for the cerebellar vermis and brain stem from a large cohort of children with normal cerebellums. MATERIALS AND METHODS: The MR imaging data were retrospectively selected from our hospital data base from January 1, 2014, to December 31, 2017. All MR imaging examinations of children between 1 day and 15 years of age, including midline sagittal sections, were included. Children with a clinical history or MR imaging abnormalities that may affect the posterior fossa were excluded. We manually measured four 2D parameters: vermian height, anterior-posterior diameter of the vermis, anterior-posterior diameter of the midbrain-pons junction, and anterior-posterior midpons diameter. The inter- and intraobserver agreement was evaluated. RESULTS: Seven hundred eighteen children were included (372 boys and 346 girls), from 1 day to 15 years of age. Normal values (third to 97th percentiles) were provided for each parameter. The vermis parameters showed a rapid growth phase during the first year, a slower growth until the fifth year, and finally a near-plateau phase. The brain stem parameters showed more progressive growth. The intra- and interobserver agreement was excellent for all parameters. CONCLUSIONS: We provide reference biometric data of the vermis and the brain stem using simple and reproducible measurements that are easy to use in daily practice. The relevance of these 2D measurements should be further validated in diseases associated with cerebellar abnormalities.

[New techniques of structural and functional MRI]. / Nouvelles techniques d'IRM morphologique et fonctionnelle.

Magnetic resonance imaging is an imaging technique allowing morphological and functional study of the brain. Algorithmic and technical advances offer new insights in such brain studies using new approaches to search epileptogenic lesion. Voxel based analysis appears as the dominant methodology to study grey and white matter using the following contrast: T1, T2, T2 relaxometry, magnetization transfert and diffusion weighted imaging. Ongoing development focuses on sulcal morphometry and gyrification index, to improve our understanding of developmental epilepsy. Magnetic resonance spectroscopy appears as a promising tool following availability of high field strength clinical MRI and evidence about its utility in the field of epileptology. Functional MRI benefits from such high field strength and new pulse sequence using diffusion gradients to probe neuronal firing.

[Structural MRI in adult partial epilepsy]. / IRM morphologique des épilepsies partielles de l'adulte.

Magnetic resonance imaging (MRI) is the prominent imaging modality in the field of epilepsy. MRI plays a major role in describing and recognizing the malformations of cortical development and hippocampal sclerosis and has improved epilepsy patient care. MRI is also accurate in detecting the other major epilepsy etiologies (vascular malformations and cicatricial lesions). Presurgical MRI is relevant since it provides a high-resolution study of the brain.

Surgical views from three-dimensional digital subtraction angiography for the planning of aneurysm surgery.

AIM: To develop a semi-automatic protocol helping to present directly and quickly three-dimensional digital subtraction angiography (3D-DSA) data in an orientation that reproduces exactly the neurosurgeon's intraoperative view. METHOD: Post-processing of 3D-DSA data (volume-rendering) was performed on an Integris workstation (Philips, Best); surgical views were obtained by visualization of the patient's head through a frontopterional approach: the 3D volume was turned 135 degrees in the sagittal plane (around the X axis) and rotated by 45 degrees and 60 degrees in the coronal plane (around the Y axis). The protocol was evaluated on a consecutive series of nine patients who had ruptured or asymptomatic anterior circulation aneurysms requiring surgical treatment. Frontopterional views of angiographic 3D data were compared with intraoperative views. RESULTS: The proposed semi-automatic algorithm is simple, fast and reproducible, and displays the 3D data in an orientation identical to the intraoperative views. The surgical anatomy of the anterior communicating artery was best reproduced with a coronal rotation of 60 degrees , with a coronal rotation of 45 degrees for the other aneurysm locations. In each case, the surgical reconstructions allowed a more accurate analysis of the vascular anatomy around the aneurysm, and facilitated pre- and perioperative planning. CONCLUSION: The present protocol displays angiographic 3D data in a projection that exactly reproduces the vascular anatomy through a frontopterional approach. It may help neurosurgeons to better anticipate any potential difficulties during access and clip-positioning arising due to the specific vascular anatomy of a given patient.

Intracranial Arteriovenous Shunting: Detection with Arterial Spin-Labeling and Susceptibility-Weighted Imaging Combined.

BACKGROUND AND PURPOSE: Arterial spin-labeling and susceptibility-weighted imaging are 2 MR imaging techniques that do not require gadolinium. The study aimed to assess the accuracy of arterial spin-labeling and SWI combined for detecting intracranial arteriovenous shunting in comparison with conventional MR imaging. MATERIALS AND METHODS: Ninety-two consecutive patients with a known (n = 24) or suspected arteriovenous shunting (n = 68) underwent digital subtraction angiography and brain MR imaging, including arterial spin-labeling/SWI and conventional angiographic MR imaging (3D TOF, 4D time-resolved, and 3D contrast-enhanced MRA). Arterial spin-labeling/SWI and conventional MR imaging were reviewed separately in a randomized order by 2 blinded radiologists who judged the presence or absence of arteriovenous shunting. The accuracy of arterial spin-labeling/SWI for the detection of arteriovenous shunting was calculated by using the area under receiver operating curve with DSA as reference standard. κ coefficients were computed to determine interobserver and intermodality agreement. RESULTS: Of the 92 patients, DSA showed arteriovenous shunting in 63 (arteriovenous malformation in 53 and dural arteriovenous fistula in 10). Interobserver agreement was excellent (κ =0.83-0.95). In 5 patients, arterial spin-labeling/SWI correctly detected arteriovenous shunting, while the conventional angiographic MR imaging did not. Compared with conventional MR imaging, arterial spin-labeling/SWI was significantly more sensitive (0.98 versus 0.90, P = .04) and equally specific (0.97) and showed significantly higher agreement with DSA (κ = 0.95 versus 0.84, P = .01) and higher area under the receiver operating curve (0.97 versus 0.93, P = .02). CONCLUSIONS: Our study showed that the combined use of arterial spin-labeling and SWI may be an alternative to contrast-enhanced MRA for the detection of intracranial arteriovenous shunting.