0:00

Now let's talk about Aria e mimics and pitfalls.

0:03

Uh, this is very important to note in this patient.

0:07

Uh, this was actually a suboptimal protocol where, uh,

0:10

we're really sort of getting some, uh,

0:12

artifact here in the posterior occipital lobes.

0:15

Uh, when this was, uh, the, we,

0:17

they actually weren't sure about this,

0:19

had the patient repeat, uh, with optimal, um,

0:22

protocol parameters, and this went away.

0:24

So that was, uh, just artifact.

0:26

Now here, this patient was scanned, uh,

0:28

initially at baseline, and this vendor, they came back

0:31

and were scanned on a different vendor.

0:32

And now we see this, and the question is, is

0:34

that development of RAE?

0:36

So, uh, what,

0:37

what they actually did was put the patient back on this

0:40

vendor scanner and it looked just like this.

0:42

So this was just a artifact

0:44

and it was not development

0:46

of Aria e Here is a patient, here's the baseline.

0:49

And then you see here on the follow-up study,

0:51

you see all this sort of SoCal flare hyperintensity,

0:54

but it turned out the patient was on supplemental oxygen.

0:58

Uh, the patient, they then took the patient off supplemental

1:00

oxygen, repeated the study,

1:01

and it looked exactly like the prior exam.

1:03

So that was a fake out. It wasn't really an ARIA E case.

1:07

Um, now this is a patient here, this is the baseline study,

1:11

and then you see this very abnormal looking study.

1:14

Um, but they felt that the,

1:16

the parameters might not have been optimal.

1:18

There was poor CSF suppression.

1:20

They actually repeated it with optimal parameters

1:22

and it all went away.

1:24

So this actually turned out to be a fake out,

1:26

but that would be very hard to know that.

1:28

Um, but that's what it turned out to be in this case.

1:31

Um, another thing to be aware of on, um, is, you know, um,

1:36

meta metal artifacts.

1:37

So this is the initial exam.

1:39

And this exam, the patient had their hearing aid in.

1:41

This is the GRE and this is the flare.

1:43

But on the flare you can see there's all

1:44

this abnormal signal intensity.

1:46

But when you look at the GRE,

1:47

you can clearly see it's artifact from the hearing aid.

1:50

And then this was a patient that, uh,

1:53

this was their post dosing.

1:54

They did develop a small area of re e, so mild RAE.

1:58

And, uh, the question is, uh, was this RAE as well,

2:01

which is why it's always mandatory

2:03

that we do DWI when we're doing therapeutic imaging.

2:06

'cause this turned out to be an acute infarct.

2:08

Then, you know, the dosing, uh, was originally suspended.

2:12

Um, but the Aria E actually just went away.

2:15

And that little focus stayed

2:16

because that's just temporal evolution of the, uh, infarct.

2:20

Now, when we talk about aria, uh, h these are some, um, uh,

2:24

pitfalls that you can see.

2:25

This was the initial MRI, you see the small,

2:27

uh, micro hemorrhage.

2:29

What happened to it? Did, did it go away?

2:31

It turns out this is just a differences in slice sampling

2:34

and a different scanner,

2:35

but that little focus is still there.

2:37

But you can see how in reverse order, you know, um,

2:40

you may think that a micro

2:41

hemorrhage developed when it didn't.

2:43

Um, the other thing to be aware of is vessels.

2:45

And so you have to track up and down

2:47

and make sure you're not looking at a vessel.

2:50

SWI imaging is much higher sensitivity

2:52

for both vessels and bleeds.

2:54

So it's a little bit harder, uh, like you're finding, uh,

2:57

whereas Waldo in

2:59

A sea of vessels, um, which is why SWI was not utilized

3:02

for the trial and also why it is not recommended

3:05

for therapeutic screening.

3:07

That's why we use, uh, GRE

3:09

and also to remain a consistent protocol.

3:11

But this just turned out to be a vessel here.

3:13

Now when basal gangly, uh, mineralization is symmetric, um,

3:16

and chunky like this, it's very easy to see.

3:18

But when it's little punctate foci,

3:20

it might be harder to tell.

3:22

I, I would, uh, you know,

3:23

I would just assume that's mineralization.

3:25

But you know, again, it's something just to be aware of.

3:27

And then also around the sinuses, um,

3:30

you can get a dropout susceptibility artifact from the air.

3:34

And so you don't wanna over call those as bleeds.

3:37

And particularly with a, sometimes around the sinuses, um,

3:40

you, you know, mastoid air cells here, um,

3:42

you can get little punctate foci,

3:44

but those aren't bleeds there.

3:46

And then, uh, the other thing to be aware of is, uh, it,

3:50

this particular patient, you see this, uh, what appears

3:53

as susceptibility artifact bilaterally in the occipital

3:56

lobes, but this was actually phase encoding artifact.

3:59

So you just look for the march across, um, the line in,

4:03

in the phase encoding direction, um,

4:05

to differentiate true hemorrhage from just artifact.