C.J.G. Bakker

Endovascular interventional magnetic resonance imaging

Minimally invasive interventional radiological procedures, such as balloon angioplasty, stent placement or coiling of aneurysms, play an increasingly important role in the treatment of patients suffering from vascular disease. The non-destructive nature of magnetic resonance imaging (MRI), its ability to combine the acquisition of high quality anatomical images and functional information, such as blood flow velocities, perfusion and diffusion, together with its inherent three dimensionality and tomographic imaging capacities, have been advocated as advantages of using the MRI technique for guidance of endovascular radiological interventions. Within this light, endovascular interventional MRI has emerged as an interesting and promising new branch of interventional radiology. In this review article, the authors will give an overview of the most important issues related to this field. In this context, we will focus on the prerequisites for endovascular interventional MRI to come to maturity. In particular, the various approaches for device tracking that were proposed will be discussed and categorized. Furthermore, dedicated MRI systems, safety and compatibility issues and promising applications that could become clinical practice in the future will be discussed.

Passive tracking of catheters and guidewires by contrast‐enhanced MR fluoroscopy

Passive MR tracking of catheters and guidewires is usually done by dynamically imaging a single thick slab, subtracting a baseline image, and combining the result with a previously acquired MR angiogram. In the in vitro and in vivo experiments reported here, it is demonstrated that this approach may be greatly simplified by using a suitable intravascular contrast agent. The proposed method, contrast‐enhanced MR fluoroscopy, combines tracking and angiography into a single sequence and allows direct visualization of the magnetically prepared parts of catheters and guidewires with respect to the vasculature at a frame rate of about one image per 1.5 seconds. Contrast‐enhanced MR fluoroscopy, although still limited in temporal resolution, thus obviates the need for subtraction and overlay techniques and eliminates the sensitivity of tracking to subject motion between acquisitions. Magn Reson Med 45:17–23, 2001.

Interventional MR: vascular applications

Abstract. Three strategies for visualisation of MR-dedicated guidewires and catheters have been proposed, namely active tracking, the technique of locally induced field inhomogeneity and passive susceptibility-based tracking. In this article the pros and cons of these techniques are discussed, including the development of MR-dedicated guidewires and catheters, scan techniques, post-processing tools, and display facilities for MR tracking. Finally, some of the results obtained with MR tracking are discussed.

Towards inherently distortion-free MR images for image-guided radiotherapy on an MRI accelerator

In MR-guided interventions, it is mandatory to establish a solid relationship between the imaging coordinate system and world coordinates. This is particularly important in image-guided radiotherapy (IGRT) on an MRI accelerator, as the interaction of matter with γ-radiation cannot be visualized. In conventional acquisitions, off-resonance effects cause discrepancies between coordinate systems. We propose to mitigate this by using only phase encoding and to reduce the longer acquisitions by under-sampling and regularized reconstruction. To illustrate the performance of this acquisition in the presence of off-resonance phenomena, phantom and in vivo images are acquired using spin-echo (SE) and purely phase-encoded sequences. Data are retrospectively under-sampled and reconstructed iteratively. We observe accurate geometries in purely phase-encoded images for all cases, whereas SE images of the same phantoms display image distortions. Regularized reconstruction yields accurate phantom images under high acceleration factors. In vivo images were reconstructed faithfully while using acceleration factors up to 4. With the proposed technique, inherently undistorted images with one-to-one correspondence to world coordinates can be obtained. It is a valuable tool in geometry quality assurance, treatment planning and online image guidance. Under-sampled acquisition combined with regularized reconstruction can be used to accelerate the acquisition while retaining geometrical accuracy.

Image guidance of endovascular interventions on a clinical MR scanner

Magnetic resonance imaging (MRI) offers potential advantages over conventional X-ray techniques for guiding and evaluating vascular interventions. Image guidance of such interventions via passive catheter tracking requires real-time image processing. Commercially available MR scanners currently do not provide this functionality. This paper describes an image processing environment that allows near-real-time MR-guided vascular interventions. It demonstrates (1) that flexibility can be achieved by separating the scanner and the image processing/display system, thereby preserving the stability of the scanner and (2) that sufficiently rapid visualization can be achieved by low-cost workstations equipped with graphics hardware. The setup of the hardware and the software is described in detail. Furthermore, image processing techniques are presented for guiding the interventionalist through simple vascular anatomy. Finally, results of a phantom balloon angioplasty experiment are presented.

Localization of intravascular devices with paramagnetic markers in MR images

Magnetic resonance imaging (MRI) offers potential advantages over conventional X-ray techniques for guiding and evaluating intravascular interventions. The development of methods to safely and robustly localize and track devices under MRI guidance is mandatory to enable automatic scan plane adaptation so as to exploit the three-dimensional imaging capabilities of the MRI scanner. With regard to the issue of radiofrequency-induced heating, passive approaches to catheter tracking are inherently safe. These techniques visualize intravascular devices by exploiting the susceptibility artifacts associated with the devices. To promote conspicuity, the devices are equipped with paramagnetic markers. This paper introduces a method to enable automatic localization of devices by its ability to recognize markers in two-dimensional MR images. The method requires a coarse segmentation of the vasculature of interest, and consists of two steps. First, it performs a series of postprocessing operations including calculation of the winding number image and of the Laplacian image to detect marker candidates in the image. Second, the device is localized by matching the detected pattern of candidates to the known distance template of the device markers. Results of an animal experiment and of a clinical application are demonstrated. Validation in phantom experiments shows that the method is able to localize the device in 95% of the cases.

Center-out radial sampling with off-resonant reconstruction for efficient and accurate localization of punctate and elongated paramagnetic structures

Accurate localization of interventional devices, for example, needles and brachytherapy seeds, is desired for interventional procedures. MRI is usually considered unsuitable for this purpose, as the induced signal voids and signal pile‐ups do not necessarily represent the exact location of the devices. Center‐out radial sampling with off‐resonance reception (co‐RASOR) has been shown to solve this problem by repositioning the signal pile‐up into the geometrical center of the interventional devices. However, the multiple acquisitions required for co‐RASOR resulted in a low efficiency and unsuitability for near real‐time interventional purposes. Herein, we aim to increase the efficiency of co‐RASOR by relying on multiple off‐resonance reconstructions of a single acquisition rather than on multiple acquisitions. The soundness of this approach is shown by demonstrating the equivalence of acquisition co‐RASOR and reconstruction co‐RASOR, both theoretically and experimentally. An algorithm is proposed and evaluated to obtain the geometric centers of the devices, while suppressing the background. This procedure is shown to be effective, in vitro as well as ex vivo, and to yield signal intensity increases in the order of 150–400% of the average signal, in the geometric center of a brachytherapy seed and a needle, respectively. The geometric accuracy of the resultant images is confirmed by computed tomography. Magn Reson Med, 2013.

Quantitative cerebral perfusion MRI and CO2 reactivity measurements in patients with symptomatic internal carotid artery occlusion

Quantitative perfusion MRI is a promising new technique capable of offering information on cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT). However, it is still unclear how these perfusion parameters relate to the underlying physiological indicators and how they compare to conventional techniques. The purpose of this study was to investigate how quantitative perfusion MRI is related to the cerebrovascular reactivity as measured by transcranial Doppler ultrasonography (TCD) in combination with a CO2 stimulus in patients with a symptomatic occlusion of the internal carotid artery (ICA). Thirty-nine patients with transient or minor disabling retinal or hemispheric ischemic symptoms and an occlusion of the ICA underwent quantitative perfusion MRI and CO2 reactivity measurements by TCD. Perfusion parameters were correlated with cerebrovascular reactivity measurements and compared with measurements of control subjects. The results of this study show a negative correlation between the cerebrovascular reactivity and the time to bolus peak (TBP) both for gray (r = -0.26, P = 0.035) and white matter (r = -0.28, P = 0.026). No correlation between resting CBV, CBF, or MTT and cerebrovascular reactivity was found. Our results indicate that an increase in TBP reflects a poor development of collateral flow, which is supported by a relatively low CO2 reactivity in these patients.

Development and testing of passive tracking markers for different field strengths and tracking speeds.

Susceptibility markers for passive tracking need to be small in order to maintain the shape and mechanical properties of the endovascular device. Nevertheless, they also must have a high magnetic moment to induce an adequate artefact at a variety of scan techniques, tracking speeds and, preferably, field strengths. Paramagnetic markers do not satisfy all of these requirements. Ferro- and ferrimagnetic materials were therefore investigated with a vibrating sample magnetometer and compared with the strongly paramagnetic dysprosium oxide. Results indicated that the magnetic behaviour of stainless steel type AISI 410 corresponds the best with ideal marker properties. Markers with different magnetic moments were constructed and tested in in vitro and in vivo experiments. The appearance of the corresponding artefacts was field strength independent above magnetic saturation of 1.5 T. Generally, the contrast-to-noise ratio decreased at increasing tracking speed and decreasing magnetic moment. Device depiction was most consistent at a frame rate of 20 frames per second.

Repeated quantitative perfusion and contrast permeability measurement in the MRI examination of a CNS tumor

Abstract. This study reports on the results of quantitative MRI perfusion and contrast permeability measurement on two occasions in one patient. The measurements were separated 81 days in time. The tumor grew considerably in this period, but no change was found with respect to perfusion and contrast permeability. Non-involved white matter values were reproduced to demonstrate repeatability. The presented approach to dynamic susceptibility contrast MRI allows fast and repeatable quantitative assessment of perfusion and is easily integrated in a conventional brain tumor protocol.