Juha Halavaara

Increased fat accumulation in the liver in HIV-infected patients with antiretroviral therapy-associated lipodystrophy

Objective: To determine liver fat content in patients with highly active antiretroviral therapy (HAART)-associated lipodystrophy. Background: Lipodystrophy in several animal models is associated with fat accumulation in insulin-sensitive tissues, such as the liver. This causes hyperinsulinaemia, dyslipidaemia and other features of insulin resistance. Design: A cross-sectional study. Subjects and methods: Three age- and weight-matched groups were compared: 25 HIV-positive men with HAART-associated lipodystrophy (HAART+LD+), nine HIV-positive men receiving HAART, but without lipodystrophy (HAART+LD−), and 35 HIV-negative healthy men (HIV−). Liver fat content was measured using proton spectroscopy. Intra-abdominal and subcutaneous fat were determined using magnetic resonance imaging. Results: Liver fat content was significantly higher in the HAART+LD+ (8 ± 10%) than the HIV− (5 ± 7%; P < 0.05) or the HAART+LD− (3 ± 5%; P < 0.01) group. Liver fat content correlated with serum fasting insulin in the HAART+LD+ (r = 0.47; P < 0.05) and HIV− groups (r = 0.65; P < 0.001), but not with the amount of intra-abdominal fat. Within the HAART+LD+ group, serum insulin did not correlate with the amount of intra-abdominal fat. The HAART+LD+ group had a lower serum leptin concentration when compared to the two other groups. Features of insulin resistance, including hepatic fat accumulation, were not found in HAART+LD− group. Conclusions: The severity of the insulin resistance syndrome in patients with HAART-associated lipodystrophy is related to the extent of fat accumulation in the liver rather than in the intra-abdominal region. Fat accumulation in the liver may therefore play a causative role in the development of insulin resistance in these patients.

Liver tumor characterization: Comparison between liver-specific gadoxetic acid disodium-enhanced MRI and biphasic CT - A multicenter trial

Objective: In our multi center trial we compared the potentials of biphasic contrast-enhanced computed tomography (CT) and a novel tissue-specific magnetic resonance imaging (MRI) contrast agent gadoxetic acid disodium in liver lesion characterization. Methods: A total of 176 patients with 252 liver lesions were analyzed. There were 104 malignant and 148 benign lesions. High-field strength (1.0 T or 1.5 T) MR systems with T1-and T2-weighted sequences were used with and without fat suppression. After gadoxetic acid disodium injection, dynamic imaging and hepatocyte phase MR imaging were performed. Biphasic with 150 mg I/kg of body weight (100-200 mL) spiral CT was also performed. Image reading consisted of on-site (by study investigators) and fully blinded off-site (by E.S.P; C.R; and A.S) evaluations. The classification (benign or malignant) and characterization (lesion type) outcomes of both techniques were assessed. All imaging results were verified against a standard of reference. Results: Both on-site and off-site evaluations demonstrated increases in the lesion classification accuracy with gadoxetic acid disodium-enhanced MRI when compared with spiral CT. This improvement was also shown for characterization. Gadoxetic acid disodium was well tolerated. Conclusions: Gadoxetic acid disodium offers a safe and diagnostically powerful tool for the evaluation of patients with focal liver lesions with a reliable assessment of lesion classification and characterization.

Wernicke's encephalopathy: is diffusion-weighted MRI useful?

We present the clinical and magnetic resonance imaging (MRI) findings of five patients with acute Wernickes encephalopathy. T2-weighted and fluid-attenuated inversion recovery (FLAIR) images demonstrated symmetrical hyperintense lesions within the dorsomedial thalami, periaqueductal white matter, and the tectum of the midbrain. None of the lesions enhanced with gadolinium. In addition to conventional MRI sequences, we performed diffusion-weighted imaging (DWI). In all patients, DWI showed symmetrical pathologic thalamic and midbrain signal hyperintensities more distinctly than did conventional T2-weighted or FLAIR sequences. The apparent diffusion coefficient (ADC) map images showed slight signal reductions in four patients, suggesting restricted diffusion within these regions. In one patient, the signal intensity within the affected thalami was isointense with the ipsilateral basal ganglia on ADC map images. For enhanced detection of pathology, we conclude that DWI should be included in the imaging protocols of patients suspected to suffer from Wernickes encephalopathy.

Preoperative assessment of focal liver lesions: multidetector computed tomography challenges magnetic resonance imaging

Purpose: To investigate prospectively multidetector computed tomography (CT) (MDCT) and magnetic resonance (MR) imaging (MRI) in the preoperative assessment of focal liver lesions. Material and Methods: Multiphasic MDCT and conventional gadolinium‐enhanced MRI were performed on 31 consecutive patients prior to hepatic surgery. All images were blindly analyzed as consensus reading. Lesion counts and their relation to vascular structures and possible extrahepatic disease were determined. The data from the MDCT and MRI were compared with the results obtained by intraoperative ultrasound (IOUS) and palpation. Histopathologic verification was available. Results: At surgery, IOUS and palpation revealed 45 solid liver lesions. From these, preoperative MDCT detected 43 (96%) and MRI 35 (78%) deposits. MDCT performed statistically better than MRI in lesion detection (P = 0.008). Assessment of lesion vascular proximity was correctly determined by MDCT in 98% of patients and by MRI in 87%. Statistical difference was found (P = 0.002). IOUS and palpation changed the preoperative surgical plan as a result of extrahepatic disease in 8/31 (26%) cases. In MDCT as well in MRI extrahepatic involvement was suspected in two cases. Conclusion: MDCT was superior to MRI and nearly equal to IOUS in liver lesion detection and in the determination of lesion vascular proximity. However, both techniques fail to reliably detect extrahepatic disease.

Neuroimaging supports the clinical diagnosis of methanol poisoning

Abstract. In addition to visual loss, methanol intoxication can cause brain damage that is revealed by neuroimaging. We report on a 34-year-old man whose visual acuity deteriorated dramatically during his journey round the world, shortly after an evening with excessive alcohol consumption. Two months after the start of visual disturbances he returned to Finland. At examination, poor visual acuity and glaucomatously cupped pale optic discs were detected. The history and clinical findings indicated possible methanol intoxication, which was supported by both CT and MRI. The MRI findings are discussed in the light of the MRI appearance of the pallidum nuclei among patients of different age groups.

Magnetic resonance imaging of the liver: true fast imaging with steady state free precession sequence facilitates rapid and reliable distinction between hepatic hemangiomas and liver malignancies.

Objective To assess the capability of the true fast imaging with steady state free precession (true FISP) sequence in the distinction between hemangiomas and malignant liver lesions. Methods Sixty-eight patients with 45 hemangiomas and 51 liver malignancies were included in this study. A 1.5-T magnetic resonance system and a phased-array body coil were used. In addition to true FISP, breath-hold and fat-suppressed, T2-weighted, half-Fourier single-shot turbo spin echo (HASTE) and both unenhanced and gadolinium (Gd)-enhanced T1-weighted sequences were acquired. Two radiologists evaluated the magnetic resonance images independently in a blinded fashion. Interobserver variations with true FISP and HASTE were determined. Lesion contrast-to-noise ratios were calculated from true FISP images. Results With true FISP, readers 1 and 2 made a correct distinction between hemangiomas and liver malignancies in 43 of 45 (96%) cases and 40 of 45 (89%) cases, respectively. The &kgr; value was 0.65. With HASTE, the success rates were 40 of 45 cases (89%) and 36 of 45 cases (80%), respectively, and the &kgr; value was 0.33. With a Gd-enhanced T1-weighted sequence, the correct classifications were 35 of 45 cases (78%) and 37 of 45 cases (82%), respectively. All hemangiomas appeared as bright and well-demarcated lesions on true FISP images. Malignant liver foci were heterogeneous with unsharp margins and nearly isointense relative to liver. The specificities of true FISP in lesion differentiation were 100% and 98% for readers 1 and 2, respectively. The mean contrast to noise ratio value of hemangiomas was 21.2 (standard deviation [SD] = 9.2), and that of malignant lesions was 4.9 (SD = 3.9). This difference was highly significant (P < 0.0001). Conclusion Noninvasive, rapid, and reliable differentiation between hemangiomas and malignant liver lesions is possible by using the true FISP sequence.

Detection of focal liver lesions with superparamagnetic iron oxide: value of STIR and SE imaging

Objective We assessed the value of superparamagnetic iron oxide (SPIO) particles on the detection of focal liver lesions by MRI. Materials and Methods Twenty patients with one to five focal liver lesions, primarily detected with ultrasonography and/or contrast-enhanced CT, were evaluated further with unenhanced and iron oxide-enhanced MRI at 1.0 T. Superparamagnetic iron oxide particles were administered intravenously as a slow infusion. Then T1-, T2-, and proton density–weighted SE images were obtained. In addition, the performance of a short T1 inversion recovery (STIR) sequence was evaluated. Results The iron oxide contrast medium had marked effects on liver signal-to-noise (S/N) and tumor-to-liver contrast-to-noise (C/N) ratios but only minimal effects on tumor S/N ratios in cases of malignant tumor foci. Lesion-to-liver contrast, expressed as differences between the tumor and liver S/N ratios, improved very significantly after SPIO infusion with all four pulse sequences. Contrast enhancement of the liver parenchyma was best in T2-weighted SE images, but the tumor-to-liver C/N values were highest with the postcontrast STIR sequence. The SPIO enhancement revealed a number of additional focal lesions (31%), also foci under 1 cm in diameter. In three benign focal lesions, SPIO infusion produced a definite reduction in the S/N ratio of the lesions in contrast to the minimal change measured in malignant foci. The favorable performance of the STIR sequence contradicts the disappointing results previously obtained at 0.6 T. Conclusion Superparamagnetic iron oxide is a promising new contrast medium for MR examinations of the liver, increasing the conspicuity and reducing the detectability threshold of focal hepatic lesions.

On- and off-resonance spin-lock MR imaging of normal human brain at 0.1 T: possibilities to modify image contrast

The aim of the present investigation was to determine spin lock (SL) relaxation parameters for the normal brain tissues and thus, to provide basis for optimizing the imaging contrast at 0.1 T. 68 healthy volunteers were included. On-resonance spin lock relaxation time (T1rho) and off-resonance spin lock relaxation parameters (T1rho(off), Me/Mo), MT parameters (T1sat, Ms/Mo), and T1, T2 were determined for the cortical gray matter, and for the frontal and parietal white matters. The T1rho for the frontal and parietal white matters ranged from 110 to 133 ms and from 122 to 155 ms with locking field strengths from 50 microT to 250 microT, respectively. Accordingly, the values for the gray matter ranged from 127 to 155 ms. With a locking field strength of 50 microT, T1rho(off) for the frontal and parietal white matters were from 114 to 217 ms and from 126 to 219 ms, and for the gray matter from 136 to 267 ms with the angle between the effective magnetic field (B(eff)) and the z-axis (theta) ranging from 60 degrees to 15 degrees, respectively. The T1rho of the white and gray matters increased significantly with increasing locking field amplitude (p < 0.001). The T1rho(off) decreased significantly with increasing theta (p < 0.001). T1rho and T1rho(off) with theta > or = 30 degrees were statistically significantly shorter in the frontal than in the parietal white matters (p < 0.05). The duration, amplitude and theta of the locking pulse provide additional parameters to optimize contrast in brain SL imaging.

Perfusion CT of the Brain in the Assessment of Flow Alterations during Brachytherapy of Meningioma

Purpose: the aim was to investigate the use of perfusion CT of the brain in the assessment of flow alterations during brachytherapy of meningiomas. Material and Methods: Six patients with an intracranial meningioma were investigated during brachytherapy treatment by stereotactic implantation of I-125 seeds. Cerebral blood flow (CBF) in the tumour centre and the tumour periphery as well as in the normal brain parenchyma was determined by perfusion CT. Follow-up examinations were performed during the first year after the implantation. the CBF of the normal brain parenchyma was used as control. Results: In the beginning of therapy, the mean±SEM blood flow in the tumour centre was 231.4±58.1 ml/100 g/min and in the periphery 223.5±53.8 ml/100 g/min. Within three months after the iodine seed implantation, the tumour blood flow had decreased 41%. At the one-year follow-up, the tumour blood flow in the centre had decreased to 68.7±45.9 ml/100 g/min. In the periphery of the tumour, it remained nearly unchanged (199.3±101.0 ml/100 g/min). the CBF values obtained from normal brain parenchyma did not decrease during the treatment. Throughout the study, the mean CBF for the normal grey matter was 38.5±2.9 ml/100 g/min, and 22.3±1.2 ml/100 g/min for the normal white matter. Conclusion: Perfusion CT seems to enable accurate monitoring of the blood flow of meningiomas during brachytherapy, and could be used in clinical situations where blood flow changes in brain and tumours should be investigated.

Determination of T1ρ values for head and neck tissues at 0.1 T : A comparison to T1 and T2 relaxation times

In order to optimize head and neck magnetic resonance (MR) imaging with the spin-lock (SL) technique, the T1rho relaxation times for normal tissues were determined. Furthermore, T1rho was compared to T1 and T2 relaxation times. Ten healthy volunteers were studied with a 0.1 T clinical MR imager. T1rho values were determined by first measuring the tissue signal intensities with different locking pulse durations (TL), and then by fitting the signal intensity values to the equation with the least-squares method. The T1rho relaxation times were shortest for the muscle and tongue, intermediate for lymphatic and parotid gland tissue and longest for fat. T1rho demonstrated statistically significant differences (p < 0.05) between all tissues, except between muscle and tongue. T1rho values measured at locking field strength (B1L) of 35 microT were close to T2 values, the only exception being fat tissue, which showed T1rho values much longer than T2 values. Determination of tissue relaxation times may be utilized to optimize image contrast, and also to achieve better tissue discrimination potential, by choosing appropriate imaging parameters for the head and neck spin-lock sequences.