R.E. Steiner

NUCLEAR MAGNETIC RESONANCE IMAGING OF THE BRAIN IN MULTIPLE SCLEROSIS

Ten patients with multiple sclerosis (MS) were scanned by means of cranial X-ray computed tomography (CT) with and without intravenous contrast enhancement, and by nuclear magnetic resonance (NMR) using an inversion-recovery sequence. Altogether 19 lesions varying in size between about 7 mm X 5 mm and 13 mm X 8 mm were demonstrated by CT. They were all situated in the periventricular region. Two patients also showed moderate ventricular enlargement. In addition to these abnormalities 112 further lesions were demonstrated on the NMR scans. These lesions varied in size from 4 mm X 3 mm to 12 mm X 7 mm and were particularly well seen in the periventricular region and brainstem. Care is required in the assessment of NMR scans to exclude artefacts, background noise, and mottle as well as normally situated grey matter and partial volume effects from cerebral sulci. NMR nevertheless demonstrates abnormalities in MS on a scale not previously seen except at necropsy.

IMAGING OF THE BRAIN BY NUCLEAR MAGNETIC RESONANCE

A nuclear magnetic resonance (NMR) machine constructed by Thorn-EMI Ltd was used to produce tomographic images of the brain in eight volunteers and fourteen patients. The use of an inversion recovery technique designed to emphasise variations in the spin-lattice time constant (T1) resulted in remarkable differentiation between grey and white matter in all subjects examined. White matter was seen both centrally and peripherally to subcortical level and the basal ganglia were clearly demarcated by the surrounding white matter and ventricular system. The posterior fossa was visualised with substantially less artefact than with X-ray computed tomography (CT) and both the brainstem and middle cerebellar peduncle were clearly shown. Pathological appearances in patients with glioblastoma multiforme, cerebral infarction, and cerebral aneurysm were demonstrated and compared with those seen with CT. The technique will require thorough clinical evaluation but appears to have considerable potential in the diagnosis of neurological disease.

NMR imaging of the brain using spin-echo sequences

Eight normal volunteers and 32 patients with a variety of neurological disease were studied with a nuclear magnetic resonance (NMR) scanner using repeated free induction decay (RFID), inversion-recovery (IR) and spin-echo (SE) sequences. The results were compared with X-ray computed tomography (CT). RFID sequences which produce images that reflect changes in proton density displayed very little grey-white matter contrast and relatively small changes in disease. IR sequences which produce images that are dependent on T1 showed a high level of grey-white matter contrast and demonstrated changes in a variety of pathological processes. Although SE scans, which have a strong T2 dependence, had shown no abnormality in previous studies of patients with neurological disease, sequences of this type with longer values of tau displayed abnormalities in cerebral infarction, haemorrhage, herpes encephalitis, multiple sclerosis, cerebral oedema, hydrocephalus, tumours and Wilsons disease. All of these conditions were associated with an increase in T2. Abnormalities were demonstrated in cases of multiple sclerosis and brainstem infarction with NMR scans where no abnormality was seen with CT. More extensive changes were seen with NMR in cases of hemisphere infarction, systemic lupus erythematosis, herpes encephalitis, hydrocephalus (periventricular oedema) and Sturge-Weber disease. The margin between malignant tumour and surrounding oedema was better defined with contrast enhanced CT in four of eight malignant tumours, equally well defined in one, and better defined with NMR in three cases. NMR spin-echo sequences provide a sensitive technique for detecting abnormalities in a variety of neurological disease.

The short TI inversion recovery sequence—An approach to MR imaging of the abdomen

Initial clinical experience with magnetic resonance imaging (MRI) of the abdomen using short TI inversion-recovery (STIR) pulse sequences is described and compared with X-ray CT in a variety of abdominal disease. The extent of abnormality shown with MRI was greater than that with CT in 21 of 30 cases and equal in 9 cases. Lesion contrast was greater with MRI in 15 cases, equal in 14 and less in 1. The level of artefact was equal in 27 cases and greater with MRI in 3 cases. The STIR pulse sequence has significant advantages in producing high soft-tissue contrast, controlling respiratory artefact, avoiding confusion with intra-abdominal fat and identifying bowel loops.

Magnetic resonance imaging of spinal cord in multiple sclerosis by fluid-attenuated inversion recovery

Magnetic resonance imaging examination of the upper spinal cord was done in sixteen adult patients with clinically definite multiple sclerosis (MS) by T2 weighted fluid attenuated inversion recovery (FLAIR) scanning in which the signal from cerebrospinal fluid was suppressed. These scans were compared with matched images obtained with conventional T1 and T2 weighted pulse sequences (including contrast enhancement). 6 lesions (five patients) were seen with the conventional scans and 37 lesions (fourteen patients) were seen with the FLAIR scans. The FLAIR sequence considerably improves the ability of MRI to demonstrate spinal involvement in MS.

NMR imaging of the brain

SummaryThe basic features of an NMR imaging system are outlined and three pulse sequences which produce images with varying dependence on proton density T1 and T2 are described. The first of these sequences, Repeated Free Induction Decay produces images which demonstrate changes in proton density as well as flow effects. The second sequence, Inversion-recovery, produces images which are dependent on T1 and show a high level of grey, white matter contrast giving considerable anatomical detail. In addition pathological processes such as infarction, haemorrhage, demyelination and malignancy produce changes in T1 enabling lesions to be localised. The third sequence, Spin-echo, produces images which are dependent on T2. These show very little grey, white matter contrast but demonstrate acute and space occupying lesions as well as cerebral oedema. The high level of grey, white matter contrast, lack of bone artefact, variety of sequences, capacity for multiplanar imaging, sensitivity to pathological change and lack of known hazard make NMR an important addition to existing techniques of neurological diagnosis.

MRI in acoustic neuroma: a review of 35 patients

SummaryThis retrospective study is aimed to assess the diagnostic efficacy of MRI in relation to contrast enhanced CT and air-CT-cisternography. MRI examinations were performed in 35 patients with suspected neurosensorial damage and suggestive of acoustic neuroma: 27 presented on MRI with unilateral tumors, 3 patients had a bilateral tumor and 5 patients were negative on all imaging modalities. The total number of acoustic neuromas detected was therefore 33. To date microscopic analysis has been performed on 12 tumors and histological data based on type Antoni A and Antoni B classification is available. Contrast enhanced CT detected 19 tumors, yielding an overall sensitivity rate of 58%. Air-CT cisternography identified an additional 5 tumors with a sensitivity rate of 100%. MRI identified 33 acoustic neuromas in 30 patients and was negative in 5 patients (sensitivity and accuracy 100%). Considering sensitivity in relation to location, MRI was much better than contrast enhanced CT for internal auditory canal (IAC) tumors (100% versus 36%) and better for cerebello-pontine angle tumors (CPA) tumors (100% versus 68%). The evolution of MRI technique, the various pulse sequences used and their actual selection is discussed. Seven patients received a paramagnetic contrast agent (Gadolinium-DTPA) with the additional benefit of a better demonstration of the tumor. The results suggest that MRI is the best non invasive technique for demonstrating acoustic neuromas.

The chest X-ray in antiglomerular basement membrane antibody disease (Goodpasture's syndrome).

The chest radiographs of 25 patients with proven antiglomerular basement membrane antibody disease (Goodpastures syndrome) were analysed. All except two of the patients had pulmonary haemorrhage at some stage of their disease. Altogether there were 39 episodes of pulmonary haemorrhage, 25 being relapses. During seven episodes the chest radiograph was normal. Relapses of pulmonary haemorrhage never occurred in isolation but were usually associated with infection (not necessarily a chest infection) or occasionally fluid overload. Conversely fluid overload or infection were always associated with pulmonary haemorrhage provided there were high or rising titres of circulating antibodies at the time. Therefore in a patient with antiglomerular basement membrane antibody disease, the presence of shadowing in the lung fields on the chest radiograph almost invariably means the patient has pulmonary haemorrhage whether or not pulmonary oedema or a chest infection are present. Limitation of shadowing by a fissure, loss of major portions of the diaphragmatic or cardiac silhouette, involvement of the lung apex or costophrenic angles suggest an underlying chest infection. Septal lines suggest fluid overload. Pleural effusions are seen with chest infections and fluid overload. The carbon monoxide uptake (KCO) was invariably high in the presence of pulmonary haemorrhage even if the chest radiograph was normal. A combined use of KCO and chest radiographs is the best method of monitoring lung disease in these patients.

Intravenous urography and renal function

Sixty-four intravenous pyelograms using varying doses of diatrizoate have been carried out in 39 patients. The subjects investigated represented a wide range of renal function, and this was studied by measuring the glomerular filtration rate by the clearance of 57 Co. vitamin B12. The fate of the contrast medium was followed by means of radioisotope labelling, and findings in plasma and urine have been related to renal function. It has been confirmed that diatrizoate is excreted by glomerular filtration, and that its concentration in the urine is therefore a function of plasma level, glomerular filtration rate, and urine flow rate. Studies on the mechanism of water handling of individuals given a large solute load were carried out, and we suggest that in patients with adequate renal function there is on average no improvement in urinary contrast concentration with doses larger than 1 ml. Urografin 60%/kg. body weight. The increase in urinary concentration achieved by 1 ml. contrast/kg. over ½ ml. contrast/kg. was not statistically significant; attention is drawn to the great variability in dehydration state in the same individual on different days. In patients with impaired renal function, urinary contrast concentrations sufficient to produce useful urograms may be achieved by using up to 2 ml. Urografin 60%/kg. body weight.

Nuclear magnetic resonance imaging (NMR), (MRI), of brain stem tumours

SummaryThe NMR scans of twenty-six patients who were referred with the clinically suspected or histologically verified diagnoses of brain stem tumour were reviewed. Twenty-one patients (eleven children and ten adults) had scans that were positive for tumour. Nine of these had histological confirmation. Eleven were irradiated without histology on the basis of the clinical diagnosis. The remaining patient was treated expectantly. The other five patients (two children and three adults) had CT and NMR scans that were negative for tumours. Clinical follow-up of these five cases for 9 to 29 months disclosed no further evidence of tumour. All but one tumour had evidence of an increased T1 and T2. Mass effects were seen in all but one case (not the same as the first exception). Multiplanar imaging was useful in determining intra- or extra-axial location as well as tumour extent. Intravenous Gadolinium-DTPA (a paramagnetic contrast agent) showed tumour enhancement in the two patients in whom it was used. NMR showed more extensive abnormality than CT in nineteen patients and similar abnormality to CT in two patients. CT demonstrated calcification better than NMR in the three cases in which it was observed.