Roland Materne

Assessment of hepatic perfusion parameters with dynamic MRI

Quantification of hepatic perfusion parameters greatly contributes to the assessment of liver function. The purpose of this study was to describe and validate the use of dynamic MRI for the noninvasive assessment of hepatic perfusion parameters. The signal from a fast T1‐weighted spoiled gradient‐echo sequence preceded by a nonslice‐selective 90° pulse and a spoiler gradient was calibrated in vitro with tubes filled with various gadolinium concentrations. Dynamic images of the liver were obtained after intravenous bolus administration of 0.05 mmol/kg of Gd‐DOTA in rabbits with normal liver function. Hepatic, aortic, and portal venous signal intensities were converted to Gd‐DOTA concentrations according to the in vitro calibration curve and fitted with a dual‐input one‐compartmental model. With MRI, hepatic blood flow was 100 ± 35 mL min‐1 100 mL‐1, the arterial fraction 24 ± 11%, the distribution volume 13.0 ± 3.7%, and the mean transit time 8.9 ± 4.1 sec. A linear relationship was observed between perfusion values obtained with MRI and with radiolabeled microspheres (r = 0.93 for hepatic blood flow [P < 0.001], r = 0.79 for arterial blood flow [P = 0.01], and r = 0.91 for portal blood flow [P < 0.001]). Our results indicate that hepatic perfusion parameters can be assessed with dynamic MRI and compartmental modeling. Magn Reson Med 47:135–142, 2002.

Capillarization of the sinusoids in liver fibrosis: Noninvasive assessment with contrast-enhanced MRI in the rabbit

Sinusoidal capillarization induces microcirculatory changes in liver cirrhosis and fibrosis. The purpose of this study was to assess whether contrast‐enhanced MRI can be used to demonstrate the effects of sinusoidal capillarization in liver fibrosis. Dynamic MRI after injection of a low‐molecular‐weight contrast agent of 0.56 kDa (Gd‐DOTA), and two high‐molecular‐weight contrast agents of 6.47 kDa and 52 kDa (P792 and P717) was performed in rabbits with liver fibrosis induced by cholesterol and diethylstilbestrol. The hepatic distribution volume accessible to the high‐molecular‐weight agents decreased in the rabbits with liver fibrosis (P792: 7.8% ± 1.7% vs. 10.1% ± 1.8% in normal rabbits, P = .038; P717: 6.2% ± 2.1% vs. 9.7% ± 1.6% in normal rabbits, P = .007), whereas the hepatic mean transit time (MTT) of the low‐molecular‐weight agent was increased (15.9 ± 8.0 s vs. 8.8 ± 2.6 s in normal rabbits, P = .015). In rabbits with liver fibrosis, the clearance of indocyanine green (ICG) was correlated with the volume accessible to the high‐molecular‐weight agents (P792: r = 0.810, P = .015; P717: r = 0.857, P = .007). The collagen content of the liver was inversely correlated with the distribution volume of P717 (r = –.833, P = .010) and with the ICG clearance (r = –.810, P = .015). It was concluded that the microcirculatory changes induced by sinusoidal capillarization in liver fibrosis can be demonstrated noninvasively with MRI. Magn Reson Med 49:692–699, 2003.

The surgical management of congenital liver cysts.

BackgroundMost series that report the results of surgical treatment for congenital liver cysts focus more on the technical aspects of the operation than on the late outcome of these patients. In this paper, we emphasize the importance of appropriate patient selection and adequate surgical technique for successful long-term outcome.MethodsTwenty-four consecutive patients with congenital liver cysts were selected for surgical treatment. According to our own classification, 13 patients had simple liver cysts, nine had multicystic liver disease, and two had type I polycystic liver disease. All of these patients were treated by the fenestration technique. An open approach was used for five patients (group 1) treated between 1984 and 1990. In 19 patients (group 2) treated since 1991, a laparoscopic approach was used. The incidence of complicated liver cysts was 40% in group 1 and 68% in group 2.ResultsThere were no treatment-related deaths in this series. The mean postoperative hospital stay was significantly shorter for patients who underwent successful laparoscopic fenestration (p < 0.05). In the open group (group 1), there were no postoperative complications, and all patients were alive and free of symptoms during a mean follow-up of 130 months, without any sign of cyst recurrence. In the laparoscopic group (group 2), four patients were converted to open surgery. One of these patients had an inaccessible posterior cyst; another had bile within the cystic cavity. A further two cases had complicated liver cysts with an uncertain diagnosis between congenital and neoplastic cysts. Four patients (21%) developed peri- or postoperative complications. During a mean follow-up time of 38.5 months, none of the patients with simple liver cysts incurred late symptoms or signs of cyst recurrence. In the six patients with multicystic liver disease, one developed disease-related cyst progression (17%) and required reoperation. One of the two patients with type I polycystic liver disease (50%) developed asymptomatic disease-related cyst progression.ConclusionsWhen patients are carefully selected and a proper surgical technique is employed, excellent long-term results with a low morbidity rate can be achieved in patients with congenital liver cysts. Patients with multicystic liver disease or type I polycystic liver disease are more prone to late cyst recurrence. A tailored approach is thus indicated for patients with congenital liver cystic disease. However, the laparoscopic approach appears to be the gold standard for the treatment of highly symptomatic or complicated simple liver cysts.

Focal nodular hyperplasia: natural course observed with CT and MRI.

PURPOSE The purpose of this work was to assess the natural course of biopsy-proven focal nodular hyperplasia (FNH). METHOD Eighteen biopsy-proven FNHs in 14 patients (12 women and 2 men) who were followed for at least 6 months with CT and/or MRI were included in the study. The volume of the lesions was calculated twice by two observers using the summation of areas method. Intra- and interobserver variability was assessed by intraclass correlation coefficients. Longitudinal data analysis was performed with generalized estimating equations. RESULTS The volume of FNH was stable in 6 cases, decreased in 10 cases, and increased in 2 cases. Intra- and interobserver variability in size measurements was 5-10%. Intraclass correlation coefficients were >0.992. Longitudinal data analysis showed that there was a general trend of lesion regression. CONCLUSION Long-term follow-up and objective measurements performed in patients with biopsy-proven lesions show that the natural course of FNH is variable. In particular, lesion regression is not rare.

Biodistribution of ultrasmall iron oxide particles in the rat liver.

Ferumoxtran, an ultrasmall superparamagnetic iron oxide particle, can be located in several tissue compartments in the liver, namely the extracellular space (blood and interstitium), reticuloendothelial cells, and possibly hepatocytes. To better understand the compartmental distribution of ferumoxtran in the liver, we performed a longitudinal study in the rat using microscopy and magnetic resonance imaging. At light microscopy, no substantial cellular uptake of ferumoxtran was observed before one hour after injection. With a dose of 15 μmol Fe/kg, the number of ferumoxtran particles in the reticuloendothelial cells peaked between one and four hours and with a 150 μmol Fe/kg dose, it peaked between eight and 24 hours. Within hepatocytes, only sparse particles were observed with electron microscopy, at a dose of 150 μmol Fe/kg. Imaging performed up until one hour after ferumoxtran injection showed a significant increase in liver signal intensity on T1‐weighted images. These results suggest that ferumoxtran mainly acts as an extracellular agent for at least one hour in the rat and that reticuloendothelial accumulation peaks at later time points. Substantial uptake within hepatocytes did not occur. J. Magn. Reson. Imaging 2001;13:594–599.

Inflammatory pseudotumor of the liver: MRI with mangafodipir trisodium.

Inflammatory pseudotumor of the liver is a rare benign mass that is often misdiagnosed as hepatocellular carcinoma at preoperative imaging. We report a case of inflammatory pseudotumor of the liver with special emphasis on the appearance at MRI after administration of mangafodipir trisodium. On T1-weighted images the lesion was slightly hypointense relative to the liver, and on T2-weighted images it was isointense with a hyperintense capsule. No tumor enhancement was seen on T1-weighted images after administration of mangafodipir trisodium. MRI with mangafodipir trisodium might help to distinguish inflammatory pseudotumor of the liver from hepatocellular carcinoma.

MR imaging of hypervascular liver tumors: Timing optimization during the arterial phase

To analyze the optimal timing strategy for the detection of hypervascular liver tumors during the arterial phase of magnetic resonance (MR) imaging, a test examination after injection of 2 mL of gadopentetate dimeglumine was performed in 47 patients. The time course of the tumor‐to‐liver contrast‐to‐noise ratio (CNR) for all studies together was determined relative to the start of injection, the time of peak aortic enhancement, and the time of peak enhancement in the tumor. All studies were grouped together and the highest CNR was transiently observed at the time of peak tumor enhancement. This CNR was significantly higher than those observed at fixed delays after peak aortic enhancement. However, the CNRs at peak tumor enhancement ±1.5 seconds did not differ significantly from those obtained after peak aortic enhancement. Finally, the CNRs obtained at fixed delays after the start of injection remained significantly lower. In hypervascular liver tumors, a higher CNR can be obtained during the arterial phase when the MR imaging delay is determined relative to the time of peak enhancement in the tumor or the aorta rather than being fixed after the start of contrast material injection. Timing based on the enhancement profile in the tumor rather than in the aorta should be performed only if rapid MR imaging is available with a time resolution of about 1.5 seconds to image the whole liver.J. Magn. Reson. Imaging 1999;9:562–567.

Gadolinium-enhanced arterial-phase MR imaging of hypervascular liver tumors: comparison between tailored and fixed scanning delays in the same patients.

The purpose of this study was to compare in the same patients tailored and fixed scanning delays during gadolinium‐enhanced arterial‐phase magnetic resonance imaging of hypervascular liver tumors. Tailored scanning delays were obtained with automated region of interest threshold triggering. A delay of 23 seconds between the start of contrast material injection and imaging was used for fixed delay examinations. Quantitative and qualitative evaluation was performed in 21 patients with normal cardiac function referred for MR assessment of hypervascular liver tumors. In the tailored examinations, the median time delay between the start of contrast material injection and the start of magnetic resonance imaging was 21 seconds (range, 18–34 seconds). The median tumor‐to‐liver contrast during tailored examinations was 19.1 versus 14.7 during fixed delay examinations. This difference, however, was not significant. Similarly, the enhancement in the aorta, the portal vein, the liver, and the tumor did not differ significantly between examinations performed with tailored and fixed delays. It is concluded that in our group of patients with hypervascular liver tumors and normal cardiac function, no significant improvement in tumor‐to‐liver contrast and enhancement during the arterial phase was found when gadolinium‐enhanced magnetic resonance imaging was performed with a tailored scanning delay rather than with a fixed delay. J. Magn. Reson. Imaging 2000;11:244–249.

Free-Breathing Accelerated Gadolinium-Enhanced MR Angiography in the Diagnosis of Renovascular Disease

OBJECTIVE The purpose of this study was to assess the feasibility and accuracy of accelerated free-breathing and breath-hold gadolinium-enhanced MR angiography of the main renal arteries compared with digital subtraction angiography. MATERIALS AND METHODS Renal MR angiograms and catheter angiograms of 47 patients (19 men, 28 women; mean age, 68.1 +/- 15.1 years; range, 28-86 years) were reviewed. Thirty-one of the patients underwent free-breathing and 16 underwent breath-hold MR angiography with the same accelerated multiphase imaging protocol. Images were analyzed for examination quality, percentage narrowing of the main renal artery, and visibility of the branches. Diagnostic values of MR angiography were calculated with catheter angiography as the standard of reference. RESULTS Sixty-five arteries, 24 of which (37%) had > 49% narrowing, were evaluated in the free-breathing group, and 37 arteries, six of which (16%) had > 49% narrowing, were evaluated in the breath-hold group. Comparison with digital subtraction angiography showed 100% (24/24) sensitivity and 95% (39/41) specificity for > 49% renal artery stenosis and 88% sensitivity (15/17) and 100% (48/48) specificity for > 74% renal artery stenosis in the free-breathing group. In the breath-hold group, sensitivity was 100% (6/6) and specificity 97% (30/31) for > 49% renal artery stenosis, and sensitivity was 100% (5/5) and specificity 100% (32/32) for > 74% renal artery stenosis. None of the examinations was nondiagnostic for the main renal arteries, but a smaller number of visible arterial tree subdivisions were found in the free-breathing group (average, 3.64 per patient) than in the breath-hold group (average, 5.87 per patient) (p = 0.035). CONCLUSION Like breath-hold examinations, accelerated free-breathing MR angiographic examinations are feasible and accurate in evaluation of the main renal arteries.

Indinavir Calculi: Diagnosis with Magnetic Resonance Urography

Indinavir sulfate is a protease inhibitor of the human immunodeficiency virus (HIV) type 1, that is widely used to treat patients with HIV infection. Indinavir therapy is associated with a significant incidence of crystalluria and urolithiasis [1]. These calculi are not opaque and consist of monohydrate indinavir crystals. Computed tomographic findings of ureteral calculi in patients with HIV receiving indinavir sulfate have recently been reported [2, 3]. Diagnosis is difficult with unenhanced computed tomography, and images after intravenous injection of an iodinated contrast agent may need to be performed to identify the cause of obstruction. We report a case of bilateral ureteral calculi demonstrated by magnetic resonance (MR) urography in an HIV-infected patient treated with indinavir sulfate.