Stefan Haneder

Renal BOLD-MRI does not reflect renal function in chronic kidney disease

Renal blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) is a noninvasive fast technique to characterize renal function. Here we evaluated the impact of renal function on the relaxation rate (R2(*)) in the cortex and medulla to provide baseline data for further use of renal BOLD-MRI. This parameter was evaluated in 400 patients scheduled for abdominal imaging who underwent transversal blood oxygen level-dependent measurements with a multi-echo gradient-echo sequence with 12 echo times. The loss of phase coherence (T2(*)) maps were generated in which kidney regions of interest were selected to differentiate the medulla and cortex, and R2(*) was equated to 1/T2(*). Individual R2(*) values were, in turn, correlated to the eGFR (MDRD formula of 280 patients with available serum creatinine measurements), age, and gender each for 1.5 and 3.0 T field-strength scans of 342 patients. At both the field strengths, no significant differences in R2(*) of the cortex and medulla were found between patient gender, age, eGFR, or between different stages of chronic kidney disease determined using the KDOQI system. Thus, BOLD-MRI of a non-specific patient population failed to discriminate between the patients with various stages of chronic kidney disease.

Peripheral magnetic resonance angiography with continuous table movement in combination with high spatial and temporal resolution time-resolved MRA With a total single dose (0.1 mmol/kg) of gadobutrol at 3.0 T.

Purpose:To prove the concept of peripheral continuous table movement (CTM) MR-angiography (MRA) in combination with high spatial and temporal resolution time-resolved TWIST-MRA in a single MR-examination at 3.0 T with a single dose (0.1 mmol/kg) of gadobutrol in total. Materials and Methods:We included 22 consecutive patients (15 m/7 f, mean age: 64 years) referred for peripheral MRA with clinical symptoms of peripheral arterial occlusive disease Fontaine stages II–IV. All of them underwent both CTM-MRA (TR: 2.4 ms/TE: 1.0 ms/flip angle: 21 degree) of the entire run-off vessels and TWIST-MRA (TR: 2.8 ms/TE: 1.1 ms/flip angle: 20 degree) of the calf station during a single MR-examination. All examinations were performed on a 3.0 T MR system (Tim Trio). Spatial resolution of the CTM-MRA datasets was technically limited to an acquired resolution of 1.2 × 1.2 × 1.96 mm3 reconstructed to 1.2 mm isotropic. The TWIST-MRA was acquired with 1.1 × 1.1 × 1.35 mm3 and reconstructed to 1.1 mm isotropic with a temporal resolution of 5.5 seconds in the calf station. A total of 0.1 mmol/kg BW gadobutrol diluted 1:1 with saline was injected at a flow rate of 1.5 mL/s of which 0.07 mmol/kg was administered for the CTM-MRA and 0.03 mmol/kg for the TWIST-MRA.CTM-MRA run off datasets were qualitatively assessed using a 4 point scale (4 = excellent, 1 = nondiagnostic) followed by TWIST-MRA datasets for the calf using the same scale. Additional relevant findings only visible in the TWIST-MRA were documented. Results:All datasets could be evaluated with a total of 397 assessable segments. CTM-MRA was diagnostic in 99% (393/397 segments) with image quality judged as excellent in 54% (213/397 segments), good in 42% (14/397), and moderate in 4% (14/397) of analyzed segments respectively. Nondiagnostic image quality was seen in 1% (4/397 segments). Venous overlay in the calf station was found in 27% (6/22 patients). TWIST-MRA was diagnostic in 100% (115/115 segments), throughout with good or excellent image quality. In 14 of 22 patients additional relevant findings were detected by TWIST-MRA. Conclusion:Single-dose gadobutrol CTM-MRA in combination with a high spatial and temporal resolution TWIST-MRA at 3.0 T is a reliable technique with good image quality. Despite the use of single dose contrast agent large field of view coverage and dynamic images can be acquired. Because of its robustness, this imaging approach of the vasculature has great potential for a broad clinical use.

Quantitative and Qualitative 23Na MR Imaging of the Human Kidneys at 3 T: Before and after a Water Load

PURPOSE To qualitatively and quantitatively assess the corticomedullary sodium 23 ((23)Na) concentration in human kidneys before and after oral administration of a water load by using 3-T magnetic resonance (MR) imaging. MATERIALS AND METHODS Fourteen healthy volunteers (mean age, 28 years; range, 24-34 years) were included in this institutional review board-approved study between July and December 2009. For (23)Na MR imaging, a density-adapted three-dimensional radial gradient echo sequence (echo time, 0.55 msec; repetition time, 120 msec; spatial resolution, 5 × 5 × 5 mm) was used with a dedicated (23)Na-tuned coil. Beforehand, the coil profile was assessed by using phantom measurements, and the volunteer images were mathematically corrected accordingly. Images of the volunteers were obtained before and 30 minutes after oral ingestion of 1 L of water. As internal reference, (23)Na concentration of the cerebrospinal fluid (CSF) was calculated. Well-defined corticomedullary complexes in each kidney were assessed, with (23)Na concentrations in the cortex and medulla assessed at various standardized points. From these values, quantitative (23)Na concentrations were derived, and the slopes of the linear portion of the concentration gradient were calculated. Paired t tests were performed. RESULTS Mean calculated (23)Na concentrations of CSF before (135.2 mmol/L ± 10.4) and after water load (135.5 mmol/L ± 11.0) fell within physiologic ranges (P = .95). An increase in average (23)Na concentration from 63.5 mmol/L ± 9.3 in the cortex to 108.0 mmol/L ± 10.9 in the medulla was identified. After the water load, this gradient was preserved, although (23)Na concentrations decreased significantly (P < .0001) to 48.6 mmol/L ± 5.3 in the cortex and 81.9 mmol/L ± 10.1 in the medulla-declines of 23.4% and 24.7%, respectively. CONCLUSION This study demonstrates the physiologic evaluation of human kidneys with 3-T (23)Na MR imaging. The (23)Na imaging technique used allows the quantification of the corticomedullary (23)Na concentration and the assessment of its change with differing physiologic conditions.

Peripheral Arterial Occlusive Disease: Evaluation of a High Spatial and Temporal Resolution 3-T MR Protocol with a Low Total Dose of Gadolinium versus Conventional Angiography

PURPOSE To evaluate a peripheral magnetic resonance (MR) angiographic protocol combining continuous table movement (CTM) MR angiography of the entire runoff vasculature with time-resolved (TWIST) 3-T MR angiography of the calves with a total gadolinium dose of 0.1 mmol per kilogram of body weight. MATERIALS AND METHODS In this retrospective institutional review board-approved study, 31 consecutive patients (22 men, nine women; mean age, 65 years ± 14 [standard deviation]) with peripheral arterial occlusive disease who had undergone a low-dose MR angiographic protocol that consisted of CTM MR angiography (repetition time msec/echo time msec, 2.4/1.0; 21° flip angle; voxel size, 1.2 mm(3); gadolinium dose, 0.07 mmol per kilogram of body weight) and TWIST MR angiography (2.8/1.1; 20° flip angle; voxel size, 1.1 mm(3); temporal resolution, 4.8-5.5 sec, gadolinium dose, 0.03 mmol/kg), as well as digital subtraction angiography (DSA), were included. Two radiologists rated image quality and stenosis degree on four-point scales. The accuracy of stenosis gradation and, specifically, the detection of high-grade stenoses (stenosis of 70%-99%) with CTM MR angiography alone and with the combined protocol were compared with accuracy of stenosis gradation and detection of high-grade stenoses with DSA. Means and standard deviations were calculated for all data. Interobserver agreement was determined with κ statistics. Positive and negative predictive values, sensitivity, specificity, and overall diagnostic accuracy were calculated for CTM MR angiography alone and for the combined protocol. RESULTS For CTM MR angiography, image quality was good or excellent in 95.9% of vessel segments; for TWIST MR angiography, image quality was good or excellent in 94.3% and 97.8% of vessel segments for readers 1 and 2, respectively. The combined protocol resulted in high overall diagnostic accuracy of more than 80% for detection of stenosis and diagnostic accuracy of 93.5% for detection of high-grade vessel stenosis. Inclusion of TWIST MR angiography increased diagnostic value over that achieved with CTM MR angiography alone. CONCLUSION A combined MR angiographic approach in which a low total gadolinium dose (0.1 mmol/kg) is used yields excellent image quality and is accurate in the diagnosis of peripheral arterial stenosis.

First multimodal embolization particles visible on x-ray/computed tomography and magnetic resonance imaging.

Objectives:Embolization therapy is gaining importance in the treatment of malignant lesions, and even more in benign lesions. Current embolization materials are not visible in imaging modalities. However, it is assumed that directly visible embolization material may provide several advantages over current embolization agents, ranging from particle shunt and reflux prevention to improved therapy control and follow-up assessment. X-ray- as well as magnetic resonance imaging (MRI)-visible embolization materials have been demonstrated in experiments. In this study, we present an embolization material with the property of being visible in more than one imaging modality, namely MRI and x-ray/computed tomography (CT). Characterization and testing of the substance in animal models was performed. Materials and Methods:To reduce the chance of adverse reactions and to facilitate clinical approval, materials have been applied that are similar to those that are approved and being used on a routine basis in diagnostic imaging. Therefore, x-ray-visible Iodine was combined with MRI-visible Iron (Fe3O4) in a macroparticle (diameter, 40–200 μm). Its core, consisting of a copolymerized monomer MAOETIB (2-methacryloyloxyethyl [2,3,5-triiodobenzoate]), was coated with ultra-small paramagnetic iron oxide nanoparticles (150 nm). After in vitro testing, including signal to noise measurements in CT and MRI (n = 5), its ability to embolize tissue was tested in an established tumor embolization model in rabbits (n = 6). Digital subtraction angiography (DSA) (Integris, Philips), CT (Definition, Siemens Healthcare Section, Forchheim, Germany), and MRI (3 Tesla Magnetom Tim Trio MRI, Siemens Healthcare Section, Forchheim, Germany) were performed before, during, and after embolization. Imaging signal changes that could be attributed to embolization particles were assessed by visual inspection and rated on an ordinal scale by 3 radiologists, from 1 to 3. Histologic analysis of organs was performed. Results:Particles provided a sufficient image contrast on DSA, CT (signal to noise [SNR], 13 ± 2.5), and MRI (SNR, 35 ± 1) in in vitro scans. Successful embolization of renal tissue was confirmed by catheter angiography, revealing at least partial perfusion stop in all kidneys. Signal changes that were attributed to particles residing within the kidney were found in all cases in all the 3 imaging modalities. Localization distribution of particles corresponded well in all imaging modalities. Dynamic imaging during embolization provided real-time monitoring of the inflow of embolization particles within DSA, CT, and MRI. Histologic visualization of the residing particles as well as associated thrombosis in renal arteries could be performed. Visual assessment of the likelihood of embolization particle presence received full rating scores (153/153) after embolization. Conclusions:Multimodal-visible embolization particles have been developed, characterized, and tested in vivo in an animal model. Their implementation in clinical radiology may provide optimization of embolization procedures with regard to prevention of particle misplacement and direct intraprocedural visualization, at the same time improving follow-up examinations by utilizing the complementary characteristics of CT and MRI. Radiation dose savings can also be considered. All these advantages could contribute to future refinements and improvements in embolization therapy. Additionally, new approaches in embolization research may open up.

Clinical applications at ultrahigh field (7 T). Where does it make the difference

Presently, three major MR vendors provide commercial 7‐T units for clinical research under ethical permission, with the number of operating 7‐T systems having increased to over 50. This rapid increase indicates the growing interest in ultrahigh‐field MRI because of improved clinical results with regard to morphological as well as functional and metabolic capabilities. As the signal‐to‐noise ratio scales linearly with the field strength (B0) of the scanner, the most obvious application at 7 T is to obtain higher spatial resolution in the brain, musculoskeletal system and breast. Of specific clinical interest for neuro‐applications is the cerebral cortex at 7 T, for the detection of changes in cortical structure as a sign of early dementia, as well as for the visualization of cortical microinfarcts and cortical plaques in multiple sclerosis. In the imaging of the hippocampus, even subfields of the internal hippocampal anatomy and pathology can be visualized with excellent resolution. The dynamic and static blood oxygenation level‐dependent contrast increases linearly with the field strength, which significantly improves the pre‐surgical evaluation of eloquent areas before tumor removal. Using susceptibility‐weighted imaging, the plaque–vessel relationship and iron accumulation in multiple sclerosis can be visualized for the first time. Multi‐nuclear clinical applications, such as sodium imaging for the evaluation of repair tissue quality after cartilage transplantation and 31P spectroscopy for the differentiation between non‐alcoholic benign liver disease and potentially progressive steatohepatitis, are only possible at ultrahigh fields. Although neuro‐ and musculoskeletal imaging have already demonstrated the clinical superiority of ultrahigh fields, whole‐body clinical applications at 7 T are still limited, mainly because of the lack of suitable coils. The purpose of this article was therefore to review the clinical studies that have been performed thus far at 7 T, compared with 3 T, as well as those studies performed at 7 T that cannot be routinely performed at 3 T. Copyright

Zoomed EPI-DWI of the Pancreas Using Two-Dimensional Spatially-Selective Radiofrequency Excitation Pulses

Background Implementation of DWI in the abdomen is challenging due to artifacts, particularly those arising from differences in tissue susceptibility. Two-dimensional, spatially-selective radiofrequency (RF) excitation pulses for single-shot echo-planar imaging (EPI) combined with a reduction in the FOV in the phase-encoding direction (i.e. zooming) leads to a decreased number of k-space acquisition lines, significantly shortening the EPI echo train and potentially susceptibility artifacts. Purpose To assess the feasibility and image quality of a zoomed diffusion-weighted EPI (z-EPI) sequence in MR imaging of the pancreas. The approach is compared to conventional single-shot EPI (c-EPI). Material and Methods 23 patients who had undergone an MRI study of the abdomen were included in this retrospective study. Examinations were performed on a 3T whole-body MR system (Magnetom Skyra, Siemens) equipped with a two-channel fully dynamic parallel transmit array (TimTX TrueShape, Siemens). The acquired sequences consisted of a conventional EPI DWI of the abdomen and a zoomed EPI DWI of the pancreas. For z-EPI, the standard sinc excitation was replaced with a two-dimensional spatially-selective RF pulse using an echo-planar transmit trajectory. Images were evaluated with regard to image blur, respiratory motion artifacts, diagnostic confidence, delineation of the pancreas, and overall scan preference. Additionally ADC values of the pancreatic head, body, and tail were calculated and compared between sequences. Results The pancreas was better delineated in every case (23/23) with z-EPI versus c-EPI. In every case (23/23), both readers preferred z-EPI overall to c-EPI. With z-EPI there was statistically significantly less image blur (p<0.0001) and respiratory motion artifact compared to c-EPI (p<0.0001). Diagnostic confidence was statistically significantly better with z-EPI (p<0.0001). No statistically significant differences in calculated ADC values were observed between the two sequences. Conclusion Zoomed diffusion-weighted EPI leads to substantial image quality improvements with reduction of susceptibility artifacts in pancreatic DWI.

Implementation of Dual-Source RF Excitation in 3 T MR-Scanners Allows for Nearly Identical ADC Values Compared to 1.5 T MR Scanners in the Abdomen

Background To retrospectively and prospectively compare abdominal apparent diffusion coefficient (ADC) values obtained within in a 1.5 T system and 3 T systems with and without dual-source parallel RF excitation techniques. Methodology/Principal Findings After IRB approval, diffusion-weighted (DW) images of the abdomen were obtained on three different MR systems (1.5 T, a first generation 3 T, and a second generation 3 T which incorporates dual-source parallel RF excitation) on 150 patients retrospectively and 19 volunteers (57 examinations total) prospectively. Seven regions of interest (ROI) were throughout the abdomen were selected to measure the ADC. Statistical analysis included independent two-sided t-tests, Mann-Whitney U tests and correlation analysis. In the DW images of the abdomen, mean ADC values were nearly identical with nonsignificant differences when comparing the 1.5 T and second generation 3 T systems in all seven anatomical regions in the patient population and six of the seven in the volunteer population (p>0.05 in all distributions). The strength of correlation measured in the volunteer population between the two scanners in the kidneys ranged from r = 0.64–0.88 and in the remaining regions (besides the spleen), r>0.85. In the patient population the first generation 3 T scanner had different mean ADC values with significant differences (p<0.05) compared to the other two scanners in each of the seven distributions. In the volunteer population, the kidneys shared similar ADC mean values in comparison to the other two scanners with nonsignificant differences. Conclusions/Significance A second generation 3 T scanner with dual-source parallel RF excitation provides nearly identical ADC values compared with the 1.5 T imaging system in abdominal imaging.

Impact of iso- and low-osmolar iodinated contrast agents on BOLD and diffusion MRI in swine kidneys.

Purpose:To assess whether functional MR imaging using blood-oxygenation level-dependent (BOLD) imaging and diffusion-weighted imaging demonstrate changes in renal oxygenation and apparent diffusion coefficient (ADC) in a pig model. Materials and Methods:After administration of either 1-g iodine/kg body weight low-osmolar iopromide or iso-osmolar iodixanol, 8 mini pigs underwent a series of repeated BOLD measurements (TR/TE 106/5.9–48.7 ms, slice thickness 4 mm) and diffusion-weighted imaging measurements (TR/TE 3900/79 ms, slice thickness 4 mm) for 1 hour at 1.5 T. In this intraindividual cross over study, the second contrast agent injection with the other iodinated contrast agent was performed at least 24 hours after the initial contrast agent injection. BOLD-based R2* values as indirect measures of the renal oxygenation were determined for the cortex, the inner medulla, and the outer medulla. ADC values were measured for the cortex and the whole kidney. Results:For both contrast agents, a drop in R2* was found in the cortex, which normalized after 55 minutes. In the outer medulla and particularly in the inner medulla, a decreased initial drop of R2* was encountered with both contrast agents, with a slow increase toward the baseline R2*. In the inner medulla, elevated R2* values were found with the iso-osmolar contrast agent only. The ADC revealed an initial increase, which slowly decayed over the measurement period. This finding was more pronounced for the cortex compared with the whole-kidney analysis. Conclusion:Functional MR imaging of the kidneys demonstrates increased R2* in the inner medulla only after the administration of the iodixanol potentially indicating hypoxia and thus a pathomechanism of contrast-induced nephropathy.

Radiotherapy for tumors of the stomach and gastroesophageal junction – a review of its role in multimodal therapy

There is broad consensus on surgical resection being the backbone of curative therapy of gastric- and gastroesophageal junction carcinoma. Nevertheless, details on therapeutic approaches in addition to surgery, such as chemotherapy, radiotherapy or radiochemotherapy are discussed controversially; especially whether external beam radiotherapy should be applied in addition to chemotherapy and surgery is debated in both entities and differs widely between regions and centers. Early landmark trials such as the Intergroup-0116 and the MAGIC trial must be interpreted in the context of potentially insufficient lymph node resection. Despite shortcomings of both trials, benefits on overall survival by radiochemotherapy and adjuvant chemotherapy were confirmed in populations of D2-resected gastric cancer patients by Asian trials.Recent results on junctional carcinoma patients strongly suggest a survival benefit of neoadjuvant radiochemotherapy in curatively resectable patients. An effect of chemotherapy in the perioperative setting as given in the MAGIC study has been confirmed by the ACCORD07 trial for junctional carcinomas; however both the studies by Stahl et al. and the excellent outcome in the CROSS trial as compared to all other therapeutic approaches indicate a superiority of neoadjuvant radiochemotherapy as compared to perioperative chemotherapy in junctional carcinoma patients. Surgery alone without neoadjuvant or perioperative therapy is considered suboptimal in patients with locally advanced disease.In gastric carcinoma patients, perioperative chemotherapy has not been compared to adjuvant radiochemotherapy in a randomized setting. Nevertheless, the results of the recently published ARTIST trial and the Chinese data by Zhu and coworkers, indicate a superiority of adjuvant radiochemotherapy as compared to adjuvant chemotherapy in terms of disease free survival in Asian patients with advanced gastric carcinoma. The ongoing CRITICS trial is supposed to provide reliable conclusions about which therapy should be preferred in Western patients with gastric carcinoma. If radiotherapy is performed, modern approaches such as intensity-modulated radiotherapy and image guidance should be applied, as these methods reduce dose to organs at risk and provide a more homogenous coverage of planning target volumes.