Cardiovascular magnetic resonance feature tracking derived strain analysis can predict return to training following exertional heatstroke.

BACKGROUND: Exertional heatstroke (EHS) is increasingly common in young trained soldiers. However, prognostic markers in EHS patients remain unclear. The objective of this study was to evaluate cardiovascular magnetic resonance (CMR) feature tracking derived left ventricle (LV) strain as a biomarker for return to training (RTT) in trained soldiers with EHS. METHODS: Trained soldiers (participants) with EHS underwent CMR cine sequences between June 2020 and August 2023. Two-dimensional (2D) LV strain parameters were derived. At 3 months after index CMR, the participants with persistent cardiac symptoms including chest pain, dyspnea, palpitations, syncope, and recurrent heat-related illness were defined as non-RTT. Multivariable logistic regression analysis was used to develop a predictive RTT model. The performance of different models was compared using the area under curve (AUC). RESULTS: A total of 80 participants (median age, 21 years; interquartile range (IQR), 20-23 years) and 27 health controls (median age, 21 years; IQR, 20-22 years) were prospectively included. Of the 77 participants, 32 had persistent cardiac symptoms and were not able to RTT at 3 months follow-up after experiencing EHS. The 2D global longitudinal strain (GLS) was significantly impaired in EHS participants compared to the healthy control group (-15.8 ± 1.7% vs -16.9 ± 1.2%, P = 0.001), which also showed significant statistical differences between participants with RTT and non-RTT (-15.0 ± 3.5% vs -16.5 ± 1.4%, P < 0.001). 2D-GLS (≤ -15.0%) (odds ratio, 1.53; 95% confidence interval: 1.08, 2.17; P = 0.016) was an independent predictor for RTT even after adjusting known risk factors. 2D-GLS provided incremental prognostic value over the clinical model and conventional CMR parameters model (AUCs: 0.72 vs 0.88, P = 0.013; 0.79 vs 0.88, P = 0.023; respectively). CONCLUSION: Two-dimensional global longitudinal strain (≤ -15.0%) is an incremental prognostic CMR biomarker to predict RTT in soldiers suffering from EHS.

Application of diffusional kurtosis imaging for insights into structurally aberrant topology in Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) has been regarded as a disconnection syndrome with functional and structural disturbances. However, as the anatomic determinants, the structural disconnections in PD have yet to be fully elucidated. PURPOSE: To non-invasively construct structural networks based on microstructural complexity and to further investigate their potential topological abnormalities in PD given the technical superiority of diffusion kurtosis imaging (DKI) to the quantification of microstructure. MATERIAL AND METHODS: The microstructural data of gray matter in both the PD group and the healthy control (HC) group were acquired using DKI. The structural networks were constructed at the group level by a covariation approach, followed by the calculation of topological properties based on graph theory and statistical comparisons between groups. RESULTS: A total of 51 patients with PD and 50 HCs were enrolled. Individuals were matched between groups with respect to demographic characteristics (P >0.05). The constructed structural networks in both the PD and HC groups featured small-world properties. In comparison with the HC group, the PD group exhibited significantly altered global properties, with higher normalized characteristic path lengths, clustering coefficients, local efficiency values, and characteristic path lengths and lower global efficiency values (P <0.05). In terms of nodal centralities, extensive nodal disruptions were observed in patients with PD (P <0.05); these disruptions were mainly distributed in the sensorimotor network, default mode network, frontal-parietal network, visual network, and subcortical network. CONCLUSION: These findings contribute to the technical application of DKI and the elucidation of disconnection syndrome in PD.

Analysis of minimal levator ani hiatus area based on MRI in female adults without pelvic floor dysfunction at different age groups.

PURPOSE: To investigate the association of minimal levator ani hiatus area with age in female adults without pelvic floor dysfunction. METHODS: 532 female subjects aged 18 ~ 90 years without pelvic floor dysfunction, divided into four groups (Group A, 18 ~ 29 years old; Group B, 30 ~ 39 years old; Group C, 40 ~ 49 years old; Group D, ≥ 50 years old) based on age, underwent traditional pelvic two-dimensional (2D) T2-weighted imaging (T2WI) axial to the body (AxB) for measuring the minimal levator ani hiatus area. 39 female volunteers were re-recruited to undergo both traditional pelvic 2D T2WI AxB and three-dimensional (3D) T2WI. An axial plane parallel to the direction of the puborectalis muscle (AxPRM) was acquired based on 3D T2WI. The difference of levator ani hiatus area measured on AxB and AxPRM images in 39 female volunteers was compared by one-sample t test, to verify if minimal levator ani hiatus area can be acquired on the traditional pelvic 2D T2WI AxB images. Spearman analysis evaluated the association of minimal levator ani hiatus area with age and the rank-sum test analyzed the area differences among four age groups. RESULTS: Female age was positively correlated with minimal levator ani hiatus area (r = 0.23; p < 0.001). The minimal levator ani hiatus areas of 532 subjects were: 15.17 ± 1.77 cm2 in Group A, 15.52 ± 2.21 cm2 in Group B, 16.03 ± 2.16 cm2 in Group C, and 16.40 ± 2.10 cm2 in Group D. ANOVA showed significant statistical differences among four age groups (F = 7.519, p < 0.0001). Significant differences in minimal levator ani hiatus areas were found between Group A and Group C (p = 0.0491), Group A and Group D (p = 0.0007), and Group B and Group D (p < 0.001). There was no statistical difference in minimal levator ani hiatus areas measured on AxB and AxPRM images in 39 female volunteers (p = 0.1000). There were no statistical difference in minimal levator ani hiatus areas between nulliparous and multiparous group for each age group (all p > 0.05). CONCLUSIONS: Based on a large sample, this study summarized the minimum levator ani hiatus area of female adults without pelvic floor dysfunction in different age groups. We found significant differences among different age groups. In addition, a positive correlation was found between age and the minimum levator ani hiatus area. These findings can provide reference criteria for diagnosing pelvic organ prolapse in female adults of different age groups.

Optimization of structural connectomes and scaled patterns of structural-functional decoupling in Parkinson's disease.

Parkinson's disease (PD) is manifested with disrupted topology of the structural connection network (SCN) and the functional connection network (FCN). However, the SCN and its interactions with the FCN remain to be further investigated. This multimodality study attempted to precisely characterize the SCN using diffusion kurtosis imaging (DKI) and further identify the neuropathological pattern of SCN-FCN decoupling, underscoring the neurodegeneration of PD. Diffusion-weighted imaging and resting-state functional imaging were available for network constructions among sixty-nine patients with PD and seventy demographically matched healthy control (HC) participants. The classification performance and topological prosperities of both the SCN and the FCN were analyzed, followed by quantification of the SCN-FCN couplings across scales. The SCN constructed by kurtosis metrics achieved optimal classification performance (area under the curve 0.89, accuracy 80.55 %, sensitivity 78.40 %, and specificity 80.65 %). Along with diverse alterations of structural and functional network topology, the PD group exhibited decoupling across scales including: reduced global coupling; increased nodal coupling within the sensorimotor network (SMN) and subcortical network (SN); higher intramodular coupling within the SMN and SN and lower intramodular coupling of the default mode network (DMN); decreased coupling between the modules of DMN-fronto-parietal network and DMN-visual network, but increased coupling between the SMN-SN module. Several associations between the coupling coefficient and topological properties of the SCN, as well as between network values and clinical scores, were observed. These findings validated the clinical implementation of DKI for structural network construction with better differentiation ability and characterized the SCN-FCN decoupling as supplementary insight into the pathological process underlying PD.

High-Resolution Vessel Wall MRI in Assessing Postoperative Restenosis of Intracranial Atherosclerotic Disease Before Drug-Coated Balloon Treatment: An Outcome Prediction Study.

BACKGROUND: Postoperative restenosis frequently occurs in intracranial atherosclerotic disease (ICAD) patients after drug-coated balloon (DCB) treatment. However, high-risk plaques associated with postoperative restenosis remain to be explored. PURPOSE: To assess whether high-resolution vessel wall MRI (HR-VWI) contributes to the identification of high-risk plaques associated with postoperative restenosis before DCB treatment. STUDY TYPE: Retrospective. SUBJECTS: A total of 70 patients with ICAD who underwent DCB treatment. FIELD STRENGTH/SEQUENCE: 3.0 T; magnetic resonance angiography, HR-VWI. ASSESSMENT: All patients underwent HR-VWI examination prior to DCB treatment. Digital subtraction angiography (DSA) measurement was assessed 6 months (±1 month) after operation to determine the vessel restenosis, classifying patients into three groups of no stenosis, mild stenosis (<50%), and restenosis (>50%). Clinical factors and HR-VWI characteristics, including vessel and lumen area at maximal lumen narrowing (MLN), plaque area and length, degree of stenosis, plaque burden, remodeling index, and enhancement amplitude, were compared among three groups. Clinical factors and HR-VWI characteristics were separately evaluated for the association with postoperative restenosis. STATISTICAL TESTS: Kolmogorov-Smirnov test, intra-class correlation coefficient, Kruskal Wallis H test, Mann-Whitney U test, receiver operating characteristic (ROC) curve, multivariable linear regression analysis. P-values <0.05 was considered statistically significant. RESULTS: During the follow-up DSA measurement, 13 lesions (18.5%) showed restenosis. With HR-VWI, significant differences among three groups were observed in plaque length, lumen area of MLN, degree of stenosis, enhancement amplitude, and plaque burden. In ROC analysis, plaque length (area under the curve [AUC] = 0.809), and enhancement amplitude (AUC = 0.880) provided higher efficacy in identification of high-risk plaques associated with postoperative restenosis than degree of stenosis (AUC = 0.746) and plaque burden (AUC = 0.759). Multivariable linear regression analysis showed that plaque length and enhancement amplitude were independent prognostic factors of postoperative restenosis. DATA CONCLUSION: HR-VWI has the potential to identify high-risk plaques in ICAD patients before DCB treatment. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY: Stage 2.

Image Improved Intravoxel Incoherent Motion MRI With Optimized Trigger Delays Based on Strain Curve Analysis to Evaluate Myocardial Microvascular Dysfunction of Exertional Heat Illness.

BACKGROUND: Intravoxel incoherent motion (IVIM) MRI has not been widely used and its role in evaluating exertional heat illness (EHI)-related myocardial involvement remains unknown. PURPOSE: To investigate the feasibility of strain curve-derived trigger delay (TD) IVIM-MRI and its role in assessing myocardial diffusion and microvascular perfusion of EHI patients. STUDY TYPE: Prospective. SUBJECTS: A total of 42 male EHI patients (median age: 21 years) and 22 age- and sex-matched healthy controls (HC). FIELD STRENGTH/SEQUENCE: A 3-T, diffusion-weighted spin-echo echo-planar-imaging sequence. ASSESSMENT: IVIM-MRI was acquired by conventional TD method (group A) or strain curve-based TD method (group B) in random order. IVIM image quality was evaluated on a 3-point Likert scale (1, nondiagnostic; 2, moderate; 3, good). Technical success was defined as image quality score = 3. IVIM-MRI-derived parameters (pseudo diffusion in the capillaries [D*], perfusion fraction [f], and slow apparent diffusion coefficient [D]) were compared between EHI and HC. STATISTICAL TESTS: Student's t-tests, chi-square tests, one-way analysis of variance, receiver operating characteristic (ROC) curve analysis, Pearson's correlation coefficient (r). The statistical significance level was set at P < 0.05. RESULTS: IVIM-MRI image quality score (median [interquartile range]: 3 [2, 3] vs. 2 [1-3]) and technical success rate (61.9%[13/21] vs. 28.6%[6/21]) were significantly improved in group B. EHI patients showed significantly decreased D* (118.1 ± 23.3 × 10-3  mm2 /sec vs. 142.7 ± 42.6 × 10-3  mm2 /sec) and f values (0.42 ± 0.12 vs. 0.51 ± 0.11) and significantly higher D values (3.0 ± 0.9 × 10-3  mm2 /sec vs. 2.5 ± 0.6 × 10-3  mm2 /sec) compared to HC. Relative to D and D*, f showed the most robust efficacy for detecting EHI-related myocardial injury with the highest area under the ROC curve (0.906: 95% confidence interval, 0.799, 0.967) and sensitivity of 88.5% and specificity of 85.6%. CONCLUSION: The strain curve-based TD method significantly improved image quality and technical success rate of IVIM-MRI, and f value may be an effective biomarker to assess myocardial microcirculation abnormalities of EHI patients. EVIDENCE LEVEL: 2. TECHNICAL EFFICACY: Stage 3.

Synthetic MRI in differentiating benign from metastatic retropharyngeal lymph node: combination with diffusion-weighted imaging.

OBJECTIVES: This study aimed to evaluate the synthetic MRI (syMRI), its combination with diffusion-weighted imaging (DWI), and morphological features for discriminating benign from metastatic retropharyngeal lymph nodes (RLNs). METHODS: Fifty-eight patients with a total of 63 RLNs (21 benign and 42 metastatic) were enrolled. The mean and standard deviation of syMRI-derived relaxometry parameters (T1, T2, PD; T1SD, T2SD, PDSD) were obtained from two different regions of interest (namely, partial-lesion and full-lesion ROI). The parameters derived from benign and metastatic RLNs were compared using Student's t or chi-square tests. Logistic regression analysis was used to construct a multi-parameter model of syMRI, syMRI + DWI, and syMRI + DWI + morphological features. Areas under the curve (AUC) were compared using the DeLong test to determine the best diagnostic approach. RESULTS: Benign RLNs had significantly higher T1, T2, PD, and T1SD values compared with metastatic RLNs in both partial-lesion and full-lesion ROI (all p < 0.05). The T1SD obtained from full-lesion ROI showed the best diagnostic performance among all syMRI-derived single parameters. The AUC of combined syMRI multiple parameters (T1, T2, PD, T1SD) were higher than those of any single parameter from syMRI. The combination of synthetic MRI and DWI can improve the AUC regardless of ROI delineation. Furthermore, the combination of synthetic MRI, DWI-derived quantitative parameters, and morphological features can significantly improve the overall diagnostic performance. CONCLUSIONS: The value of syMRI has been validated in differential diagnosis of benign and metastatic RLNs, and syMRI + DWI + morphological features can further improve the diagnostic efficiency for discriminating these two entities. KEY POINTS: • Synthetic MRI was useful in differential diagnosis of benign and metastatic RLNs. • The combination of syMRI, DWI, and morphological features can significantly improve the diagnostic efficiency.

Ultra-short echo time MR imaging in assessing cartilage endplate damage and relationship between its lesion and disc degeneration for chronic low back pain patients.

OBJECTIVE: To investigate the feasibility of ultra-short echo time (UTE) magnetic resonance imaging (MRI) in the assessment of cartilage endplate (CEP) damage and further evaluate the relationship between total endplate score (TEPS) and lumbar intervertebral disc (IVD) degeneration for chronic low back pain patients. MATERIALS AND METHODS: IVD were measured in 35 patients using UTE imaging at 3T MR. Subtracted UTE images between short and long TEs were obtained to depict anatomy of CEP. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated to assess the image quality quantitatively. A new grading criterion for endplate damage evaluation was developed based on Rajasekaran.S grading system in this study. Two radiologists were employed to evaluate CEP and bony vertebral endplates (VEP) using this new grading criterion and assess TEPS, independently. Cohen's kappa analysis was applied to evaluate the inter-observer agreement of endplate damage assessment between two radiologists, and the Kendall's TAU-B analysis was employed to determine the relationship between TEPS and IVD degeneration evaluated with Pfirrmann grading. RESULTS: Well structural CEP was depicted on subtracted UTE images and confirmed by high SNR (33.06±2.92) and CNR values (9.4±2.08). Qualified subtracted UTE images were used by two radiologists to evaluate the degree of CEP and VEP damage. Excellent inter-observer agreement was confirmed by high value in Cohen's kappa test (0.839, P < 0.001). Ensured by this, 138 endplates from 69 IVDs of 35 patients were classified into six grades based on the new grading criterion and TEPS of each endplate was calculated. In addition, the degeneration degree of IVDs were classified into five grades. Finally, using Kendall's TAU-B analysis, significant relationship was obtained between endplate damage related TEPS and IVD degeneration (r = 0.864, P < 0.001). CONCLUSION: Ensured by high image quality, UTE imaging might be considered an effective tool to assess CEP damage. Additionally, further calculated TEPS has shown strong positive association with IVD degeneration, suggesting that the severity of endplate damage is highly linked with the degree of IVD degeneration.

High-Resolution Vessel Wall MR Imaging in Diagnosis and Length Measurement of Cerebral Arterial Thrombosis: A Feasibility Study.

BACKGROUND: Detecting and measuring intraluminal thrombus has prognostic and therapeutic implications for stroke patients. PURPOSE: To investigate the feasibility of 3D isotropic high-resolution T1w-CUBE imaging to detect and measure intraluminal thrombus in stroke patients. STUDY TYPE: Retrospective. SUBJECTS: A total of 93 patients with acute (N = 39) and subacute (N = 54) stroke. FIELD STRENGTH/SEQUENCE: A 3.0 T/spin-echo echo-planar diffusion-weighted imaging (DWI), high-resolution T1w-CUBE imaging and 3D flow compensated gradient-echo susceptibility-weighted imaging (SWI). ASSESSMENT: Data assessment was performed by three neuroradiologists with 11, 13, and 20 years of clinical experience. The accuracy of T1W-CUBE and SWI in diagnosing thrombosis was compared by using digital subtraction angiography (DSA) as the reference. For thrombus length measurement, the image quality of proximal and distal thrombus of T1w-CUBE images was first evaluated with a 4-point rating system. Then, the proximal and distal positions to lesions were determined on T1w-CUBE images and compared with those from DSA acquired during endovascular reperfusion therapy. If comparable both locations were found between CUBE and DSA, CUBE imaging can thus be considered for accurate measurement of thrombus length. STATISTICAL TESTS: Fleiss' Kappa; the area under the receiver operating characteristic (ROC) curve (AUC); Pearson's chi-squared test with Yates' continuity correction. RESULTS: Moderate-to-good interobserver agreements were validated with all Kappa coefficients higher than 0.40 in thrombus diagnosis and measurement. CUBE imaging showed higher clinical efficacy than SWI (AUC: 0.966 vs. 0.850) in thrombus diagnosis. Additionally, high quality of CUBE imaging was confirmed with 3 or 4 points rated by all three observers. Compared to intraoperative DSA, T1w CUBE showed consistent proximal and distal positions of thrombi in 16 of the 18 patients, validating the accuracy of T1w-CUBE in measuring thrombus length. DATA CONCLUSION: T1w-CUBE imaging has potential to facilitate diagnosis and measurement of intraluminal thrombus. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 2.

Differentiating Benign from Malignant Renal Tumors Using T2- and Diffusion-Weighted Images: A Comparison of Deep Learning and Radiomics Models Versus Assessment from Radiologists.

BACKGROUND: Differentiating benign from malignant renal tumors is important for selection of the most effective treatment. PURPOSE: To develop magnetic resonance imaging (MRI)-based deep learning (DL) models for differentiation of benign and malignant renal tumors and to compare their discrimination performance with the performance of radiomics models and assessment by radiologists. STUDY TYPE: Retrospective. POPULATION: A total of 217 patients were randomly assigned to a training cohort (N = 173) or a testing cohort (N = 44). FIELD STRENGTH/SEQUENCE: Diffusion-weighted imaging (DWI) and fast spin-echo sequence T2-weighted imaging (T2WI) at 3.0T. ASSESSMENT: A radiologist manually labeled the region of interest (ROI) on each image. Three DL models using ResNet-18 architecture and three radiomics models using random forest were developed using T2WI alone, DWI alone, and a combination of the two image sets to discriminate between benign and malignant renal tumors. The diagnostic performance of two radiologists was assessed based on professional experience. We also compared the performance of each model and the radiologists. STATISTICAL TESTS: The area under the receiver operating characteristic (ROC) curve (AUC) was used to assess the performance of each model and the radiologists. P < 0.05 indicated statistical significance. RESULTS: The AUC of the DL models based on T2WI, DWI, and the combination was 0.906, 0.846, and 0.925 in the testing cohorts, respectively. The AUC of the combination DL model was significantly better than that of the models based on individual sequences (0.925 > 0.906, 0.925 > 0.846). The AUC of the radiomics models based on T2WI, DWI, and the combination was 0.824, 0.742, and 0.826 in the testing cohorts, respectively. The AUC of two radiologists was 0.724 and 0.667 in the testing cohorts. CONCLUSION: Thus, the MRI-based DL model is useful for differentiating benign from malignant renal tumors in clinic, and the DL model based on T2WI + DWI had the best performance. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2.

Influence of post-label delay time on the performance of 3D pseudo-continuous arterial spin labeling magnetic resonance imaging in the characterization of parotid gland tumors.

OBJECTIVE: To evaluate the influence of post-label delay times (PLDs) on the performance of 3D pseudo-continuous arterial spin labeling (pCASL) magnetic resonance imaging for characterizing parotid gland tumors and to explore the optimal PLDs for the differential diagnosis. MATERIALS AND METHOD: Fifty-eight consecutive patients with parotid gland tumors were enrolled, including 33 patients with pleomorphic adenomas (PAs), 16 patients with Warthin's tumors (WTs), and 9 patients with malignant tumors (MTs). 3D pCASL was scanned for each patient five times, with PLDs of 1025 ms, 1525 ms, 2025 ms, 2525 ms, and 3025 ms. Tumor blood flow (TBF) was calculated, and compared among different PLDs and tumor groups. Performance of TBF at different PLDs was evaluated using receiver operating characteristic analysis. RESULTS: With an increasing PLD, TBF tended to gradually increase in PAs (p < 0.001), while TBF tended to slightly increase and then gradually decrease in WTs (p = 0.001), and PAs showed significantly lower TBF than WTs at all 5 PLDs (p < 0.05). PAs showed significantly lower TBF than MTs at 4 PLDs (p < 0.05), except at 3025 ms (p = 0.062). WTs showed higher TBF than MTs at all 5 PLDs; however, differences did not reach significance (p > 0.05). Setting a TBF of 64.350 mL/100g/min at a PLD of 1525 ms, or a TBF of 23.700 mL/100g/min at a PLD of 1025 ms as the cutoff values, optimal performance could be obtained for differentiating PAs from WTs (AUC = 0.905) or from MTs (AUC = 0.872). CONCLUSIONS: Short PLDs (1025 ms or 1525 ms) are suggested to be used in 3D pCASL for characterizing parotid gland tumors in clinical practice. KEY POINTS: • With 5 different PLDs, 3D pCASL can reflect the variation of blood flow in parotid gland tumors. • 3D pCASL is useful for characterizing PAs from WTs or MTs. • Short PLDs (1025 ms or 1525 ms) are suggested to be used in 3D pCASL for characterizing parotid gland tumors in clinical practice.

Can R2 ' mapping evaluate hypoxia in renal ischemia reperfusion injury quantitatively? An experimental study.

PURPOSE: To explore if R2 ' mapping can assess renal hypoxia in rabbits with ischemia reperfusion injury (IRI). METHODS: Forty rabbits were randomly divided into 4 groups according to the clipping time: the sham group and 45 min, 60 min, and 75 min for the mild, moderate, and severe groups (with n = 10 each group), respectively. Intravenous furosemide (FU) was administered 24 h after IRI. All rabbits were performed 5 times (IRIpre , IRI24h , FU5min , FU12min , and FU24min ) with a 3.0 Tesla MR. The R2 ' values and the hypoxic scores were then recorded. The repeated measurement analysis of variance and Spearman correlation analysis was used for statistical analysis. RESULTS: Compared to the baseline, the medullary R2 ' values increased significantly 24 h after the IRI (baseline 19.31 ± 1.21 s-1 , mild group 20.05 ± 1.26 s-1 , moderate group 25.38 ± 1.38 s-1 , and severe group 25.79 ± 1.10 s-1 ; each P < .001). FU led to a significant decrease in the medullary R2 ' value (sham group 11.17 ± 4.33 s-1 , mild group 7.80 ± 0.74 s-1 , moderate group 3.92 ± 0.28 s-1 , and severe group 3.82 ± 0.23 s-1 ; each P < .05). Quantitative hypoxic scores revealed significant differences among the 4 groups in the outer medulla (P < .001 each). The medullary R2 ' differences (before and after intravenous FU) were significantly correlated with the hypoxic scores, respectively (P < .001). CONCLUSION: R2 ' mapping can evaluate the renal hypoxia in the procession of IRI in rabbits and might serve as a quantitative biomarker for IRI.

Can Arterial Spin Labeling Perfusion Imaging be Used to Differentiate Nasopharyngeal Carcinoma From Nasopharyngeal Lymphoma?

BACKGROUND: Differentiating nasopharyngeal carcinoma (NPC) from nasopharyngeal lymphoma (NPL) is useful for deciding the appropriate treatment. However, the diagnostic accuracy of current imaging methods is low. PURPOSE: To explore the feasibility of arterial spin labeling (ASL) perfusion imaging in the qualitative and quantitative differentiation between NPC and NPL to improve the diagnosis of malignancies in the nasopharynx. STUDY TYPE: Retrospective. POPULATION: Ninety seven patients: NPC (65 cases) and NPL (32 cases), histologically confirmed. FIELD STRENGTH/SEQUENCE: 3T/3D fast spin echo pseudo-continuous ASL imaging with spiral readout scheme, 3D inverse recovery- fast spoiled gradient recalled echo brain volume (BRAVO) imaging. ASSESSMENT: Cerebral blood flow (CBF) images from ASL perfusion imaging were assessed by three radiologists. Each tumor was visually scored based on CBF images. Intratumoral CBF and intramuscular CBF values were obtained from intratumoral and lateral pterygoid muscle areas, respectively. Through dividing intratumoral CBF by intramuscular CBF, normalized CBF (nCBF) was further calculated. STATISTICAL TESTS: Fleiss's kappa and intraclass correlation coefficients (ICCs) were used to assess interobserver agreement among the three readers. The Mann-Whitney U-test was used to compare visual scoring, and an unpaired t-test was performed to compare CBF value between the NPC and NPL groups. The area under the curve (AUC) value was used to quantify the diagnostic ability of each parameter. RESULTS: Good interobserver agreements were validated by high Fleiss's kappa and ICC values (all >0.80). NPCs showed significantly higher visual scores than NPLs (P < 0.05). Both intratumoral CBF and nCBF in NPC were significantly higher than those in NPL (both P < 0.05). Intratumoral CBF showed the highest AUC of 0.861 (P < 0.05) in differentiating NPC (n = 65) from NPL (n = 32), while the AUCs of nCBF and visual scoring were 0.847 and 0.753, respectively. DATA CONCLUSION: For the diagnosis of distinguishing NPC from NPL, ASL perfusion imaging demonstrated high diagnostic efficiency. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2.

Intravoxel Incoherent Motion and Dynamic Contrast-Enhanced Magnetic Resonance Imaging to Early Detect Tissue Injury and Microcirculation Alteration in Hepatic Injury Induced by Intestinal Ischemia-Reperfusion in a Rat Model.

BACKGROUND: Intravoxel incoherent motion (IVIM) can provide quantitative information about water diffusion and perfusion that can be used to evaluate hepatic injury, but it has not been studied in hepatic injury induced by intestinal ischemia-reperfusion (IIR). Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) can provide perfusion data, but it is unclear whether it can provide useful information for assessing hepatic injury induced by IIR. PURPOSE: To examine whether IVIM and DCE-MRI can detect early IIR-induced hepatic changes, and to evaluate the relationship between IVIM and DCE-derived parameters and biochemical indicators and histological scores. STUDY TYPE: Prospective pre-clinical study. POPULATION: Forty-two male Sprague-Dawley rats. FIELD STRENGTH/SEQUENCE: IVIM-diffusion-weighted imaging (DWI) using diffusion-weighted echo-planar imaging sequence and DCE-MRI using fast spoiled gradient recalled-based sequence at 3.0 T. ASSESSMENT: All rats were randomly divided into the control group (Sham), the simple ischemia group, the ischemia-reperfusion (IR) group (IR1h, IR2h, IR3h, and IR4h) in a model of secondary hepatic injury caused by IIR, and IIR was induced by clamping the superior mesenteric artery for 60 minutes and then removing the vascular clamp. Advanced Workstation (AW) 4.6 was used to calculate the imaging parameters (apparent diffusion coefficient [ADC], true diffusion coefficient [D], perfusion-related diffusion [D* ] and volume fraction [f]) of IVIM. OmniKinetics (OK) software was used to calculate the DCE imaging parameters (Ktrans , Kep , and Ve ). Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were analyzed with an automatic biochemical analyzer. Superoxide dismutase (SOD) activity was assessed using the nitro-blue tetrazolium method. Malondialdehyde (MDA) was determined by thiobarbituric acid colorimetry. Histopathology was performed with hematoxylin and eosin staining. STATISTICAL TESTS: One-way analysis of variance (ANOVA) and Bonferroni post-hoc tests were used to analyze the imaging parameters and biochemical indicators among the different groups. Pearson correlation analysis was applied to determine the correlation between imaging parameters and biochemical indicators or histological score. RESULTS: ALT and MDA reached peak levels at IR4h, while SOD reached the minimum level at IR4h (all P < 0.05). ADC, D, D* , and f gradually decreased as reperfusion continued, and Ktrans and Ve gradually increased (all P < 0.05). The degrees of change for f and Ve were greater than those of other imaging parameters at IR1h (all P < 0.05). All groups showed good correlation between imaging parameters and SOD and MDA (r[ADC] = 0.615, -0.666, r[D] = 0.493, -0.612, r[D* ] = 0.607, -0.647, r[f] = 0.637, -0.682, r[Ktrans ] = -0.522, 0.500, r[Ve ] = -0.590, 0.665, respectively; all P < 0.05). However, the IR groups showed poor or no correlation between the imaging parameters and SOD and MDA (P [Ktrans and MDA] = 0.050, P [D and SOD] = 0.125, P [the remaining imaging parameters] < 0.05). All groups showed a positive correlation between histological score and Ktrans and Ve (r = 0.775, 0.874, all P < 0.05), and a negative correlation between histological score and ADC, D, f, and D* (r = -0.739, -0.821, -0.868, -0.841, respectively; all P < 0.05). For the IR groups, there was a positive correlation between histological score and Ktrans and Ve (r = 0.747, 0.802, all P < 0.05), and a negative correlation between histological score and ADC, D, f, and D* (r = -0.567, -0.712, -0.715, -0.779, respectively; all P < 0.05). DATA CONCLUSION: The combined application of IVIM and DCE-MRI has the potential to be used as an imaging tool for monitoring IIR-induced hepatic histopathology. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 2.

Can 3D Pseudo-Continuous Territorial Arterial Spin Labeling Effectively Diagnose Patients With Recanalization of Unilateral Middle Cerebral Artery Stenosis?

BACKGROUND: Unilateral middle cerebral artery (MCA) stenosis, as an independent risk factor for stroke, requires an intervention operation for vessel recanalization. Accurate perfusion measurement is thus essential after the operation. PURPOSE: To explore the feasibility of three-dimensional (3D) pseudo-continuous territorial arterial-spin-labeling (tASL) in evaluating MCA recanalization. STUDY TYPE: Prospective and longitudinal. SUBJECTS: Forty-seven patients with unilateral MCA stenosis or occlusion. FIELD STRENGTH/SEQUENCE: A 3.0 T, 3D time-of-flight fast-field-echo magnetic resonance (MR) angiography sequence, spin-echo echo-planar diffusion-weighted imaging sequence, 3D fast-spin-echo pseudo-continuous ASL (pcASL) and tASL sequences. ASSESSMENT: All patients underwent MR examination before and after MCA recanalization and scored using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at admission and discharge. An mRS score <2 was defined as a good prognosis. 3D-pcASL and tASL cerebral blood flow (CBF) maps were obtained, and the corresponding Alberta Stroke Program Early CT Score (ASPECTS)-based scores were evaluated. STATISTICAL TESTS: The Kolmogorov-Smirnov test, intra-class correlation coefficient, paired t-test, receiver operating characteristic (ROC) curve, and multivariable logistic regression analysis. RESULTS: After recanalization, tASL derived absolute CBFs between the affected and contralateral sides were significantly higher than before the operation (mean: 34.3 ± 8.5 mL/100 g/min vs. 40.6 ± 9.2 mL/100 g/min, 42.6 ± 9.8 mL/100 g/min vs. 43.5 ± 9.9 mL/100 g/min, both P < 0.05). In ROC analysis, tASL provided good prognosis (area under ROC curve [AUC] = 0.829; 95% CI: 0.651-1.000, P < 0.05), while pcASL had lower prognostic value (AUC = 0.760; 95% CI: 0.574-0.946, P < 0.05). The NIHSS score before recanalization, pcASL, and tASL-based ASPECTS scores were significantly associated with good clinical outcome (P < 0.05). Multivariable analysis revealed that ASPECTS-based scores of pcASL and tASL before and after surgery were independent predictors of good clinical outcome (all P < 0.05). DATA CONCLUSION: tASL can determine hypoperfusion in the responsible vascular perfusion area and predict clinical outcome. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 2.

Can Hybrid Arterial Spin Labeling-Tagged Zero-Echo-Time Magnetic Resonance Angiography Be an Effective Candidate in the Evaluation of Intracranial Artery Diseases? A Clinical Feasibility Study.

BACKGROUND: Flow related artifacts in continuous arterial spin labeling (cASL) zero-echo-time (ZTE) magnetic resonance angiography (MRA) could influence the vasculature visualization. PURPOSE: To investigate the clinical feasibility for the intracranial artery diseases assessment by utilizing hybrid ASL-ZTE-MRA (hASL-ZTE-MRA). STUDY TYPE: Prospective, technical development. POPULATION: Sixty-seven subjects with known/suspected cerebrovascular diseases. FIELD STRENGTH/SEQUENCE: Gradient echo based cASL-/hASL- ZTE-MRA at 3.0 T. ASSESSMENT: Subjective/objective evaluation for sound-levels. Image quality (IQ), signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were analyzed within artery segments. Stenotic grading, aneurysm measurement, and signal intensity of lesions were further analyzed. STATISTICAL TESTS: Kolmogorov-Smirnov test for data normality check. Between two MRAs: Wilcoxon signed-rank test for sound experience/IQ ratings analysis; Paired t test for SNR/CNR comparison. One-way analysis of variance for sound intensity comparison. For stenosis grading/aneurysm measurement: Kendall's W test/intraclass correlation coefficient (ICC) for interobserver agreement test within each modality, weighted kappa statistics/ICC for intermodality agreement test between each MRA and computed tomography angiography. RESULTS: Sound-level perception/intensity was similar (P = 0.86, P = 0.55) between MRAs. The mean IQ score for hASL-ZTE-MRA was on diagnostic scale and slightly higher (P < 0.05) than that of cASL-ZTE-MRA. hASL-ZTE-MRA provided higher (P < 0.05) SNR/CNR than that of cASL-ZTE-MRA. Signal uniformity was improved on hASL-ZTE-MRA, particularly among the anterior circulation (P < 0.05). Comparing to cASL-ZTE-MRA, on hASL-ZTE-MRA, stenotic lesions were accurately assessed; flow in the stent or aneurysm remnant was better depicted (P < 0.05); AVM nidus was preferred with increased SNR (P < 0.05). No significant differences for the aneurysm measurement were found between MRAs (P = 0.95), in addition to the slightly higher SNR (P < 0.05) on hASL-ZTE-MRA. DATA CONCLUSION: Comparing to cASL-ZTE-MRA, hASL-ZTE-MRA is robust and feasible for the evaluation of intracranial artery diseases with diagnostic IQ, improved vessel contrast, and better signal heterogeneity. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: 2.

Diagnostic performance of multiparametric MRI in the evaluation of treatment response in glioma patients at 3T.

BACKGROUND: MRI is one of the most important techniques to assess the treatment response of gliomas. However, differentiating tumor recurrence (TuR) from treatment effects (TrE) remains challenging. PURPOSE: To compare the diagnostic performance of MR diffusion-weighted imaging (DWI), arterial spin labeling (ASL), proton MR spectroscopy (MRS), and amide proton transfer (APT) imaging in differentiating between TuR and TrE in posttreatment glioma patients. STUDY TYPE: Prospective. POPULATION: Thirty patients with suspected tumor progression. FIELD STRENGTH/SEQUENCE: DWI, ASL, proton MRS, and APT imaging were performed at 3T MR. ASSESSMENT: MR indices, including ADC, relative cerebral blood flow (rCBF), ratios of Cho/Cr, Cho/NAA, and NAA/Cr and APT-weighted (APTw) effect were obtained from DWI, ASL, proton MRS, and APT imaging, respectively. Indices were measured in the contralateral normal-appearing white matter and lesions defined on the Gd-enhanced T1 w image. TuR or TrE was either determined histologically or clinically from longitudinal MRI follow-up for at least 6 months. STATISTICAL TESTS: The diagnostic performance of the indices was evaluated using Student's t-test, receiver operating characteristic (ROC) curve, and multivariate logistic regression analyses. RESULTS: Among the 30 patients, 16 were diagnosed as having TuR and the rest having TrE. The recurrent tumors showed a significantly higher APTw effect (1.56 ± 1.14%) and rCBF (1.44 ± 0.61) compared with lesions representing treatment effects (-0.44 ± 1.34% and 0.72 ± 0.25, respectively, with P < 0.001). The areas under the curve (AUCs) were 0.87 and 0.90 for APTw and rCBF, respectively, in differentiating between TuR and TrE. Combining APTw and rCBF achieved a higher AUC of 0.93. MRS index ratios of Cho/Cr (P = 0.25), Cho/NAA (P = 0.16), and NAA/Cr (P = 0.86) and ADC (P = 0.37) showed no significant differences between TuR and TrE lesions, with AUCs lower than 0.70. DATA CONCLUSION: Compared with DWI and MRS, ASL and APT imaging techniques showed better diagnostic capability in distinguishing TuR from TrE. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 4 J. Magn. Reson. Imaging 2020;51:1154-1161.

Comparing mono-exponential, bi-exponential, and stretched-exponential diffusion-weighted MR imaging for stratifying non-alcoholic fatty liver disease in a rabbit model.

OBJECTIVES: To compare diffusion parameters obtained from mono-exponential, bi-exponential, and stretched-exponential diffusion-weighted imaging (DWI) in stratifying non-alcoholic fatty liver disease (NAFLD). METHODS: Thirty-two New Zealand rabbits were fed a high-fat/cholesterol or standard diet to obtain different stages of NAFLD before 12 b-values (0-800 s/mm2) DWI. The apparent diffusion coefficient (ADC) from the mono-exponential model; pure water diffusion (D), pseudo-diffusion (D*), and perfusion fraction (f) from bi-exponential DWI; and distributed diffusion coefficient (DDC) and water molecular diffusion heterogeneity index (α) from stretched-exponential DWI were calculated for hepatic parenchyma. The goodness of fit of the three models was compared. NAFLD severity was pathologically graded as normal, simple steatosis, borderline, and non-alcoholic steatohepatitis (NASH). Spearman rank correlation analysis and receiver operating characteristic curves were used to assess NAFLD severity. RESULTS: Upon comparison, the goodness of fit chi-square from stretched-exponential fitting (0.077 ± 0.012) was significantly lower than that for the bi-exponential (0.110 ± 0.090) and mono-exponential (0.181 ± 0.131) models (p < 0.05). Seven normal, 8 simple steatosis, 6 borderline, and 11 NASH livers were pathologically confirmed from 32 rabbits. Both α and D increased with increasing NAFLD severity (r = 0.811 and 0.373, respectively; p < 0.05). ADC, f, and DDC decreased as NAFLD severity increased (r = - 0.529, - 0.717, and - 0.541, respectively; p < 0.05). Both α (area under the curve [AUC] = 0.952) and f (AUC = 0.931) had significantly greater AUCs than ADC (AUC = 0.727) in the differentiation of NASH from borderline or less severe groups (p < 0.05). CONCLUSIONS: Stretched-exponential DWI with higher fitting efficiency performed, as well as bi-exponential DWI, better than mono-exponential DWI in the stratification of NAFLD severity. KEY POINTS: • Stretched-exponential diffusion model fitting was more reliable than the bi-exponential and mono-exponential diffusion models (p = 0.039 and p < 0.001, respectively). • As NAFLD severity increased, the diffusion heterogeneity index (α) increased, while the perfusion fraction (f) decreased (r = 0.811, - 0.717, p < 0.05). • Both α and f showed superior NASH diagnostic performance (AUC = 0.952, 0.931) compared with ADC (AUC = 0.727, p < 0.05).

Diffusion kurtosis imaging in liver: a preliminary reproducibility study in healthy volunteers.

OBJECTIVES: To systematically test the reproducibility of DKI technique in normal liver and report a complete set of DKI measurement data. MATERIALS AND METHODS: Thirty-two healthy volunteers were examined with liver DKI twice on the GE 3.0 T MRI scanner and reviewed by three professional experts. DKI-derived parameters fractional anisotropy of kurtosis (FAk), mean diffusivity (Md), axial diffusivity (Da), radial diffusivity (Dr), mean kurtosis (Mk), axial kurtosis (Ka), and radial kurtosis (Kr) in eight segments divided by Couinaud octagonal method were collected. Inter-class correlation coefficient (ICC) was used to assess the agreement between three experts. For each expert, the reproducibility of twice scans was evaluated by Bland-Altman method. Multivariate analysis of variance was to explore the regional distribution characteristics of DKI-derived parameters, and showed with box-plot graph. RESULTS: Using ICC analysis, except for FAk (ICC 0.312, 0.307), other DKI metric values showed high reproducibility (0.716 < ICC < 0.907) between three experts for each of two DKI measurements. With Bland-Altman method, liver segment 5 (S5) showed the best reproducibility between two DKI measurement, and the reproducibility of segment 4 (S4) was the worst. The reproducibility of the right lobe was significantly higher than the left lobe. The values of diffusion metrics (Md, Da, and Dr) and kurtosis metrics (Mk, Ka, and Kr) existed significantly difference between the right and left hepatic lobes. CONCLUSION: DKI has shown excellent reproducibility in liver imaging. The range of values for multiple DKI parameters, derived from the normal liver, was reported, and may provide data reference for further clinical DKI applications. Additionally, DKI technique is a non-invasive method to reflect the perfusion or structural differences between the left and right hepatic lobes from the molecular level.

Preoperative assessment of extrathyroidal extension of papillary thyroid carcinomas by ultrasound and magnetic resonance imaging: a comparative study.

PURPOSE: The purpose of this study was to assess and compare the diagnostic performances of preoperative ultrasonography (US) and magnetic resonance imaging (MRI) in predicting extrathyroidal extension (ETE) in patients with papillary thyroid carcinoma (PTC). MATERIALS AND METHODS: This retrospective study was approved by our institutional review board. Preoperative US and MRI were performed on 225 patients who underwent surgery for PTC between May 2014 and December 2018. The US and MRI features of ETE of each case were retrospectively and independently investigated by two radiologists. The diagnostic performances of US and MRI, including their sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) for ETE, and their accuracy in predicting ETE were analyzed. RESULTS: Higher sensitivity and NPV in predicting minimal ETE were observed in US (87.5% and 76.2%, respectively) compared with MRI (71.3% and 61.7%, respectively) (p = 0.006 and p = 0.046, respectively). Meanwhile, MRI (85.4%) showed higher sensitivity than US (66.7%) in assessing extensive ETE (p = 0.005). MRI also showed significantly higher specificity and PPV than US in assessing overall ETE (p = 0.025 and p = 0.025, respectively). CONCLUSION: Preoperative US should be used as the first line in predicting minimal ETE, and MRI should be added in extensive ETE assessment. Compared with US, MRI had higher specificity and PPV in detecting the overall ETE of PTC.