Fully Automated Valve Segmentation for Blood Flow Assessment From 4D Flow MRI Including Automated Cardiac Valve Tracking and Transvalvular Velocity Mapping.

BACKGROUND: Automated 4D flow MRI valvular flow quantification without time-consuming manual segmentation might improve workflow. PURPOSE: Compare automated valve segmentation (AS) to manual (MS), and manually corrected automated segmentation (AMS), in corrected atrioventricular septum defect (c-AVSD) patients and healthy volunteers, for assessing net forward volume (NFV) and regurgitation fraction (RF). STUDY TYPE: Retrospective. POPULATION: 27 c-AVSD patients (median, 23 years; interquartile range, 16-31 years) and 24 healthy volunteers (25 years; 12.5-36.5 years). FIELD STRENGTH/SEQUENCE: Whole-heart 4D flow MRI and cine steady-state free precession at 3T. ASSESSMENT: After automatic valve tracking, valve annuli were segmented on time-resolved reformatted trans-valvular velocity images by AS, MS, and AMS. NFV was calculated for all valves, and RF for right and left atrioventricular valves (RAVV and LAVV). NFV variation (standard deviation divided by mean NFV) and NFV differences (NFV difference of a valve vs. mean NFV of other valves) expressed internal NFV consistency. STATISTICAL TESTS: Comparisons between methods were assessed by Wilcoxon signed-rank tests, and intra/interobserver variability by intraclass correlation coefficients (ICCs). P < 0.05 was considered statistically significant, with multiple testing correction. RESULTS: AMS mean analysis time was significantly shorter compared with MS (5.3 ± 1.6 minutes vs. 9.1 ± 2.5 minutes). MS NFV variation (6.0%) was significantly smaller compared with AMS (6.3%), and AS (8.2%). Median NFV difference of RAVV, LAVV, PV, and AoV between segmentation methods ranged from -0.7-1.0 mL, -0.5-2.8 mL, -1.1-3.6 mL, and - 3.1--2.1 mL, respectively. Median RAVV and LAVV RF, between 7.1%-7.5% and 3.8%-4.3%, respectively, were not significantly different between methods. Intraobserver/interobserver agreement for AMS and MS was strong-to-excellent for NFV and RF (ICC ≥0.88). DATA CONCLUSION: MS demonstrates strongest internal consistency, followed closely by AMS, and AS. Automated segmentation, with or without manual correction, can be considered for 4D flow MRI valvular flow quantification. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 3.

The Apparent Diffusion Coefficient (ADC) is a useful biomarker in predicting metastatic colon cancer using the ADC-value of the primary tumor.

PURPOSE: To investigate the role of the apparent diffusion coefficient (ADC) as a potential imaging biomarker to predict metastasis (lymph node metastasis and distant metastasis) in colon cancer based on the ADC-value of the primary tumor. METHODS: Thirty patients (21M, 9F) were included retrospectively. All patients received a 1.5T MRI of the colon including T2 and DWI sequences. ADC maps were calculated for each patient. An expert reader manually delineated all colon tumors to measure mean ADC and histogram metrics (mean, min, max, median, standard deviation (SD), skewness, kurtosis, 5th-95th percentiles) were calculated. Advanced colon cancer was defined as lymph node mestastasis (N+) or distant metastasis (M+). The student Mann Whitney U-test was used to assess the differences between the ADC means of early and advanced colon cancer. To compare the accuracy of lymph node metastasis (N+) prediction based on morpholigical criteria versus ADC-value of the primary tumor, two blinded readers, determined the lymph node metastasis (N0 vs N+) based on morphological criteria. The sensitivity and specificity in predicting lymph node metastasis was calculated for both readers and for the ADC-value of the primary tumor, with histopathology results as the gold standard. RESULTS: There was a significant difference between the mean ADC-value of advanced versus early tumors (p = 0.002). The optimal cut off value was 1179 * 10-3 mm2/s with an area under the curve (AUC) of 0.83 and a sensitivity and specificity of 81% and 86% respectively to predict advanced tumors. Histogram analyses did not add any significant additional value. The sensitivity and specificity for the prediction of lymph node metastasis based on morphological criteria were 40% and 63% for reader 1 and 30% and 88% for reader 2 respectively. The primary tumor ADC-value using 1.179 * 10-3 mm2/s as threshold had a 100% sensitivity and specificity in predicting lymph node metastasis. CONCLUSION: The ADC-value of the primary tumor has the potential to predict advanced colon cancer, defined as lymph node metastasis or distant metastasis, with lower ADC values significantly associated with advanced tumors. Furthermore the ADC-value of the primary tumor increases the prediction accuracy of lymph node metastasis compared with morphological criteria.

Endocardial center motion for quantification of left ventricular discoordination in heart failure using cine MRI.

OBJECTIVE: To compare a novel cardiovascular magnetic resonance technique for the assessment of left ventricular (LV) mechanical discoordination by characterizing the endocardial center motion (ECM) in short-axis cine MRI in healthy volunteers and heart failure patients with left bundle branch block (HF-LBBB). APPROACH: To evaluate ECM analysis as mechanical discoordination measure, we retrospectively compared spatial and temporal features of the ECM between a group of healthy volunteers (n = 14) and conduction defect patients (HF-LBBB, n = 31). We tracked the center of the endocardial borders on short-axis view MRI cine loops during the cardiac cycle. From the ECM trajectory we calculated the overall traveled distance, the enclosed area, the eccentricity of the trajectory, and the maximum traveled distance. The ECM can be visualized in spatial coordinates as well as by its temporal behavior. We evaluated the classification performance of these measures for LBBB detection. We also quantified the coherence of the ECM on the longitudinal direction by considering the variability of the ECM measures between different short-axis slices. MAIN RESULTS: Patients with LBBB showed significantly higher traveled distance (p < 0.0001), enclosed area (p < 0.002), eccentricity (p < 0.02), and peak displacement (p < 0.02) of the endocardial center. Patients with positive late gadolinium enhancement showed a higher variability of ECM measures across different slices (p < 0.05). SIGNIFICANCE: ECM analysis is feasible and it allows the assessment of left ventricular mechanical discoordination. Differences in ECM measures permit one to distinguish between LBBB and healthy volunteers.

MRI for Local Staging of Colon Cancer: Can MRI Become the Optimal Staging Modality for Patients With Colon Cancer?

BACKGROUND: Colon cancer is currently staged with CT. However, MRI is superior in the detection of colorectal liver metastasis, and MRI is standard in local staging of rectal cancer. Optimal (local) staging of colon cancer could become crucial in selecting patients for neoadjuvant treatment in the near future (Fluoropyrimidine Oxaliplatin and Targeted Receptor Preoperative Therapy trial). OBJECTIVE: The purpose of this study was to evaluate the diagnostic performance of MRI for local staging of colon cancer. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at the Maastricht University Medical Centre. PATIENTS: In total, 55 patients with biopsy-proven colon carcinoma were included. MAIN OUTCOME MEASURES: All of the patients underwent an MRI (1.5-tesla; T2 and diffusion-weighted imaging) of the abdomen and were retrospectively analyzed by 2 blinded, independent readers. Histopathology after resection was the reference standard. Both readers evaluated tumor characteristics, including invasion through bowel wall (T3/T4 tumors), invasion beyond bowel wall of ≥5 mm and/or invasion of surrounding organs (T3cd/T4), serosal involvement, extramural vascular invasion, and malignant lymph nodes (N+). Interobserver agreement was compared using κ statistics. RESULTS: MRI had a high sensitivity (72%-91%) and specificity (84%-89%) in detecting T3/T4 tumors (35/55) and a low sensitivity (43%-67%) and high specificity (75%-88%) in detecting T3cd/T4 tumors (15/55). For detecting serosal involvement and extramural vascular invasion, MRI had a high sensitivity and moderate specificity, as well as a moderate sensitivity and specificity in the detection of nodal involvement. Interobserver agreements were predominantly good; the more experienced reader achieved better results in the majority of these categories. LIMITATIONS: The study was limited by its retrospective nature and moderate number of inclusions. CONCLUSIONS: MRI has a good sensitivity for tumor invasion through the bowel wall, extramural vascular invasion, and serosal involvement. In addition, together with its superior liver imaging, MRI might become the optimal staging modality for colon cancer. However, more research is needed to confirm this. See Video Abstract at http://links.lww.com/DCR/A309.

Comparison of cardiac magnetic resonance imaging and bio-impedance spectroscopy for the assessment of fluid displacement induced by external leg compression.

Heart failure is marked by frequent hospital admissions, often as a consequence of pulmonary congestion. Current gold standard techniques for thoracic fluid measurement require invasive heamodynamic access and therefore they are not suitable for continuous monitoring. Changes in thoracic impedance (TI) may enable non-invasive early detection of congestion and prevention of unplanned hospitalizations. However, the usefulness of TI to assess thoracic fluid status is limited by inter-subject variability and by the lack of reliable normalization methods. Indicator dilution methods allow absolute fluid volume estimation; cardiac magnetic resonance (CMR) has been recently proposed to apply indicator dilution methods in a minimally-invasive manner. In this study, we aim to compare bio-impedance spectroscopy (BIS) and CMR for the assessment of thoracic fluid status, and to determine their ability to detect fluid displacement induced by a leg compression procedure in healthy volunteers. A pressure gradient was applied across each subject's legs for 5 min (100-60 mmHg, distal to proximal). Each subject underwent a continuous TI-BIS measurement during the procedure, and repeated CMR-based indicator dilution measurements on a 1.5 T scanner at baseline, during compression, and after pressure release. The Cole-Cole and the local density random walk models were used for parameter extraction from TI-BIS and indicator dilution measurements, respectively. Intra-thoracic blood volume index (ITBI) derived from CMR, and extracellular fluid resistance (R E) from TI-BIS, were considered as thoracic fluid status measures. Eight healthy volunteers were included in this study. An increase in ITBI of 45.2 ± 47.2 ml m-2 was observed after the leg inflation (13.1 ± 15.1% w.r.t. baseline, p < 0.05), while a decrease of -0.84 ± 0.39 Ω in R E (-1.7 ± 0.9% w.r.t. baseline, p < 0.05) was observed. ITBV and R E normalized by body mass index were strongly inversely correlated (r = -0.93, p < 0.05). In conclusion, an acute fluid displacement to the thoracic circulation was induced in healthy volunteers. Significant changes were observed in the considered thoracic fluid measures derived from BIS and CMR. Good correlation was observed between the two measurement techniques. Further clinical studies will be necessary to prospectively evaluate the value of a combination of the two techniques for prediction of re-hospitalizations after admission for heart failure.

Model-Based Characterization of the Transpulmonary Circulation by Dynamic Contrast-Enhanced Magnetic Resonance Imaging in Heart Failure and Healthy Volunteers.

OBJECTIVES: Novel quantitative measures of transpulmonary circulation status may allow the improvement of heart failure (HF) patient management. In this work, we propose a method for the assessment of the transpulmonary circulation using measurements from indicator time intensity curves, derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) series. The derived indicator dilution parameters in healthy volunteers (HVs) and HF patients were compared, and repeatability was assessed. Furthermore, we compared the parameters derived using the proposed method with standard measures of cardiovascular function, such as left ventricular (LV) volumes and ejection fraction. MATERIALS AND METHODS: In total, 19 HVs and 33 HF patients underwent a DCE-MRI scan on a 1.5 T MRI scanner using a T1-weighted spoiled gradient echo sequence. Image loops with 1 heartbeat temporal resolution were acquired in 4-chamber view during ventricular late diastole, after the injection of a 0.1-mmol gadoteriol bolus. In a subset of subjects (8 HFs, 2 HVs), a second injection of a 0.3-mmol gadoteriol bolus was performed with the same imaging settings. The study was approved by the local institutional review board.Indicator dilution curves were derived, averaging the MR signal within regions of interest in the right and left ventricle; parametric deconvolution was performed between the right and LV indicator dilution curves to identify the impulse response of the transpulmonary dilution system. The local density random walk model was used to parametrize the impulse response; pulmonary transit time (PTT) was defined as the mean transit time of the indicator. λ, related to the Péclet number (ratio between convection and diffusion) for the dilution process, was also estimated. RESULTS: Pulmonary transit time was significantly prolonged in HF patients (8.70 ± 1.87 seconds vs 6.68 ± 1.89 seconds in HV, P < 0.005) and even stronger when normalized to subject heart rate (normalized PTT, 9.90 ± 2.16 vs 7.11 ± 2.17 in HV, dimensionless, P < 0.001). λ was significantly smaller in HF patients (8.59 ± 4.24 in HF vs 12.50 ± 17.09 in HV, dimensionless, P < 0.005), indicating a longer tail for the impulse response. Pulmonary transit time correlated well with established cardiovascular parameters (LV end-diastolic volume index, r = 0.61, P < 0.0001; LV ejection fraction, r = -0.64, P < 0.0001). The measurement of indicator dilution parameters was repeatable (correlation between estimates based on the 2 repetitions for PTT: r = 0.94, P < 0.001, difference between 2 repetitions 0.01 ± 0.60 second, for λ: r = 0.74, P < 0.01, difference 0.69 ± 4.39). CONCLUSIONS: Characterization of the transpulmonary circulation by DCE-MRI is feasible in HF patients and HVs. Significant differences are observed between indicator dilution parameters measured in HVs and HF patients; preliminary results suggest good repeatability for the proposed parameters.

Pulmonary transit time measurement by contrast-enhanced ultrasound in left ventricular dyssynchrony.

BACKGROUND: Pulmonary transit time (PTT) is an indirect measure of preload and left ventricular function, which can be estimated using the indicator dilution theory by contrast-enhanced ultrasound (CEUS). In this study, we first assessed the accuracy of PTT-CEUS by comparing it with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Secondly, we tested the hypothesis that PTT-CEUS correlates with the severity of heart failure, assessed by MRI and N-terminal pro-B-type natriuretic peptide (NT-proBNP). METHODS AND RESULTS: Twenty patients referred to our hospital for cardiac resynchronization therapy (CRT) were enrolled. DCE-MRI, CEUS, and NT-proBNP measurements were performed within an hour. Mean transit time (MTT) was obtained by estimating the time evolution of indicator concentration within regions of interest drawn in the right and left ventricles in video loops of DCE-MRI and CEUS. PTT was estimated as the difference of the left and right ventricular MTT. Normalized PTT (nPTT) was obtained by multiplication of PTT with the heart rate. Mean PTT-CEUS was 10.5±2.4s and PTT-DCE-MRI was 10.4±2.0s (P=0.88). The correlations of PTT and nPTT by CEUS and DCE-MRI were strong; r=0.75 (P=0.0001) and r=0.76 (P=0.0001), respectively. Bland-Altman analysis revealed a bias of 0.1s for PTT. nPTT-CEUS correlated moderately with left ventricle volumes. The correlations for PTT-CEUS and nPTT-CEUS were moderate to strong with NT-proBNP; r=0.54 (P=0.022) and r=0.68 (P=0.002), respectively. CONCLUSIONS: (n)PTT-CEUS showed strong agreement with that by DCE-MRI. Given the good correlation with NT-proBNP level, (n)PTT-CEUS may provide a novel, clinically feasible measure to quantify the severity of heart failure. CLINICAL TRIAL REGISTRY: NCT01735838.

Automatic indicator dilution curve extraction in dynamic-contrast enhanced imaging using spectral clustering.

Indicator dilution theory provides a framework for the measurement of several cardiovascular parameters. Recently, dynamic imaging and contrast agents have been proposed to apply the method in a minimally invasive way. However, the use of contrast-enhanced sequences requires the definition of regions of interest (ROIs) in the dynamic image series; a time-consuming and operator dependent task, commonly performed manually. In this work, we propose a method for the automatic extraction of indicator dilution curves, exploiting the time domain correlation between pixels belonging to the same region. Individual time intensity curves were projected into a low dimensional subspace using principal component analysis; subsequently, clustering was performed to identify the different ROIs. The method was assessed on clinically available DCE-MRI and DCE-US recordings, comparing the derived IDCs with those obtained manually. The robustness to noise of the proposed approach was shown on simulated data. The tracer kinetic parameters derived on real images were in agreement with those obtained from manual annotation. The presented method is a clinically useful preprocessing step prior to further ROI-based cardiac quantifications.

Site-specific association between distal aortic pulse wave velocity and peripheral arterial stenosis severity: a prospective cardiovascular magnetic resonance study.

BACKGROUND: Vascular disease expression in one location may not be representative for disease severity in other vascular territories, however, strong correlation between disease expression and severity within the same vascular segment may be expected. Therefore, we hypothesized that aortic stiffening is more strongly associated with disease expression in a vascular territory directly linked to that aortic segment rather than in a more remote segment. We prospectively compared the association between aortic wall stiffness, expressed by pulse wave velocity (PWV), sampled in the distal aorta, with the severity of peripheral arterial occlusive disease (PAOD) as compared to atherosclerotic markers sampled in remote vascular territories such as PWV in the proximal aorta and the normalized wall index (NWI), representing the vessel wall thickness, of the left common carotid artery. METHODS: Forty-two patients (23 men; mean age 64±10 years) underwent velocity-encoded cardiovascular magnetic resonance (CMR) in the proximal and distal aorta, whole-body contrast-enhanced MR angiography (CE-MRA) and carotid vessel wall imaging with black-blood CMR in the work-up for PAOD. Strength of associations between aortic stiffness, carotid NWI and peripheral vascular stenosis grade were assessed and evaluated with multiple linear regression. RESULTS: Stenosis severity correlated well with PWV in the distal aorta (Pearson rP=0.64, p<0.001, Spearman rS=0.65, p<0.001) but to a lesser extent with PWV in the proximal aorta (rP=0.48, p=0.002, rS=0.22, p=0.18). Carotid NWI was not associated with peripheral stenosis severity (rP=0.17, p=0.28, rS=0.14, p=0.37) nor with PWV in the proximal aorta (rP=0.22, p=0.17) nor in the distal aorta (rP=0.21, p=0.18). Correlation between stenosis severity and distal aortic PWV remained statistically significant after correction for age and gender. CONCLUSIONS: Distal aortic wall stiffness is more directly related to peripheral arterial stenosis severity than markers from more remote vascular territories such as proximal aortic wall stiffness or carotid arterial wall thickness. Site-specific evaluation of vascular disease may be required for full vascular risk estimation.

Comparison of gadobenate dimeglumine-enhanced breast MRI and gadopentetate dimeglumine-enhanced breast MRI with mammography and ultrasound for the detection of breast cancer.

PURPOSE: To compare gadobenate dimeglumine-enhanced magnetic resonance imaging (MRI) with gadopentetate dimeglumine-enhanced MRI, mammography, and ultrasound for breast cancer detection across different malignant lesion types and across different densities of breast tissue. MATERIALS AND METHODS: In all, 153 women with Breast Imaging Reporting and Data System (BI-RADS) 3­5 findings on mammography and/or ultrasound underwent identical breast MRI exams at 1.5T with gadobenate dimeglumine and gadopentetate dimeglumine. Images were evaluated by three independent blinded radiologists. Mammography, ultrasound, and combined mammography and/or ultrasound findings were available for 108, 109, and 131 women. Imaging findings were matched with histology data by a fourth, independent, blinded radiologist. Malignant lesion detection rates and diagnostic performance were compared. RESULTS: In all, 120, 120, and 140 confirmed malignant lesions were present in patients undergoing MRI+mammography, MRI+ultrasound, and MRI+mammography and/or ultrasound, respectively. Significantly greater cancer detection rates were noted by all three readers for comparisons of gadobenate dimeglumine-enhanced MRI with mammography (Δ15.8­17.5%; P < 0.0001), ultrasound (Δ18.3­20.0%; P < 0.0001), and mammography and/or ultrasound (Δ8.6­10.7%; P ≤ 0.0105) but not for comparisons of gadopentetate dimeglumine-enhanced MRI with conventional techniques (P > 0.05). The false-positive detection rates were lower on gadobenate dimeglumine-enhanced MRI than on conventional imaging (4.0­5.5% vs. 11.1% at mammography; 6.3­8.4% vs. 15.5% at ultrasound). Significantly improved cancer detection on MRI was noted in heterogeneously dense breast (91.2­97.3% on gadobenate dimeglumine-enhanced MRI vs. 77.2­84.9% on gadopentetate dimeglumine-enhanced MRI vs. 71.9-84.9% with conventional techniques) and for invasive cancers (93.2­96.2% for invasive ductal carcinoma [IDC] on gadobenate dimeglumine-enhanced MRI vs. 79.7­88.5% on gadopentetate dimeglumine-enhanced MRI vs. 77.0­84.4% with conventional techniques). Overall diagnostic performance for the detection of cancer was superior on gadobenate dimeglumine-enhanced MRI than on conventional imaging or gadopentetate dimeglumine-enhanced MRI. CONCLUSION: Gadobenate dimeglumine-enhanced MRI significantly improves cancer detection compared to gadopentetate dimeglumine-enhanced MRI, mammography, and ultrasound in a selected group of patients undergoing breast MRI for preoperative staging or because of inconclusive findings at conventional imaging.

Peripheral arterial occlusive disease: 3.0-T versus 1.5-T MR angiography compared with digital subtraction angiography.

PURPOSE: To prospectively evaluate the diagnostic accuracy of 3-T versus 1.5-T contrast material-enhanced (CE) magnetic resonance (MR) angiography with high spatial resolution in patients who have peripheral arterial occlusive disease, with conventional digital subtraction angiography (DSA) serving as the reference standard. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. DSA and standardized single-injection, three-station, moving-table CE MR angiography, with similar acquisition protocols and contrast agent doses at 3 T and 1.5 T, were consecutively performed in 19 patients (13 men and six women; mean age ± standard deviation, 67 years ± 9). Stenosis was scored visually in 500 arterial segments (97.5% of all available) in consensus by two radiologists in a blinded manner (the radiologists were unaware of the field strength and prior DSA and MR angiographic results and used randomized analysis order). Contrast-to-noise ratio was determined in the vascular tree of both legs. Statistical significance in stenosis scoring was evaluated by using generalized estimating equations. Contrast-to-noise differences were evaluated with paired t tests. Agreement between MR angiography and DSA was evaluated by using Fleiss-Cohen κ statistics. RESULTS: Both 3-T and 1.5-T CE MR angiography showed similar excellent agreement with DSA regarding stenosis classification (κ = 0.96 and 0.93, respectively). All sensitivity and specificity values exceeded 90%. Mean contrast-to-noise ratio was 3.0-4.2 times higher at 3 T than at 1.5 T. CONCLUSION: Standardized single-injection, three-station, moving-table 3-T CE MR angiography is reliable for classification of stenosis in patients suspected of having peripheral arterial occlusive disease, and diagnostic performance was similar to that seen with 1.5-T MR angiography. There was a significantly increased contrast-to-noise ratio for identical contrast agent dose at 3-T MR angiography.

Multicenter, double-blind, randomized, intraindividual crossover comparison of gadobenate dimeglumine and gadopentetate dimeglumine for Breast MR imaging (DETECT Trial).

PURPOSE: To intraindividually compare 0.1 mmol/kg doses of gadobenate dimeglumine and gadopentetate dimeglumine for contrast material-enhanced breast magnetic resonance (MR) imaging by using a prospective, multicenter double-blind, randomized protocol. MATERIALS AND METHODS: Institutional review board approval and patient informed consent were obtained. One hundred sixty-two women (mean age, 52.8 years ± 12.3 [standard deviation]) enrolled at 17 sites in Europe and China between July 2007 and May 2009 underwent at least one breast MR imaging examination at 1.5 T by using three-dimensional spoiled gradient-echo sequences. Of these, 151 women received both contrast agents in randomized order in otherwise identical examinations separated by more than 2 but less than 7 days. Images, acquired at 2-minute or shorter intervals after contrast agent injection, were evaluated independently by three blinded radiologists unaffiliated with enrollment centers. Histopathologic confirmation was available for all malignant lesions (n = 144), while benign lesions were confirmed either by using histopathologic examination (n = 52) or by at least 12-month diagnostic follow-up (n = 20) with mammography and/or ultrasonography. Determinations of malignant lesion detection rates and diagnostic performance (sensitivity, specificity, accuracy, positive predictive value [PPV], and negative predictive value [NPV]) were performed and compared (McNemar and Wald tests). A full safety assessment was performed. RESULTS: Significant superiority for gadobenate dimeglumine was noted by readers 1, 2, and 3 for malignant lesion detection rate (91.7%, 93.1%, 94.4% vs 79.9%, 80.6%, 83.3%, respectively; P ≤ .0003). Readers 1, 2, and 3 reported significantly superior diagnostic performance (sensitivity, specificity, and accuracy) for breast cancer detection with gadobenate dimeglumine (91.1%, 94.5%, 95.2% vs 81.2%, 82.6%, 84.6%; 99.0%, 98.2%, 96.9% vs 97.8%, 96.9%, 93.8%; 98.2%, 97.8%, 96.7% vs 96.1%, 95.4%, 92.8%, respectively; P ≤ .0094) and significantly superior PPV (91.1%, 85.2%, 77.2% vs 80.7%, 75.5%, 60.9%, respectively; P ≤ .0002) and NPV (99.0%, 99.4%, 99.4% vs 97.8%, 98.0%, 98.1%, respectively; P ≤ .0003). No safety concerns were noted with either agent. CONCLUSION: Gadobenate dimeglumine is superior to gadopentetate dimeglumine for breast cancer diagnosis. © RSNA, 2010 Clinical trial registration no. NCT00486473 (http://www.clinicaltrials.gov/). SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100968/-/DC1.

Free-breathing MRI for the assessment of myocardial infarction: clinical validation.

OBJECTIVE: The objective of our study was to validate free-breathing 2D inversion recovery delayed-enhancement MRI for the assessment of myocardial infarction compared with a breath-hold 3D technique. SUBJECTS AND METHODS: Institutional review board approval and written informed consent were obtained. Thirty-two patients (25 men, seven women; mean age, 68 years; age range, 39-84 years) underwent breath-hold gradient-echo 3D inversion-recovery delayed-enhancement MRI and free-breathing respiratory-triggered 2D inversion-recovery delayed-enhancement MRI of the heart (scanning time, 50-80 seconds). Infarct size was quantitatively analyzed as a percentage of the left ventricle. The location and transmural extent of myocardial infarction were assessed by visual scoring. Intraclass correlation and Bland-Altman analysis were used to evaluate the agreement between the techniques for infarct quantification. Kappa statistics were used to analyze the visual score. RESULTS: Excellent agreement between the two techniques was observed for infarct quantification (intraclass correlation = 0.99 [p < 0.01]; mean difference +/- SD = 0.32% +/- 2.4%). The agreement in assessing transmural extent of infarction was good to excellent between the free-breathing technique and the 3D breath-hold technique (kappa varied between 0.70 and 0.96 for all segments). No regions of infarction were missed using the free-breathing approach. CONCLUSION: The free-breathing 2D delayed-enhancement MRI sequence is a fast and reliable tool for detecting myocardial infarction.

Prostate cancer: detection of lymph node metastases outside the routine surgical area with ferumoxtran-10-enhanced MR imaging.

PURPOSE: To prospectively evaluate the feasibility of magnetic resonance (MR) imaging with ferumoxtran-10 in patients with prostate cancer to depict lymph node metastases outside the routine pelvic lymph node dissection (PLND) area. MATERIALS AND METHODS: The study was approved by the institutional review boards at all four hospitals; patients provided written informed consent. Two hundred ninety-six consecutive men (mean age, 67 years; range, 47-83 years) with prostate cancer and an intermediate-to-high risk for nodal metastases (prostate-specific antigen level >10 ng/mL, Gleason score >6, or stage T3 disease) were enrolled. MR lymphography of the pelvis was performed 24 hours after intravenous drip infusion of ferumoxtran-10. Positive nodes at MR lymphography were indicated to be inside or outside the routine dissection area (RDA). On the basis of MR lymphography computed tomographic (CT)-guided biopsy, routine PLND, or MR imaging-guided minimal extended PLND was performed. RESULTS: MR lymphography findings were positive in 58 patients. Of these, 44 had histopathologic confirmation of lymph node metastases. In 18 of 44 patients (41%), MR lymphography findings showed nodes exclusively outside the RDA, which were confirmed with MR lymphography-guided extended PLND (n = 13) and CT-guided biopsy (n = 5). In another 18 patients (41%), positive nodes were located both inside and outside the RDA at MR lymphography. In these 18 patients, routine PLND was used to confirm the nodes inside the RDA (n = 11); CT-guided biopsy was used to confirm nodes outside the RDA (n = 7). In the remaining eight patients, MR lymphography findings showed only nodes inside the RDA, which was confirmed with PLND (n = 5) and CT-guided biopsy (n = 3). In 14 of the 58 patients (24%), there was no histologic confirmation. CONCLUSION: In 41% of patients with prostate cancer, nodal metastases outside the area of routine PLND were detected by using MR imaging with ferumoxtran-10.

MRI with a lymph-node-specific contrast agent as an alternative to CT scan and lymph-node dissection in patients with prostate cancer: a prospective multicohort study.

BACKGROUND: In patients with prostate cancer who are deemed to be at intermediate or high risk of having nodal metastases, invasive diagnostic pelvic lymph-node dissection (PLND) is the gold standard for the detection of nodal disease. However, a new lymph-node-specific MR-contrast agent ferumoxtran-10 can detect metastases in normal-sized nodes (ie, <8 mm in size) by use of MR lymphoangiography (MRL). In this prospective, multicentre cohort study, we aimed to compare the diagnostic accuracy of MRL with up-to-date multidetector CT (MDCT), and test the hypothesis that a negative MRL finding obviates the need for a PLND. METHODS: We included consecutive patients with prostate cancer who had an intermediate or high risk (risk of >5% according to routinely used nomograms) of having lymph-node metastases. All patients were assessed by MDCT and MRL, and underwent PLND or fine-needle aspiration biopsy. Imaging results were correlated with histopathology. The primary outcomes were sensitivity, specificity, accuracy, NPV, and PPV of MRL and MDCT. This study is registered with ClinicalTrials.gov, number NCT00185029. FINDINGS: The study was done in 11 hospitals in the Netherlands between April 8, 2003, and April 19, 2005. 375 consecutive patients were included. 61 of 375 (16%) patients had lymph-node metastases. Sensitivity was 34% (21 of 61; 95% CI 23-48) for MDCT and 82% (50 of 61; 70-90) for MRL (McNemar's test p<0.05). Specificity was 97% (303 of 314; 94-98) for MDCT and 93% (291 of 314; 89-95) for MRL. Positive predictive value (PPV) was 66% (21 of 32; 47-81) for MDCT and 69% (50 of 73; 56-79) for MRL. Negative predictive value (NPV) was 88% (303 of 343; 84-91) for MDCT and 96% (291 of 302; 93-98) for MRL (McNemar's test p<0.05). Of the 61 patients with lymph-node metastases, 50 were detected by MRL, of which 40 (80%) had metastases in normal-sized lymph nodes. The high sensitivity and NPV of MRL imply that in patients with a negative MRL, the chance of positive lymph nodes is less than 11/302 (4%). INTERPRETATION: MRL had significantly higher sensitivity and NPV than MDCT for patients with prostate cancer who had intermediate or high risk of having lymph-node metastases. In such patients, after a negative MRL, the post-test probability of having lymph-node metastases is low enough to omit a PLND.

The influence of myocardial scar and dyssynchrony on reverse remodeling in cardiac resynchronization therapy.

AIM: The influence of location and extent of transmural scar and its relation with dyssynchrony in cardiac resynchronization therapy (CRT) was investigated as posterolateral scar tissue has been invoked as a cause of non-response to CRT. METHODS AND RESULTS: Fifty-seven patients eligible for CRT were assessed for transmural scar with gadolinium-enhanced MRI and for left ventricular (LV) dyssynchrony with tissue Doppler. After implant, both atrioventricular and interventricular pacing intervals were optimized. LV reverse remodeling was defined as >/=10% decrease in LV end-systolic volume after 3 months. Sixteen patients had transmural scar in the posterolateral (PL) area (LV lead location), 14 at a remote site (non-PL) and 27 patients had no scar. LV reverse remodeling was observed in respectively 25%, 64% and 89% (P = 0.0001). Univariate analyses showed a relation with LV dyssynchrony (P = 0.004) and with absence of PL scar (P = 0.04) but not with QRS duration and the extent of LV scar tissue. In multivariate analysis, only LV dyssynchrony (OR: 19.62; 95% CI: 2.5-151.9; P = 0.004) independently predicted LV reverse remodeling. CONCLUSION: In this study LV dyssynchrony remains the most important determinant of response to CRT, even in the presence of posterolateral scar provided atrioventricular and interventricular pacing intervals are optimized.

Cardiac function and position more than 5 years after pneumonectomy.

BACKGROUND: Pneumonectomy not only reduces the pulmonary vascular bed but also changes the position of the heart and large vessels, which may affect the function of the heart. We investigated long-term effects of pneumonectomy on right ventricular (RV) and left ventricular (LV) function and whether this function is influenced by the side of pneumonectomy or the migration of the heart to its new position. METHODS: In 15 patients who underwent pneumonectomy and survived for more than 5 years, we evaluated by dynamic magnetic resonance imaging the function of the RV and LV and the position of the heart within the thorax. RESULTS: Long-term effect of pneumonectomy on the position of the heart is characterized by a lateral shift after right-sided pneumonectomy and rotation of the heart after left-sided pneumonectomy. Postoperatively, heart rate was high (p = 0.006) and stroke volume was low (p = 0.001), compared with the reference values, indicating impaired cardiac function. Patients after right-sided pneumonectomy had an abnormal low RV end-diastolic volume of 99 +/- 29 mL together with a normal LV function. No signs of RV hypertrophy were found. In left-sided pneumonectomy patients, RV volumes were normal whereas LV ejection fraction was abnormally low. CONCLUSIONS: The long-term effects of pneumonectomy on the position of the heart are characterized by a lateral shift in patients after right-sided pneumonectomy and rotation of the heart in patients after left-sided pneumonectomy. Overall, cardiac function in long-term survivors after pneumonectomy is compromised, and might be explained by the altered position of the heart.

Inflow stenoses in dysfunctional hemodialysis access fistulae and grafts.

BACKGROUND: The aim of the study is to prospectively determine the incidence of inflow stenoses in dysfunctional hemodialysis access arteriovenous fistulae (AVFs) and grafts (AVGs). METHODS: Contrast-enhanced magnetic resonance angiography (CE-MRA) was performed of 66 dysfunctional AVFs and 35 AVGs in 56 men and 45 women (mean age, 62 years; age range, 31 to 86 years). Complete inflow (from the subclavian artery), shunt region, and complete outflow (including subclavian vein) were shown at CE-MRA. In addition to standard digital subtraction angiography (DSA) of the shunt region and outflow, DSA of the complete inflow was obtained through access catheterization of all cases in which CE-MRA showed an inflow stenosis. Vascular stenosis is defined as greater than 50% decrease in luminal diameter compared with an uninvolved vascular segment located adjacent to the stenosis. Endovascular intervention of stenoses was performed in connection with DSA. RESULTS: CE-MRA showed 19 arterial stenoses in 14 patients (14%). DSA confirmed 18 of these lesions in 13 patients and showed no additional inflow lesions. Of the 13 patients, 7 patients had arterial stenoses only and 6 patients had accompanying stenoses in the shunt region and/or outflow. Referral criteria for the 13 patients to undergo access evaluation had been decreased flow rates (9 patients), steal symptoms (2 patients), and insufficient access maturation (2 patients). Access flow of the 9 patients with a low-flow access improved from 477 +/- 74 mL/min to 825 +/- 199 mL/min after angioplasty. One patient with steal symptoms became symptom free after angioplasty. Endovascular intervention in 3 patients proved to be unsuccessful. CONCLUSION: Inflow stenoses are not uncommon in dysfunctional hemodialysis access shunts. We suggest that radiological evaluation comprise assessment of the complete arterial inflow.

Prostate cancer evaluated with ferumoxtran-10-enhanced T2*-weighted MR Imaging at 1.5 and 3.0 T: early experience.

PURPOSE: To prospectively evaluate the feasibility of ferumoxtran-10-enhanced magnetic resonance (MR) imaging at high magnetic field strength (3.0 T) and to compare image quality between 1.5- and 3.0-T MR imaging in terms of lymph node detection in patients with prostate cancer. MATERIALS AND METHODS: This study was institutional review board approved, and all patients gave written informed consent. Forty-eight consecutive patients aged 51-79 years (mean, 65.5 years) with prostate cancer were enrolled. T2*-weighted 1.5- and 3.0-T MR images of the pelvis were acquired in a sagittal plane parallel to the psoas muscle 24 hours after ferumoxtran-10 administration. A pelvic and body phased-array coil was used and yielded an in-plane resolution of 0.56 x 0.56 x 3.00 mm at 1.5 T and 0.50 x 0.50 x 2.50 mm at 3.0 T. All images were evaluated by three readers for total image quality, lymph node border delineation, muscle-fat contrast, and vessel-fat contrast. Statistical significance was calculated by using the Mann-Whitney U test. Subsequently, the general linear mixed model was used to estimate the contributions of three factors-patient, reader, and technique-to the variability of the imaging results. RESULTS: Significantly (P < .05) better muscle-fat contrast, vessel-fat contrast, lymph node border delineation, and total image quality were observed at 3.0-T MR imaging. The general linear mixed model revealed that the variability of all results could be attributed to the use of 3.0-T imaging. CONCLUSION: Ferumoxtran-10-enhanced MR imaging can be performed at high magnetic field strengths and result in improved image quality, which may lead to improved detection of small positive lymph nodes.