Vessel territory mapping after cerebral revascularization surgery using selective angiographic flat detector perfusion imaging.

The technical feasibility and diagnostic potential of angiographic flat-detector perfusion imaging technique, combining digital subtraction angiography with a flat-detector computed tomography steady-state perfusion imaging, was explored in patients treated with direct or indirect revascularization surgery. This short communication is about an imaging modality with great potential for evaluation, comparison and grading of vascular perfusion territory areas and anatomical location selectively perfused by direct and indirect cerebral bypasses.

Can indocyanine green perfusion imaging detect microangiopathy in mastectomy skin flaps?

Intraoperative vascular imaging using indocyanine green (ICG) angiography may better predict flap viability than clinical judgement alone. Intraoperative ICG angiography was used in a chronic corticosteroid user undergoing bilateral nipple sparing mastectomy with expander placement. Large blood vessels were visualized, however, the skin surrounding these vessels remained dark. The flap demarcated to full-thickness necrosis that matched the intraoperative SPY findings. Visualization of intact blood vessels may not be sufficient to rule out flap necrosis in some patients. In these circumstances, interpretation of perfusion with consideration of patient factors will be required to accurately predict flap viability.

Does perfusion computed tomography correlate to pathology in colorectal liver metastases?

INTRODUCTION: Targeted therapy against tumor angiogenesis is widely used in clinical practice for patients with colorectal liver metastases (CRLM). Possible predictive biomarkers for tumor angiogenesis, such as, microvessel density (MVD), hypoxia and cell proliferation, can be determined using immunohistochemical staining. However, patients ineligible for surgical treatment need to undergo invasive diagnostic interventions in order to determine these biomarkers. CT perfusion (CTP) is an emerging functional imaging technique, which can non-invasively determine vascular properties of solid tumors. The purpose of this study was to evaluate CTP with histological biomarkers in CRLM. MATERIAL AND METHODS: Patients with CRLM underwent CTP one day before liver surgery. CTP analysis was performed on the entire volume of the largest metastases in each patient. Dual-input maximum slope analysis was used and data concerning arterial flow (AF), portal flow (PF) and perfusion index (PI) were recorded. Immunohistochemical staining with CD34, M75/CA-IX and MIB-1 was performed on the rim in the midsection of the tumor to determine respectively MVD, hypoxia and cell proliferation. RESULTS: Twenty CRLM in 20 patients were studied. Mean size of the largest CRLM was 37 mm (95% CI 21-54 mm). Mean AF and PF were respectively 64 ml/min/100ml (95% CI 48-79) and 30 ml/min/100ml (95% CI 22-38). Mean PI was 68% (95% CI 62-73). No significant correlation was found between tumor growth patterns and CTP (p = 0.95). MVD did not significantly correlate to AF (r = 0.05; p = 0.84), PF (r = 0.17; p = 0.47) and PI (r = -0.12; p = 0.63). Cell proliferation also did not significantly correlate to AF (r = 0.07; p = 0.78), PF (r = -0.01; p = 0.95) and PI (r = 0.15; p = 0.52). Hypoxia did not significantly correlate to AF (r = -0.05; p = 0.83), however, significantly to PF (r = 0.51; p = 0.02) and a trend to negative correlation with PF (r = -0.43; p = 0.06). However, after controlling the false discovery rate, no significant correlation between CTP and used immunohistochemical biomarkers was found. CONCLUSION: In conclusion, this feasibility study found a trend to negative correlation between PI and hypoxia, CTP might therefore possibly evaluate this prognostic marker in CRLM non-invasively. However, CTP is not an appropriate technique for the assessment of microvessels or cell proliferation in CRLM.

Diagnostic performance of arterial spin-labeled perfusion imaging and diffusion-weighted imaging in full-term neonatal hypoxic-ischemic encephalopathy.

We evaluated the performance of arterial spin-labeled perfusion imaging and diffusion-weighted imaging in diagnosing full-term neonatal hypoxic-ischemic encephalopathy. Arterial spin-labeled, diffusion-weighted imaging and conventional magnetic resonance imaging (T1-weighted imaging, T2-weighted imaging and T2 fluid-attenuated inversion recovery) were performed in 23 full-term neonates with hypoxic-ischemic encephalopathy group 10 normal neonates (Control group). The cerebral blood flow and the apparent diffusion coefficient were measured in the bilateral basal ganglia, thalamus and frontal white matter. The effect of neonatal age on the CBF and apparent diffusion coefficient values were further investigated after dividing the 23 ischemic encephalopathy cases into three subgroups (1-3 days, 4-7 days, and 8-15 days). The cerebral blood flow values in the thalamus and lenticular nucleus were significantly higher. The apparent diffusion coefficient values in the thalamus, frontal white matter and lenticular nucleus head were significantly lower in the hypoxic-ischemic encephalopathy group than those in the Control group (p < 0.05). There were no significant differences between the ischemic encephalopathy and Control groups in the cerebral blood flow values in the caudate nucleus head and frontal lobe white matter (p > 0.05). The cerebral blood flow and apparent diffusion coefficient values in the thalamus and lenticular nucleus were negatively correlated. Comparison among different age subgroups of hypoxic-ischemic encephalopathyneonates showed that the cerebral blood flow value was higher. In comparison, the apparent diffusion coefficient value was lower in the 1-3 days old neonates than those in the older neonates (p < 0.05). Arterial spin-labeled and diffusion-weighted imaging could reflect the ischemic encephalopathy pathological processes more comprehensively. The cerebral blood flow measurement and apparent diffusion coefficient values in the thalamus and the lenticular nucleus may represent a novel way to diagnose ischemic encephalopathy early.

Perfusion weighted imaging using combined gradient/spin echo EPIK: Brain tumour applications in hybrid MR-PET.

Advanced perfusion-weighted imaging (PWI) methods that combine gradient echo (GE) and spin echo (SE) data are important tools for the study of brain tumours. In PWI, single-shot, EPI-based methods have been widely used due to their relatively high imaging speed. However, when used with increasing spatial resolution, single-shot EPI methods often show limitations in whole-brain coverage for multi-contrast applications. To overcome this limitation, this work employs a new version of EPI with keyhole (EPIK) to provide five echoes: two with GEs, two with mixed GESE and one with SE; the sequence is termed "GESE-EPIK." The performance of GESE-EPIK is evaluated against its nearest relative, EPI, in terms of the temporal signal-to-noise ratio (tSNR). Here, data from brain tumour patients were acquired using a hybrid 3T MR-BrainPET scanner. GESE-EPIK resulted in reduced susceptibility artefacts, shorter TEs for the five echoes and increased brain coverage when compared to EPI. Moreover, compared to EPI, EPIK achieved a comparable tSNR for the first and second echoes and significantly higher tSNR for other echoes. A new method to obtain multi-echo GE and SE data with shorter TEs and increased brain coverage is demonstrated. As proposed here, the workflow can be shortened and the integration of multimodal clinical MR-PET studies can be facilitated.

Assessment of computed tomography perfusion software in predicting spatial location and volume of infarct in acute ischemic stroke patients: a comparison of Sphere, Vitrea, and RAPID.

BACKGROUND: CT perfusion (CTP) infarct and penumbra estimations determine the eligibility of patients with acute ischemic stroke (AIS) for endovascular intervention. This study aimed to determine volumetric and spatial agreement of predicted RAPID, Vitrea, and Sphere CTP infarct with follow-up fluid attenuation inversion recovery (FLAIR) MRI infarct. METHODS: 108 consecutive patients with AIS and large vessel occlusion were included in the study between April 2019 and January 2020 . Patients were divided into two groups: endovascular intervention (n=58) and conservative treatment (n=50). Intervention patients were treated with mechanical thrombectomy and achieved successful reperfusion (Thrombolysis in Cerebral Infarction 2b/2 c/3) while patients in the conservative treatment group did not receive mechanical thrombectomy or intravenous thrombolysis. Intervention and conservative treatment patients were included to assess infarct and penumbra estimations, respectively. It was assumed that in all patients treated conservatively, penumbra converted to infarct. CTP infarct and penumbra volumes were segmented from RAPID, Vitrea, and Sphere to assess volumetric and spatial agreement with follow-up FLAIR MRI. RESULTS: Mean infarct differences (95% CIs) between each CTP software and FLAIR MRI for each cohort were: intervention cohort: RAPID=9.0±7.7 mL, Sphere=-0.2±8.7 mL, Vitrea=-7.9±8.9 mL; conservative treatment cohort: RAPID=-31.9±21.6 mL, Sphere=-26.8±17.4 mL, Vitrea=-15.3±13.7 mL. Overlap and Dice coefficients for predicted infarct were (overlap, Dice): intervention cohort: RAPID=(0.57, 0.44), Sphere=(0.68, 0.60), Vitrea=(0.70, 0.60); conservative treatment cohort: RAPID=(0.71, 0.56), Sphere=(0.73, 0.60), Vitrea=(0.72, 0.64). CONCLUSIONS: Sphere proved the most accurate in patients who had intervention infarct assessment as Vitrea and RAPID overestimated and underestimated infarct, respectively. Vitrea proved the most accurate in penumbra assessment for patients treated conservatively although all software overestimated penumbra.

3D-perfusion analysis of burn wounds using hyperspectral imaging.

BACKGROUND: Determination of the depth of burn wounds is still a challenge in clinical practise and fundamental for an optimal treatment. Hyperspectral imaging (HSI) has a high potential to be established as a new contact-free measuring method in medicine. From hyperspectral spectra 3D-perfusion parameters can be estimated and the microcirculatory of burn wounds over the first 72h after thermal injury can be objectively described. METHODS: We used a hyperspectral imaging camera and extended data processing methods to calculate 3D-perfusion parameters of burn wounds from adult patients. The data processing results in the estimation of perfusion parameters like volume fraction and oxygenation of haemoglobin for 6 different layers of the injured skin. The parameters are presented as depth profiles. We analyzed and compared measurements of wounds of different degrees of damage and present the methodology and preliminary results. RESULTS: The depth profiles of the perfusion parameters show characteristic features and differences depending on the degree of damage. With Hyperspectral Imaging and the advanced data processing the perfusion characteristics of burn wounds can be visualized in more detail. Based on the analysis of this perfusion characteristics, a new and better reliable classification of burn degrees can be developed supporting the surgeon in the early selection of the optimal treatment.

[Diagnostic Value of the Dual Source CT Dual Energy Pulmonary Perfusion Imaging for Pulmonary Embolism].

Objective To assess the diagnostic value of dual energy pulmonary perfusion imaging(DEPI)for pulmonary embolism.Methods The clinical data of 87 patients with suspected pulmonary embolism who had received DEPI between August 2017 and July 2018 in Jiaxing Second Hospital were retrospectively analyzed.With the findings of CT pulmonary angiography(CTPA)as the reference standard and with patients and pulmonary lobes as evaluation units,respectively,a diagnostic test was performed to calculate the diagnostic coincidence rate,sensitivity,specificity,positive predictive value,negative predictive value,Youden index,positive likelihood ratio,negative likelihood ratio,and Kappa coefficient value for the diagnosis of DEPI and CTPA.Results The coincidence rate,sensitivity,specificity,positive predictive value,negative predictive value,Youden index,positive likelihood ratio,and negative likelihood ratio were 85.06%,88.41%,72.22%,92.42%,61.90%,0.61,3.18,and 0.16,respectively,when applying the patients as evaluation units.When the pulmonary lobes were invoked as evaluation units,the above-mentioned indexes were 89.57%,76.80%,96.82%,93.20%,88.02%,0.74,24.15,and 0.24,respectively.The diagnostic results of DEPI and CTPA had a good and excellent consistency,respectively(Kappa value=0.571,0.765).Conclusions DEPI has high accuracy,sensitivity,and specificity in the detection of pulmonary embolism.The combination of DEPI with CTPA can simultaneously obtain the anatomical structure and functional information images,greatly improving the diagnostic accuracy for pulmonary embolism.Thus,it can be used as the preferred examination for patients with clinically suspected pulmonary embolism.

Response assessment in paediatric low-grade glioma: recommendations from the Response Assessment in Pediatric Neuro-Oncology (RAPNO) working group.

Paediatric low-grade gliomas (also known as pLGG) are the most common type of CNS tumours in children. In general, paediatric low-grade gliomas show clinical and biological features that are distinct from adult low-grade gliomas, and the developing paediatric brain is more susceptible to toxic late effects of the tumour and its treatment. Therefore, response assessment in children requires additional considerations compared with the adult Response Assessment in Neuro-Oncology criteria. There are no standardised response criteria in paediatric clinical trials, which makes it more difficult to compare responses across studies. The Response Assessment in Pediatric Neuro-Oncology working group, consisting of an international panel of paediatric and adult neuro-oncologists, clinicians, radiologists, radiation oncologists, and neurosurgeons, was established to address issues and unique challenges in assessing response in children with CNS tumours. We established a subcommittee to develop consensus recommendations for response assessment in paediatric low-grade gliomas. Final recommendations were based on literature review, current practice, and expert opinion of working group members. Consensus recommendations include imaging response assessments, with additional guidelines for visual functional outcomes in patients with optic pathway tumours. As with previous consensus recommendations, these recommendations will need to be validated in prospective clinical trials.

Comparison of MRI IVIM and MR perfusion imaging in acute ischemic stroke due to large vessel occlusion.

PURPOSE: Intravoxel incoherent motion is a diffusion-weighted imaging magnetic resonance imaging technique that measures microvascular perfusion from a multi-b value sequence. Intravoxel incoherent motion microvascular perfusion has not been directly compared to conventional dynamic susceptibility contrast perfusion-weighted imaging in the context of acute ischemic stroke. We determined the degree of correlation between perfusion-weighted imaging and intravoxel incoherent motion parameter maps in patients with acute ischemic stroke. METHODS: We performed a retrospective cohort study of acute ischemic stroke patients undergoing thrombectomy treatment triage by magnetic resonance imaging. Intravoxel incoherent motion perfusion fraction maps were derived using two-step voxel-by-voxel post-processing. Ischemic core, penumbra, non-ischemia, and contralateral hemisphere were delineated based upon diffusion-weighted imaging and perfusion-weighted imaging using a Tmax >6 s threshold. Signal intensity within different brain compartments were measured on intravoxel incoherent motion (IVIM f, IVIM D*, IVIM fD*) parametric maps and compared the differences using one-way ANOVA. Ischemic volumes were measured on perfusion-weighted imaging and intravoxel incoherent motion parametric maps. Bland-Altman analysis and voxel-based volumetric comparison were used to determine the agreements among ischemic volumes of perfusion-weighted imaging and intravoxel incoherent motion perfusion parameters. Inter-rater reliability on intravoxel incoherent motion maps was also assessed. Significance level was set at α < 0.05. RESULTS: Twenty patients (11 males, 55%; mean age 67.1 ± 13.8 years) were included. Vessel occlusions involved the internal carotid artery (6 patients, 30%) and M1 segment of the middle cerebral artery (14, 70%). Mean pre-treatment core infarct volume was 19.07 ± 23.56 ml. Mean pre-treatment ischemic volumes on perfusion-weighted imaging were 10.90 ± 13.33 ml (CBV), 24.83 ± 23.08 ml (CBF), 58.87 ± 37.85 ml (MTT), and 47.53 ± 26.78 ml (Tmax). Mean pre-treatment ischemic volumes on corresponding IVIM parameters were 23.20 ± 25.63 ml (IVIM f), 14.01 ± 16.81 ml (IVIM D*), and 27.41 ± 40.01 ml (IVIM fD*). IVIM f, D, and fD* demonstrated significant differences (P < 0.001). The best agreement in term of ischemic volumes and voxel-based overlap was between IVIM fD* and CBF with mean volume difference of 0.5 ml and mean dice similarity coefficient (DSC) of 0.630 ± 0.136. CONCLUSION: There are moderate differences in brain perfusion assessment between intravoxel incoherent motion and perfusion-weighted imaging parametric maps, and IVIM fD* and perfusion-weighted imaging CBF show excellent agreement. Intravoxel incoherent motion is promising for cerebral perfusion assessment in acute ischemic stroke patients.

Towards 4D dedicated breast CT perfusion imaging of cancer: development and validation of computer simulated images.

Dedicated breast CT is a fully tomographic breast imaging modality with potential for various applications throughout breast cancer care. If implemented to perform dynamic contrast-enhanced (CE) imaging (4D breast CT), it could be useful to obtain functional information at high combined spatio-temporal resolution. Before developing a 4D dedicated breast CT system, a computer simulation method for breast CT perfusion imaging is proposed. The simulation uses previously developed patient-based 4D digital breast phantoms, and generates realistic images with the selected acquisition parameters, allowing to investigate the effect of different acquisition settings on image quality. The simulation pipeline includes all steps of the image generation process, from ray tracing and scatter map generation, to the addition of realistic resolution losses and noise models. The pipeline was validated against experimental measurements performed on physical phantoms with a dedicated breast CT system, in terms of average error compared to ground truth projections (6.0% ± 1.65%), Hounsfield unit (HU) values in a homogeneous phantom (acquired: -149 HU ± 2 HU; simulated: -140 HU ± 2 HU), signal-to-noise ratio (SNR) (average error 6.7% ± 4.2%), noise power spectra (NPS) (average error 4.3% ± 2.5%), modulation transfer function (MTF) (average error 8.4% ± 7.2%), and attenuation of different adipose/glandular equivalent mixtures (average error 6.9% ± 4.0%) and glandular plus iodinated contrast medium concentrations equivalent mixtures (average error of 9.1% ± 9.0%). 4D patient images were then simulated for different 4D digital breast phantoms at different air kerma levels to determine the effect of noise on the extracted tumor perfusion curves. In conclusion, the proposed pipeline could simulate images with a good level of realism, resulting in a tool that can be used for the design, development, and optimization of a 4D dedicated breast CT system.

Hyperspectral imaging for noninvasive tissue perfusion measurements of the lower leg: review of literature and introduction of a standardized measurement protocol with a portable system.

INTRODUCTION: Hyperspectral imaging (HSI) is a noninvasive technique for transcutaneous measurements of tissue perfusion. This study (1) provides a review of the current literature on HSI for tissue perfusion measurements of the lower leg and (2) introduces a standardized measurement protocol for HSI measurements with a portable system. EVIDENCE ACQUISITION: A literature search was performed for studies on tissue perfusion measurements with HSI in the lower extremity. A standardized protocol was developed to perform HSI measurements in 43 healthy volunteers at the plantar side of the foot and at the lateral side of the calf, with 3 consecutive hyperspectral images at each location. EVIDENCE SYNTHESIS: The literature review identified 9 studies, including 2 of healthy volunteers, 4 of patients with diabetes mellitus, and 3 of patients with peripheral arterial disease. In 5 of 7 patient studies, HSI values were associated with severity of disease or wound healing. In our study, the healthy volunteers' HSI values for oxyhemoglobin, deoxyhemoglobin, and oxygen saturation were (mean±SD) 82.8±24, 55.7±15.7, and 59.2±11.7, respectively, at the plantar surface of the foot, and 40.8±11, 38.0±7.8, and 51.7±10.5, respectively, at the lateral side of the calf. HSI values differed significantly between the calf and plantar locations. Intraoperator reliability between the 3 consecutive images ranged from 81% to 89%. CONCLUSIONS: Limited evidence indicates that HSI is associated with severity of peripheral arterial disease and diabetes mellitus, and with wound healing. Hyperspectral images with a portable system can be taken with high precision when a standardized measurement protocol is used. However, differences exist at several locations at the lower extremity, so each measurement location should be used as its own reference when consecutive measurements are performed during follow-up. More studies with larger patient cohorts should be performed before HSI can be incorporated as standard tool in the diagnostic armamentarium of the vascular specialist.

Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence.

PURPOSE: Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) was introduced as a hybrid SPECT/CT imaging modality two decades ago. The main advantage of SPECT/CT is the increased specificity achieved through a more precise localization and characterization of functional findings. The improved diagnostic accuracy is also associated with greater diagnostic confidence and better inter-specialty communication. METHODS: This review presents a critical assessment of the relevant literature published so far on the role of SPECT/CT in a variety of clinical conditions. It also includes an update on the established evidence demonstrating both the advantages and limitations of this modality. CONCLUSIONS: For the majority of applications, SPECT/CT should be a routine imaging technique, fully integrated into the clinical decision-making process, including oncology, endocrinology, orthopaedics, paediatrics, and cardiology. Large-scale prospective studies are lacking, however, on the use of SPECT/CT in certain clinical domains such as neurology and lung disorders. The review also presents data on the complementary role of SPECT/CT with other imaging modalities and a comparative analysis, where available.

Comparison of acquisition protocols for ventilation/perfusion SPECT-a Monte Carlo study.

One of the most commonly used imaging techniques for diagnosing pulmonary embolism (PE) is ventilation/perfusion (V/P) scintigraphy. The aim of this study was to evaluate the performance of the currently used imaging protocols for V/P single photon emission computed tomography (V/P SPECT) at two nuclear medicine department sites and to investigate the effect of altering important protocol parameters. The Monte Carlo technique was used to simulate 4D digital phantoms with perfusion defects. Six imaging protocols were included in the study and a total of 72 digital patients were simulated. Six dually trained radiologists/nuclear medicine physicians reviewed the images and reported all perfusion mismatch findings. The radiologists also visually graded the image quality. No statistically significant differences in diagnostic performance were found between the studied protocols, but visual grading analysis pointed out one protocol as significantly superior to four of the other protocols. Considering the study results, we have decided to harmonize our clinical protocols for imaging patients with suspected PE. The administered Technegas and macro aggregated albumin activities have been altered, a low energy all purpose collimator is used instead of a low energy high resolution collimator and the acquisition times have been lowered.

Off-resonance correction for pseudo-continuous arterial spin labeling using the optimized encoding scheme.

Pseudo-continuous arterial spin labeling (PCASL) MRI has become a popular tool for non-invasive perfusion imaging and angiography. However, it suffers from sensitivity to off-resonance effects within the labeling plane, which can be exacerbated at high field or in the presence of metallic implants, leading to spatially varying signal loss and cerebral blood flow underestimation. In this work we propose a prospective correction technique based on the optimized encoding scheme, which allows the rapid calculation of transverse gradient blips and RF phase modulations that best cancel phase offsets due to off-resonance at the locations of the feeding arteries within the labeling plane. This calculation is based upon a rapidly acquired single-slice fieldmap and is applicable to any number and arrangement of arteries. In addition, this approach is applicable to both conventional PCASL and a vessel-selective variant known as vessel-encoded PCASL (VEPCASL). Through simulations and experiments in healthy volunteers it was shown that in the presence of off-resonance effects a strong bias in the strength of the perfusion signal across vascular territories can be introduced, the signal-to-noise ratio (SNR) efficiency of PCASL and VEPCASL can be severely compromised (∼40% reduction in vivo), and that vessel-selective signal in VEPCASL can be incorrectly assigned. Distortion of the spatial regions placed in the label or control conditions in the presence of off-resonance effects was confirmed in phantom experiments. The application of the proposed correction restored SNR efficiency to levels present in the absence of off-resonance effects and corrected errors in the vascular territory maps derived from VEPCASL. Due to the rapid nature of the required calculations and fieldmap acquisition, this approach could be inserted into protocols with minimal effect on the total scan time.

Achieving comparable perfusion results across vendors. The next step in standardizing stroke care: a technical report.

BACKGROUND: The role of mechanical thrombectomy in acute ischemic stroke (AIS) has been further expanded by recent trials which relied on the results of CT perfusion (CTP) imaging. However, CTP parameters for ischemia and infarct can vary significantly across different vendors. METHODS: We compared the outcomes of the Siemens CTP software against the clinically validated RAPID software in 45 consecutive patients with suspected AIS. Both perfusion softwares initially processed images using vendor defined parameters for hypoperfusion and non-viable tissue. The software thresholds on the Siemens software were decrementally altered to see if concordant results between softwares could be attained. RESULTS: At baseline settings, the mean values for core infarct and hypoperfusion were different (mean of 30/69 mL, respectively, for RAPID and 49/77 mL for Siemens). However, reducing the threshold values for the later software showed a concordance of values at a relative cerebral blood flow <20%, with resulting core infarct and hypoperfusion volumes at 31/69 mL, respectively, for the Siemens software. A Wilcoxon paired test showed no significant difference between the calculated core infarct and hypoperfusion values, both for the entire population as well as for the subgroup of patients with large vessel occlusion. CONCLUSION: Equivalent CTP results between vendor softwares may be attainable by altering the thresholds for hypoperfused and non-viable tissue, despite differences in acquisition techniques, post-processing, and scanners.

Independent and incremental value of ventilation/perfusion PET/CT and CT pulmonary angiography for pulmonary embolism diagnosis: results of the PECAN pilot study.

PURPOSE: This pilot study assessed the independent and incremental value of 68Ga-V/Q PET/CT as compared with CT pulmonary angiography (CTPA) for the management of cancer patients with suspected acute pulmonary embolism (PE). METHODS: All 24 cancer patients with suspected acute PE prospectively recruited underwent both 68Ga-V/Q PET/CT and CTPA within 24 h. PET/CT was acquired after inhalation of Galligas prepared using a Technegas generator and administration of 68Ga-macroaggregated albumin. Initially, PET/CT and CTPA scans were read independently with the reader blinded to the results of the other imaging study. CTPA and PET/CT were then coregistered and reviewed by consensus between a radiologist and nuclear medicine physician. The therapeutic management was established by the managing physician based on all available data. RESULTS: The diagnostic conclusion was concordantly negative in 18 patients (75%). Of the six discordant diagnoses on independent reading, combined interpretation of V/Q PET/CTPA enabled a consensus conclusion in two patients, excluding PE in one and confirming PE in the other, similar to the initial diagnostic conclusion of the V/Q PET/CT. Of the remaining four patients, three had a single subsegmental thrombus on CTPA but a negative V/Q PET/CT scan, and two of these did not receive long-term anticoagulation and did not have a venous thromboembolic event during a 3-year follow-up period. The third patient, along with a patient with a positive V/Q PET/CT scan but a negative CTPA scan, presented with acute complications preventing any conclusions with regard to the appropriateness of the V/Q PET/CT results in the management of PE. Overall, V/Q PET had an impact on management in four patients (17%). CONCLUSION: In this pilot study, we demonstrated the feasibility and potential utility of V/Q PET/CT for the management of patients with suspected PE. V/Q PET/CT may be of particular relevance in patients with equivocal findings or isolated subsegmental findings on CTPA, adding further discriminatory information to allow important decision-making regarding the use or withholding of anticoagulation. Given the other advantages of V/Q PET/CT (reduced acquisition time, low radiation dose), and with the increasing availability of 68Ga generators, PET/CT is a potential replacement for V/Q SPECT/CT imaging.

Advanced MR imaging and 18F-DOPA PET characteristics of H3K27M-mutant and wild-type pediatric diffuse midline gliomas.

PURPOSE: The aim of this study was to investigate MRI-derived diffusion weighted imaging (DWI), 1H-MR spectroscopy (1H-MRS) and arterial spin labeling (ASL) perfusion imaging in comparison with 18F-dihydroxyphenylalanine (DOPA) PET with respect to diagnostic evaluation of pediatric diffuse midline gliomas (DMG) H3K27M-mutant and wild-type. METHODS: We retrospectively analyzed 22 pediatric patients with DMG histologically proved and molecularly classified as H3K27M-mutant (12 subjects) and wild-type (10 subjects) who underwent DWI, 1H-MRS, and ASL performed within 2 weeks of 18F-DOPA PET. DWI-derived relative minimum apparent diffusion coefficient (rADC min), 1H-MRS data [choline/N-acetylaspartate (Cho/NAA), choline/creatine (Cho/Cr), and presence of lactate] and relative ASL-derived cerebral blood flow max (rCBF max) were compared with 18F-DOPA uptake Tumor/Normal tissue (T/N) and Tumor/Striatum (T/S) ratios, and correlated with histological and molecular features of DMG. Statistics included Pearson's chi-square and Mann-Whitney U tests, Spearman's rank correlation and receiver operating characteristic (ROC) analysis. RESULTS: The highest degrees of correlation among different techniques were found between T/S, rADC min and Cho/NAA ratio (p < 0.01), and between rCBF max and rADC min (p < 0.01). Significant differences between histologically classified low- and high-grade DMG, independently of H3K27M-mutation, were found among all imaging techniques (p ≤ 0.02). Significant differences in terms of rCBF max, rADC min, Cho/NAA and 18F-DOPA uptake were also found between molecularly classified mutant and wild-type DMG (p ≤ 0.02), even though wild-type DMG included low-grade astrocytomas, not present among mutant DMG. When comparing only histologically defined high-grade mutant and wild-type DMG, only the 18F-DOPA PET data T/S demonstrated statistically significant differences independently of histology (p < 0.003). ROC analysis demonstrated that T/S ratio was the best parameter for differentiating mutant from wild-type DMG (AUC 0.94, p < 0.001). CONCLUSIONS: Advanced MRI and 18F-DOPA PET characteristics of DMG depend on histological features; however, 18F-DOPA PET-T/S was the only parameter able to discriminate H3K27M-mutant from wild-type DMG independently of histology.

Referring Physicians Assess the Quality of Outpatient Diagnostic Imaging Services: Development and Psychometric Evaluation of a Questionnaire.

GOAL: In order to ensure high-quality cooperation between referring physicians and imaging services, it is important to assess the quality of imaging services as perceived by referring physicians. The present study aimed to develop and validate a questionnaire for referring physicians to assess the quality of outpatient diagnostic imaging services. MATERIALS & METHODS: The questionnaire was developed by discussing and modifying an existing instrument by the German Association of Surgeons. After qualitative pretesting, the instrument was tested with physicians referring to four outpatient diagnostic imaging services in Switzerland. The results were first assessed using descriptive statistics. The final instrument was tested for validity using the concept of known-groups validity. The hypothesis underlying this procedure was that physicians referring frequently to services estimated the quality of these services to be higher than physicians who referred less often to services. The differences in ratings were assessed using a one-sided two-sample Wilcoxon test. The final questionnaire was tested for internal consistency and reliability using Cronbach's Alpha. RESULTS: Results show a high level of satisfaction of referring physicians with the relevant services but also potential for quality improvement initiatives. The psychometric evaluation of the final questionnaire shows that it is a valid instrument, showing significant differences between the ratings of physicians referring with high and low frequency. Furthermore, the instrument proves to be consistent and reliable. CONCLUSION: The final instrument presents a valid, consistent and reliable option for assess the quality of outpatient diagnostic imaging services as perceived by referring physicians. Results can be used as a basis for quality improvement. KEY POINTS: · A newly developed questionnaire assesses the quality of outpatient diagnostic imaging services as perceived by referring physicians. The questionnaire was developed and tested in Switzerland.. · Psychometric evaluation showed the questionnaire to be a valid, consistent and reliable instrument.. · Results are of interest for imaging services as well as for initiatives encompassing several services.. CITATION FORMAT: · Jossen M, Valeri F, Heilmaier C et al. Referring Physicians Assess the Quality of Outpatient Diagnostic Imaging Services: Development and Psychometric Evaluation of a Questionnaire. Fortschr Röntgenstr 2019; 191: 725 - 731.

Absolute quantitative MR perfusion and comparison against stable-isotope microspheres.

PURPOSE: This work sought to compare a quantitative T1 bookend dynamic susceptibility contrast MRI based perfusion protocol for absolute cerebral blood flow (qCBF) against CBF measured by the stable-isotope neutron capture microsphere method, a recognized reference standard for measuring tissue blood flow, at normocapnia, hypercapnia, and in acute stroke. METHODS: CBF was measured in anesthetized female canines by MRI and microspheres over 2 consecutive days for each case. On day 1, 5 canines were measured before and during a physiological challenge induced by carbogen inhalation; on day 2, 4 canines were measured following permanent occlusion of the middle cerebral artery. CBF and cerebrovascular reactivity measured by MRI and microsphere deposition were compared. RESULTS: MRI correlated strongly with microspheres at the hemispheric level for CBF during normo- and hypercapnic states (r2 = 0.96), for individual cerebrovascular reactivity (r2 = 0.84), and for postocclusion CBF (r2 = 0.82). Correction for the delay and dispersion of the contrast bolus resulted in a significant improvement in the correlation between MRI and microsphere deposition in the ischemic state (r2 = 0.96). In all comparisons, moderate correlations were found at the regional level. CONCLUSION: In an experimental canine model with and without permanent occlusion of the middle cerebral artery, MRI-based qCBF yielded moderate to strong correlations for absolute quantitative CBF and cerebrovascular reactivity measurements during normocapnia and hypercapnia. Correction for delay and dispersion greatly improved the quantitation during occlusion of the middle cerebral artery, underscoring the importance for this correction under focal ischemic condition.