Strengths and limitations of coronary angiography with turbo high-pitch third-generation dual-source CT.

AIM: To define practical limitations of diagnostic image quality for recently introduced turbo high-pitch scan mode (THP) in third-generation dual-source computed tomography (CT). MATERIALS AND METHODS: Two hundred and twenty-nine consecutive patients undergoing CT coronary angiography were included in this retrospective single-centre analysis. A contrast-enhanced volume dataset was acquired in THP. Image quality of coronary segments was classified as diagnostic or non-diagnostic by three blinded readers. Segments were stated as non-diagnostic if at least one of three readers could neither exclude nor confirm significant stenoses. Multivariable logistic regression was used to assess relationships between number of non-diagnostic segments and common influencing factors. RESULTS: Median effective radiation dose was 0.6 (interquartile range [IQR], 0.4-0.8) mSv overall and 0.3 (IQR, 0.3-0.4) mSv in the 70 kV subgroup of this middle aged, predominantly pre-obese cohort (age: 61 [IQR, 52-67] years; body mass index [BMI]: 26 [IQR, 23-29] kg/m2) with a low-moderate median Agatston score (AS) 0 (IQR, 0-70). Diagnostic image quality was found in 98.1% of 3,678 coronary segments. AS was independently associated with diagnostic image quality (B=0.34; p=0.02), whereas heart rate, BMI, and presence of arrhythmia were not. The portion of diagnostic coronary segments decreased slightly in obese patients with heart rates >65 beats/min and dropped significantly in patients with an AS >600 (p=0.003). CONCLUSION: THP enables CT coronary angiography with minimal radiation exposure and is most appropriate in non-obese patients with stable sinus rhythm ≤65 beats/min and a calcium score ≤600.

[1H-MR spectroscopy in anorexia nervosa: the characteristic differences between patients and healthy subjects]. / 1H-MR-Spektroskopie bei Anorexia nervosa: charakteristische Unterschiede zwischen Patienten und gesunden Probanden.

PURPOSE: The neurophysiological and neuromorphological changes in patients with anorexia nervosa (AN) are well-known but the reason of both is still unknown. We have evaluated the usefulness of hydrogen (H1) magnetic resonance spectroscopy in anorexia nervosa. METHOD: We investigated 15 patients with clinically diagnosed AN (ICD F50.0) and 17 controls without eating disorders. The body mass index (BMI) was 15.8 and 21, respectively. The spectroscopy was recorded on two voxels in the parieto-occipital white matter or in the thalamus with a water-suppressed STEAM-sequence. The metabolites were recorded with respect to phosphocreatine (PCr). RESULTS: The ratio of NAA/PCr in both voxels were not significantly different when comparing patients vs. controls. Patients showed significantly higher ratios of choline-containing components (Cho) or, respectively Cho/PCr and NAA/PCr in the white matter. Distinct, but not significant differences were detected both for m-Ino and m-Ino/PCr in the parieto-occipital region and for the Cho- and m-Ino contained ratios in the thalamus. CONCLUSION: AN is not associated with neuronal damage. The ratio of Cho/PCr and NAA/Cho may reflect the disturbance of membrane-turnover. It is possible that the increase of membrane catabolism leads to a hyperosmolar state. The change of m-Ino/PCr ratio may reflect the regulation of osmolarity.

[1H-MR spectroscopy in anorexia nervosa: reversible cerebral metabolic changes]. / 1H-MR-Spektroskopie bei Anorexia nervosa: reversible zerebrale Metabolitenänderungen.

PURPOSE: By using localized 1H-MR spectroscopy in the brain of patients with anorexia nervosa we wanted to verify our preliminary results and to look for a reversibility of the metabolic changes under therapy. METHODS: In 22 patients and 17 healthy volunteers (11 follow-up examinations) single voxel 1H-MR spectroscopy (TE = 50 ms, TM = 30 ms, TR = 1500 ms, voxel (2 cm)3, acq.: 256) was used in two different localizations (thalamus and parieto-occipital region). The first examination of the patients was performed before therapy, the follow-up examination at the end of therapy. RESULTS: In both regions of the brain we found a statistically significant elevation of the Cho/Cr-ratio in comparison to normal controls. The follow-up examinations revealed reversibility of the metabolic changes under successful therapy. CONCLUSIONS: 1H-MR spectroscopy reveals metabolic changes in the brain of patients with anorexia nervosa, which are reversible under successful therapy. These metabolic changes can be conclusively explained using a biochemical model.

Cerebral blood flow and cerebrovascular reserve capacity: estimation by dynamic magnetic resonance imaging.

We have developed a new method for estimation of regional CBF (rCBF) and cerebrovascular reserve capacity on a pixel-by-pixel basis by means of dynamic magnetic resonance imaging (MRI). Thirteen healthy volunteers, 8 patients with occlusion and/or high grade stenosis of the internal carotid artery (ICA), and 2 patients with acute stroke underwent dynamic susceptibility-weighted contrast enhanced MRI. Using principles of indicator dilution theory and deconvolution analysis, maps of rCBF, regional cerebral blood volume, and of the mean transit time (MTT) were calculated. In patients with ICA occlusion/stenosis, cerebrovascular reserve capacity was assessed by the rCBF increase after acetazolamide stimulation. Mean gray and white matter rCBF values in normals were 67.1 and 23.7 mL x 100 g(-1) x min(-1), respectively. Before acetazolamide stimulation, six of eight patients with ICA occlusions showed decreased rCBF values; and in seven patients increased MTT values were observed in tissue ipsilateral to the occlusion. After acetazolamide stimulation, decreased cerebrovascular reserve capacity was observed in five of eight patients with ICA occlusion. In acute stroke, rCBF in the central core of ischemia was less than 8 mL x 100 g(-1) x min(-1). In peri-infarct tissue, rCBF and MTT were higher than in unaffected tissue but rCBF was normal. Dynamic MRI provides important clinical information on the hemodynamic state of brain tissue in patients with occlusive cerebrovascular disease or acute stroke.

Proton magnetic resonance spectroscopy in acute, juvenile anorexia nervosa.

Anorexia nervosa is usually associated with a shrinkage of the brain that is at least partially reversible with weight gain. The pathogenesis of this brain abnormality is unclear. The purpose of this study was to investigate potential alterations in localized proton magnetic resonance (1H MR) spectra of anorectic patients immediately after an interval of excessive weight loss. Twelve patients and seventeen control subjects were examined. Water suppressed 1H MR spectra were recorded from two voxels placed in the thalamus and in the parieto-occipital white matter. The spectra of ten patients could be evaluated. Comparing patients and control subjects, significantly higher signal intensity ratios of choline containing compounds (Cho) relative to total creatine (Cr) as well as significantly lower ratios of N-acetyl-aspartate (NAA) relative to Cho were found in the white matter region. We hypothesize that these results indicate an abnormal starvation, associated membrane turnover, which predominantly takes place in the white matter. No evidence for neuronal degeneration was found in the thalamus or in the white matter region.

[Functional magnetic resonance tomography in psychopathological research]. / Funktionelle Magnetresonanztomographie in der psychopathologischen Forschung.

Mental disorders are characterised by psychopathological symptoms which correspond to functional brain states. Functional magnetic resonance imaging (fMRI) is used for the non-invasive study of cerebral activation patterns in man. First of all, the neurobiological principles and presuppositions of the method are outlined. Results from the Heidelberg imaging lab on several simple sensorimotor tasks as well as higher cognitive functions, such as working and semantic memory, are then presented. Thereafter, results from preliminary fMRI studies of psychopathological symptoms are discussed, with emphasis on hallucinations, psychomotoric phenomena, emotions, as well as obsessions and compulsions. Functional MRI is limited by the physics underlying the method, as well as by practical constraints regarding its use in conjunction with mentally ill patients. Within this framework, the problems of signal-to-noise ratio, data analysis strategies, motion correction, and neurovascular coupling are considered. Because of the rapid development of the field of fMRI, maps of higher cognitive functions and their respective pathology seem to be coming within easy reach.

Functional magnetic resonance imaging of category-specific cortical activation: evidence for semantic maps.

Functional magnetic resonance imaging (fMRI) was used to examine the pattern of cortical activity during a picture naming task. Subjects (n=12) had to covertly name either animals or furniture items. Functional scanning was performed using a conventional 1.5-Tesla whole-body MRI system. Images obtained during naming the two categories were compared using a non-parametric test. The study revealed evidence for domain-specific lexical regions in left middle, right middle and inferior frontal areas, as well as in superior and middle temporal areas. The results corroborate neuropsychological data and demonstrate directly and non-invasively in human volunteers that semantic representations in frontal and temporal areas are, to some degree, localized and possibly implemented as multiple maps. A completely distributed storage of semantic information is rendered unlikely.

[Methodological approaches to quantitative evaluation of microcirculation in tissues with dynamic magnetic resonance tomography]. / Methodische Ansätze zur quantitativen Beurteilung der Mikrozirkulation im Gewebe mit der dynamischen Magnetresonanztomographie.

The development of rapid magnetic resonance imaging (MRI) sequences makes it possible to detect the fast kinetics of tissue response after intravenous administration of paramagnetic contrast media (CM), reflecting the status of tissue microcirculation. In this paper, the basic physical and tracer kinetic principles of dynamic relativity and susceptibility contrast MRI techniques are reviewed. The quantitative analysis of the acquired dynamic image data is broken up into an MR specific part, in which the observed signal variations are related to the CM concentration in the tissue, and an MR independent part, in which the computed concentration-time-courses are analyzed by tracer kinetic modeling. The purpose of the applied models is to describe the underlying physiological processes in mathematical terms and thus to enable the estimation of tissue specific parameters from measured dynamic image series. Whereas the capillary permeability can be estimated from dynamic relativity contrast enhanced MRI studies, the regional blood volume as well as the regional blood flow can be determined from dynamic susceptibility contrast enhanced image series. However, since there are no intravascular but only diffusible CM available at present, the application of the susceptibility technique is currently restricted to brain tissues with intact blood brain barrier. The practical realization of both dynamic MRI techniques is demonstrated by case studies.

Functional MR imaging of the prefrontal cortex: specific activation in a working memory task.

Functional magnetic resonance imaging was used to identify cortical regions activated by a working memory task involving letter detection. Twenty four normal subjects were scanned with a conventional 1.5-T magnet while performing one of two tasks: In the activation task, subjects responded by pressing a button whenever any presented letter was the same as the second last in the sequence. In the control condition, subjects had to respond to a single predefined letter without memory update requirements. The activation task and the control condition were identical with regard to perceptual input and motor output. They were different only regarding the task demand. Movement artifacts were minimized in a two way strategy and eight subjects were excluded from further analysis. Functional MR data from the remaining 16 subjects were analyzed on the basis of anatomical regions-of-interest which were manually defined in each subject. The engagement of working memory produced significant activation in the dorsolateral prefrontal cortex (Brodmann's areas 9, 10, 46, and 47) in both hemispheres. Results demonstrate the applicability of the paradigm within a clinical MRI setup and corroborate previous findings of non-lateralized dorsolateral prefrontal activation during continuous context updating and active maintenance.

Cerebrovascular reserve capacity in patients with occlusive cerebrovascular disease: assessment with dynamic susceptibility contrast-enhanced MR imaging and the acetazolamide stimulation test.

PURPOSE: To quantitatively assess cerebrovascular reserve capacity in patients with occlusive cerebrovascular disease. MATERIALS AND METHODS: In 21 symptomatic patients with occlusive cerebrovascular disease, magnetic resonance (MR) imaging was performed with a 1.5-T system. Before, during, and after a brief bolus injection of gadopentetate dimeglumine into the antecubital vain, a series of 32 rapid T2*-weighted gradient-echo images of two different sections were acquired simultaneously to measure the concentration-time-curves in the brain tissue and in the brain-feeding arteries. Principles of indicator dilution analysis were applied to compute regional cerebral blood flow (rCBF) and volume. Each patient underwent two examinations, the first before and the second after acetazolamide stimulation. RESULTS: In the asymptomatic hemisphere, a mean increase in rCBF value of 47.1% was observed after acetazolamide stimulation. In the affected areas of the symptomatic hemisphere, a statistically significantly reduced response to acetazolamide stimulation was found, indicating a severely compromised cerebrovascular reserve capacity. CONCLUSION: MR imaging with the described techniques provides quantitative information about the cerebrovascular reserve capacity in patients with occlusive cerebrovascular disease.

Functional MR imaging of semantic information processing and learning-related effects using psychometrically controlled stimulation paradigms.

Functional magnetic resonance imaging (fMRI), in conjunction with carefully designed, psychometrically optimized stimulation procedures, was used to investigate the relation between brain activation and the processing of word associations. A semantic discrimination task of word-pair similarity was performed by normal subjects (n = 17) within a clinical 1.5-Tesla whole-body MRI system. A color similarity task of psychometrically equivalent difficulty, as indicated by behavioral data acquired online during fMRI, served as active control condition. Comparisons between tasks dramatically improved results compared to comparisons between task and resting condition. The language paradigm selectively activated left frontal and left fronto-temporal areas. Cortical activation during the semantic task decreased significantly over three runs of the same word list and was paralleled by decreased reaction times. No such changes were observed in the active control condition indicating selective learning of the language task only. When combined with psychological activation schemes and the acquisition of behavioral data, fMRI represents a powerful tool for the study of brain-behavior interaction.

[Functional magnetic resonance tomography during the activation of working memory]. / Funktionelle Magnetresonanztomographie bei Aktivierung des Arbeitsgedächtnisses.

AIMS: Functional magnetic resonance imaging was used in conjunction with a letter detection task for the study of working memory in 16 normal subjects. Because of movement artifacts, data from only 9 subjects were analysed. METHODS: In the activation task, subjects responded by pressing a button whenever any presented letter was the same as the second last in the sequence. In the control condition, the subjects had to respond to a fixed letter. Hence, the activation condition and the control condition differed only subjectively, i.e., regarding the task demand, whereas the stimuli and the type and frequency of response were identical. RESULTS: The activation condition produced significant activation in the dorsolateral prefrontal cortex (Brodmann's areas 10, 46, and 9). CONCLUSIONS: In contrast to experimental tasks previously used rather extensively to study the prefrontal cortex, the present paradigm is characterized by its simplicity, interpretability, and its ties to known neurophysiology of the frontal cortex.

Assessment of regional cerebral blood volume in acute human stroke by use of single-slice dynamic susceptibility contrast-enhanced magnetic resonance imaging.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the clinical usefulness of dynamic susceptibility contrast-enhanced MRI (DSC-MRI) in acute cerebral ischemia. METHODS: During bolus injection of gadolinium-diethylenetriamine pentaacetic acid, a series of rapid T2*-weighted images was recorded from one slice. Concentration-time curves and images of regional cerebral blood volume (rCBV) were calculated from this data set. DSC-MRI, MR angiography, conventional spin-echo MRI (SE-MRI), and CT were performed in 11 patients within 6 hours after stroke onset and before thrombolytic or anticoagulant treatment was begun. A follow-up MRI examination was performed 24 to 48 hours after stroke onset. RESULTS: In 7 of 11 patients (group 1) with territorial infarcts of the middle (n = 6) or posterior cerebral artery (n = 1), DSC-MRI showed reduced rCBV in the affected territory before conventional SE-MRI displayed ischemic lesions. DSC-MRI was helpful to differentiate severely ischemic tissue from peri-infarct parenchyma. Partial reperfusion (n = 3), unchanged reduction of rCBV (n = 2), and progressive reduction of rCBV (n = 2) were observed in the follow-up study. Normal DSC-MRI findings were present in 4 of 11 patients (group 2) with lacunar infarcts. CONCLUSIONS: DSC-MRI accomplished the detection of the ischemic territory in the very early stage (< 6 hours) before SE-MRI delivered unequivocal results. DSC-MRI might be helpful to discriminate completely ischemic tissue from potentially salvageable ischemic parenchyma at risk and may play an important role in stroke therapy and evaluation.

MRI of encephalitis in children: comparison of CT and MRI in the acute stage with long-term follow-up.

We examined 14 children aged 28 days to 12.7 years with encephalitis by CT or MRI. Of the patients examined by CT 58% had a normal first scan, whereas all MRI investigations demonstrated abnormalities. The clinical features correlated with several MRI investigations. On MRI herpes (HSV) encephalitis started in the medial temporal lobe and encephalomalacia developed within a few weeks. All patients had a follow-up examination 0.5 to 6.5 years after the acute phase. MRI revealed abnormalities in 13 of the 14 children; one boy, with lesions in only the white matter, had a normal follow-up MRI. Even with immediate, optimal therapy the children demonstrated severe parenchymal abnormalities. Signal abnormalities seen in the acute phase of the disease were likely to persist. In children with HSV encephalitis atypical lesions in different areas were seen.

Age dependency of the regional cerebral blood volume (rCBV) measured with dynamic susceptibility contrast MR imaging (DSC).

The changes of the regional cerebral blood volume (rCBV) with age were studied using dynamic susceptibility contrast MRI (DSC). We examined an unselected, random sample of 71 consecutive patients referred for work-up of suspected intracranial tumors (35 normal examinations, 36 tumors) with a standard 1.5 T clinical MR system. Determination of the rCBV was performed with a T2*-weighted simultaneous dual (SD) FLASH sequence (TR/TE1/TE2/alpha = 32/25/16/10 degrees, 55 images) after bolus injection of Gd-DTPA. Absolute quantification of the rCBV was achieved by normalizing the measured tissue concentration-time curves with the integrated arterial input function (AIF), which was simultaneously measured in the brain feeding arteries. The rCBV (mean +/- SD) was 8.4 +/- 2.9 ml/100 g and 4.2 +/- 1.7 ml/100 g in gray and white matter, respectively, with a decline of about 3% and 6% per decade for white and gray matter, respectively. We conclude that DSC using a SD FLASH sequence allows the simultaneous measurement of the AIF and the tissue concentration-time curve and thus an absolute quantification of the rCBV, which is the basis for interperson comparisons and follow-up studies.

[Noninvasive quantification of cerebral blood volume and blood flow with dynamic MR tomography. Studies of probands and patients with cerebrovascular insufficiency]. / Nichtinvasive Quantifizierung des zerebralen Blutvolumens und Blutflusses mit der dynamischen MR-Tomographie. Untersuchungen an Probanden und Patienten mit zerebrovaskulärer Insuffizienz.

PURPOSE: A non-invasive MR-method for the quantification of regional cerebral blood flow (rCBF) and blood volume (rCBV) is used to examine healthy volunteers and patients with cerebrovascular disorders. MATERIALS AND METHODS: 20 healthy volunteers and 10 patients with severe cerebrovascular disorders were examined. MR imaging was performed on a 1.5 T imaging system. Before, during and following brief antecubital vein bolus injection of Gd-DTPA, a series of 32 rapid T2*-weighted gradient echo images of two different slices ere simultaneously acquired in order to measure th concentration-time-curves in the brain tissue and the arterial input function in the brain feeding arteries. From these series of images the concentration-time-curves were computed. Principles of indicator dilution analysis were applied to compute rCBF and rCBV. The volunteers underwent one examination each. All patients underwent two examinations, one before and the second after azetazolamide stimulation. RESULTS: In volunteers the measured rCBF and rCBV values are in good agreement with data from positron emission tomography studies. In patients with cerebrovascular disorders in the asymptomatic hemisphere a mean increase of rCBF of 43,45 +/- 18.04% was observed after azetazolamide stimulation. In the affected areas of the symptomatic hemisphere in 8 from 10 patients the acetazolamide test reveals a significantly reduced response to azetazolamide stimulation, indicating an exhausted cerebrovascular reserve capacity. CONCLUSION: Dynamic MR-Imaging can provide quantitative information about rCBF and rCBV. In patients with cerebrovascular disorders, this method can be applied to estimate the cerebrovascular reserve capacity.

[Titanium aneurysm clips and their advantages in diagnostic imaging]. / Titananeurysmaclips und ihre Vorteile in der bildgebenden Diagnostik.

Aneurysms clips made of a titanium alloy (TiAl6V4) were used in clinical practice for the first time. The design of the clips is identical to the routinely used Yasargil series. In 30 patients, 38 symptomatic and asymptomatic aneurysms were fixed with 45 clips. Metallurgical advantages of the new alloy are better biocompatibility, less magnetic susceptibility, and lower X-ray density. The postoperative imaging results are superior to the conventionally used alloys with respect to artifact reduction in computed tomography, angiography, and magnetic resonance imaging. With a follow-up period of 7 months, a statement on biocompatibility cannot yet be given.

[Neurofunctional MRI imaging of higher cognitive performance of the human brain]. / Neurofunktionelle MR-Bildgebung höherer kognitiver Leistungen des menschlichen Gehirns.

Functional magnetic resonance imaging (fMRI) offers a powerful experimental tool for mapping activated cortical regions in man. Thereby, the paramagnetic deoxyhemoglobin in the red blood cells acts as an endogenous susceptibility contrast agent, which allows the noninvasive detection of stimulus-induced transient changes in regional cerebral blood flow and volume. Fifteen normal subjects were examined on a conventional 1.5-T MR system to visualize cortical activation during the performance of high-level cognitive tasks. A computer-controlled videoprojector was employed to present psychometrically optimized activation paradigms. Reaction times and error rates of the volunteers were acquired online during stimulus presentation. The time course of cortical activation was measured in a series of strongly T2*-weighted gradient-echo images from three or four adjacent slices. For anatomical correlation, picture elements showing a stimulus-related significant signal increase were color-coded and superimposed on T1-weighted spin-echo images. Analysis of the fMRI data revealed a subtle (range 2-5%), but statistically significant (P < 0.05) increase in signal intensity during the periods of induced cortical activation. Judgment of semantic relatedness of word pairs, for example, activated selectively cortical areas in left frontal and left temporal brain regions. The strength of cortex activation in the semantic task decreased significantly in the course of stimulus presentation and was paralleled by a decrease in the corresponding reaction times. With its move into the area of cognitive neuroscience, fMRI calls both for the careful design of activation schemes and for the acquisition of behavioral data. For example, brain regions involved in language processing could only be identified clearly when psychometrically matched activation paradigms were employed. The reaction time data correlated well with selective learning and thus helped to facilitate interpretation of the fMRI data sets.

Quantification of regional cerebral blood flow and volume with dynamic susceptibility contrast-enhanced MR imaging.

PURPOSE: Quantification of regional cerebral blood flow (rCBF) and volume (rCBV) with dynamic magnetic resonance (MR) imaging. MATERIALS AND METHODS: After bolus administration of a paramagnetic contrast medium, rapid T2*-weighted gradient-echo images of two sections were acquired for the simultaneous creation of concentration-time curves in the brain-feeding arteries and in brain tissue. Absolute rCBF and rCBV values were determined for gray and white brain matter in 12 subjects with use of principles of the indicator dilution theory. RESULTS: The mean rCBF value in gray matter was 69.7 mL/min +/- 29.7 per 100 g tissue and in white matter, 33.6 mL/min +/- 11.5 per 100 g tissue; the average rCBV was 8.0 mL +/- 3.1 per 100 g tissue and 4.2 mL +/- 1.0 per 100 g tissue, respectively. An age-related decrease in rCBF and rCBV for gray and white matter was observed. CONCLUSION: Preliminary data demonstrate that the proposed technique allows the quantification of rCBF and rCBV. Although the results are in good agreement with data from positron emission tomography studies, further evaluation is needed to establish the validity of method.