Arachnoid cysts: the role of the BLADE technique.

BACKGROUND: This study aims at demonstrating the ability of BLADE sequences to reduce or even eliminate all the image artifacts as well as verifying the significance of using this technique in certain pathological conditions. MATERIAL AND METHODS: This study involved fourteen consecutive patients (5 females, 9 males), who routinely underwent magnetic resonance imaging (MRI) brain examination, between 2010-2014. The applied routine protocol for brain MRI examination included the following sequences: i) T2-weighted (W) fluid-attenuated inversion recovery (FLAIR) axial; ii) T2-W turbo spin echo (TSE) axial; iii) T2*-W axial, iv) T1-W TSE sagittal; v) Diffusion-weighted (DWI) axial; vi) T1-W TSE axial; vii) T1-W TSE axial+contrast. Additionally, the T2-W FLAIR BLADE sequence was added to the protocol in cases of cystic tumors. Two radiologists independently evaluated all the images at two separate settings, which were performed 3 weeks apart. The presence of image artifacts such as motion, flow, chemical shift and Gibbs ringing artifacts, were also evaluated by the radiologists. In the measurements of the cysts, the extent of the divergence by the two MRI techniques (conventional and BLADE) was used by the two radiologists to evaluate the accuracy of the two techniques to determine the size of the cysts. RESULTS: BLADE sequences were found to be more reliable than the conventional ones regarding the estimation of the cyst size. The qualitative analysis showed that the T2 FLAIR BLADE sequences were superior to the conventional T2 FLAIR with statistical significance (p <0.001) in the following fields: i) overall image quality, ii) cerebrospinal fluid (CSF) nulling; iii) contrast between pathology and its surrounding; iv) borders of the pathology; v) motion artifacts; vi) flow artifacts; vii) chemical shift artifacts and viii) Gibbs ringing artifacts. CONCLUSIONS: BLADE sequence was found to decrease both flow artifacts in the temporal lobes and motion artifacts from the orbits. Additionally, it was shown to improve flow artifacts and image quality in cystic pathologies such as arachnoid cysts. Hippokratia 2016, 20(3): 244-248.

Elimination of motion and pulsation artifacts using BLADE sequences in shoulder MR imaging.

OBJECTIVES: To evaluate the ability of proton-density with fat-suppression BLADE (proprietary name for periodically rotated overlapping parallel lines with enhanced reconstruction in MR systems from Siemens Healthcare, PDFS BLADE) and turbo inversion recovery magnitude-BLADE (TIRM BLADE) sequences to reduce motion and pulsation artifacts in shoulder magnetic resonance examinations. MATERIALS AND METHODS: Forty-one consecutive patients who had been routinely scanned for shoulder examination participated in the study. The following pairs of sequences with and without BLADE were compared: (a) Oblique coronal proton-density sequence with fat saturation of 25 patients and (b) oblique sagittal T2 TIRM-weighed sequence of 20 patients. Qualitative analysis was performed by two experienced radiologists. Image motion and pulsation artifacts were also evaluated. RESULTS: In oblique coronal PDFS BLADE sequences, motion artifacts have been significantly eliminated, even in five cases of non-diagnostic value with conventional imaging. Similarly, in oblique sagittal T2 TIRM BLADE sequences, image quality has been improved, even in six cases of non-diagnostic value with conventional imaging. Furthermore, flow artifacts have been improved in more than 80% of all the cases. CONCLUSIONS: The use of BLADE sequences is recommended in shoulder imaging, especially in uncooperative patients because it effectively eliminates motion and pulsation artifacts.

Radiobiological evaluation of breast cancer radiotherapy accounting for the effects of patient positioning and breathing in dose delivery. A meta analysis.

In breast cancer radiotherapy, significant discrepancies in dose delivery can contribute to underdosage of the tumor or overdosage of normal tissue, which is potentially related to a reduction of local tumor control and an increase of side effects. To study the impact of these factors in breast cancer radiotherapy, a meta analysis of the clinical data reported by Mavroidis et al. (2002) in Acta Oncol (41:471-85), showing the patient setup and breathing uncertainties characterizing three different irradiation techniques, were employed. The uncertainties in dose delivery are simulated based on fifteen breast cancer patients (5 mastectomized, 5 resected with negative node involvement (R-) and 5 resected with positive node involvement (R1)), who were treated by three different irradiation techniques, respectively. The positioning and breathing effects were taken into consideration in the determination of the real dose distributions delivered to the CTV and lung in each patient. The combined frequency distributions of the positioning and breathing distributions were obtained by convolution. For each patient the effectiveness of the dose distribution applied is calculated by the Poisson and relative seriality models and a set of parameters that describe the dose-response relations of the target and lung. The three representative radiation techniques are compared based on radiobiological measures by using the complication-free tumor control probability, P(+) and the biologically effective uniform dose, (BEUD)concepts. For the Mastectomy case, the average P(+) values of the planned and delivered dose distributions are 93.8% for a (BEUD)(CTV) of 51.8 Gy and 85.0% for a (BEUD)(CTV) of 50.3 Gy, respectively. The respective total control probabilities, P(B) values are 94.8% and 92.5%, whereas the corresponding total complication probabilities, P(1) values are 0.9% and 7.4%. For the R- case, the average P(+) values are 89.4% for a (BEUD)(CTV) of 48.9 Gy and 88.6% for a (BEUD)(CTV) of 49.2 Gy and 85.5% for a (BEUD)(CTV) of 49.1 Gy, respectively. The respective PB values are 90.2% and 90.1%, whereas the corresponding P(+) values are 4.1% and 4.6%. The combined effects of positioning uncertainties and breathing can introduce a significant deviation between the planned and delivered dose distributions in lung in breast cancer radiotherapy. The positioning and breathing uncertainties do not affect much the dose distribution to the CTV. The simulated delivered dose distributions show larger lung complication probabilities than the treatment plans. This means that in clinical practice the true expected complications are underestimated. Radiation pneumonitis of Grade 1-2 is more frequent and any radiotherapy optimization should use this as a more clinically relevant endpoint.

Investigating the clinical aspects of using CT vs. CT-MRI images during organ delineation and treatment planning in prostate cancer radiotherapy.

In order to apply highly conformal dose distributions, which are characterized by steep dose fall-offs, it is necessary to know the exact target location and extension. This study aims at evaluating the impact of using combined CT-MRI images in organ delineation compared to using CT images alone, on the clinical results. For 10 prostate cancer patients, the respective CT and MRI images at treatment position were acquired. The CTV was delineated using the CT and MRI images, separately, whereas bladder and rectum were delineated using the CT images alone. Based on the CT and MRI images, two CTVs were produced for each patient. The mutual information algorithm was used in the fusion of the two image sets. In this way, the structures drawn on the MRI images were transferred to the CT images in order to produce the treatment plans. For each set of structures of each patient, IMRT and 3D-CRT treatment plans were produced. The individual treatment plans were compared using the biologically effective uniform dose () and the complication-free tumor control probability (P(+)) concepts together with the DVHs of the targets and organs at risk and common dosimetric criteria. For the IMRT treatment, at the optimum dose level of the average CT and CT-MRI delineated CTV dose distributions, the P(+) values are 74.7% in both cases for a of 91.5 Gy and 92.1 Gy, respectively. The respective average total control probabilities, PB are 90.0% and 90.2%, whereas the corresponding average total complication probabilities, P(I) are 15.3% and 15.4%. Similarly, for the 3D-CRT treatment, the average P(+) values are 42.5% and 46.7%, respectively for a of 86.4 Gy and 86.7 Gy, respectively. The respective average P(B) values are 80.0% and 80.6%, whereas the corresponding average P(I) values are 37.4% and 33.8%, respectively. For both radiation modalities, the improvement mainly stems from the better sparing of rectum. According to these results, the expected clinical effectiveness of IMRT can be increased by a maximum ΔP(+) of around 0.9%, whereas of 3D-CRT by about 4.2% when combined CT-MRI delineation is performed instead of using CT images alone. It is apparent that in both IMRT and 3D-CRT radiation modalities, the better knowledge of the CTV extension improved the produced dose distribution. It is shown that the CTV is irradiated more effectively, while the complication probabilities of bladder and rectum, which is the principal organs at risk, are lower in the CT-MRI based treatment plans.

Comparison of T1-weighted spin-echo and 3D T1-weighted multi-shot Echo Planar pulse sequences in imaging the brain at it.

The purpose of this study was to evaluate the ability of three dimensional T1-weighted multi-shot Echo Planar Imaging (3D T1w EPI) MR pulse sequence to provide comparable to T1w Spin Echo (SE) results in various diseases of the brain, during shorter acquisition times. Thirty-six patients (aged 30-74 years) with various indications were included in the study. All examinations were performed with a 1T MR scanner with a maximum gradient strength of 15 mT/m. The SE sequence lasted 3 min 50s and the 3D T1w EPI 59s. The quantitative analysis included number of enhancing lesions, signal-to-noise ratio of the enhancing lesions and contrast-to-noise ratio (CNR) between enhancing lesions and white matter in both sequences before and after i.v. administration of 0.1 mmol/kg gadopentetate dimeglumine. In addition, the percentage increase of enhancement was measured in each lesion of each sequence. The qualitative analysis included a) conspicuity of the lesions and b) presence of artifacts. The T1w SE sequence was significantly better compared to 3D T1w EPI in all quantitative measurements with the exception of CNR of enhancing lesions before contrast administration and the percentage enhancement. The conspicuity of the lesions did not differ between the two sequences. The EPI sequence presented with significantly more artifacts. We conclude that the 3D T1w EPI sequence could not be used instead of the conventional T1w SE, in routine imaging of the brain. Its overall diagnostic capability, could be useful only in uncooperative patients.

MR imaging of the liver using an ultrafast 3D multi-shot EPI sequence. Comparison with four other T1-weighted sequences.

PURPOSE: To compare a 3D echo planar imaging (EPI) sequence with four other T1-weighted sequences for imaging of the liver at 1 T. MATERIAL AND METHODS: Twenty volunteers were included in our imaging protocol. Spin-echo (SE), turbo SE (TSE), turbo field echo (TFE) in 2D and 3D acquisition mode, fast field echo (T1-FFE) and 3D EPI sequences were applied. Signal-to-noise (S/N) ratio of the liver, contrast-to-noise (C/N) ratio and relative contrast (ReCon) between the liver and the spleen, scanning time per slice and artifact levels were evaluated. RESULTS: 3D EPI provided a statistically equivalent S/N ratio of the liver with SE and T1-FFE sequences (p>0.05), while it provided a statistically higher S/ N ratio of the liver compared to TFE sequences (p<0.05). The TSE technique provided a statistically higher S/N ratio of the liver compared to 3D EPI (p<0.05). With regard to the liver-spleen C/N ratio, 3D EPI provided statistically equivalent results compared to all sequences except T1-FFE, where 3D EPI was superior. With regard to liver-spleen ReCon, 3D EPI was statistically equivalent to SE, TSE and T1-FFE, while it provided significantly higher liver-spleen ReCon than 3D TFE and significantly lower than 2D TFE. CONCLUSION: 3D EPI provided sufficient ReCon and C/N ratio and produced motion-free images in one breath-hold period. Further clinical studies are required to estimate the sensitivity, specificity and accuracy of the sequence.

Prescription of bronchodilator drugs by primary health care physicians in asthma.

With the purpose of estimating the use of bronchodilators in asthma management as prescribed by primary health physicians (PHCP) in Greece, 62 PHCP answered a questionnaire about the manner of choice of treatment, the person who trained the patients in the use of inhalers, and the pharmacological treatment. 65% of PHCP selected the treatment according to the pulmonologist's recommendations and 34% by themselves. 26% of the PHCP trained their patients in the use of inhalers, and 40% considered that it was done by another physician. Forty-three physicians used adrenergic inhalers as the first choice of medicine. The second most popular medicine in asthma management is theophylline tablets (15% of all medicines). Consequently, PHCP in Greece frequently select asthma treatment according to the pulmonologist's recommendations, and consider that another physician has trained the patients how to use the inhalers. They frequently prescribe adrenergic inhalers, theophylline tablets and corticosteroid inhalers.