The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Spiral T1 Spin-Echo for Routine Postcontrast Brain MRI Exams: A Multicenter Multireader Clinical Evaluation.

BACKGROUND AND PURPOSE: Spiral MR imaging has several advantages compared with Cartesian MR imaging that can be leveraged for added clinical value. A multicenter multireader study was designed to compare spiral with standard-of-care Cartesian postcontrast structural brain MR imaging on the basis of relative performance in 10 metrics of image quality, artifact prevalence, and diagnostic benefit. MATERIALS AND METHODS: Seven clinical sites acquired 88 total subjects. For each subject, sites acquired 2 postcontrast MR imaging scans: a spiral 2D T1 spin-echo, and 1 of 4 routine Cartesian 2D T1 spin-echo/TSE scans (fully sampled spin-echo at 3T, 1.5T, partial Fourier, TSE). The spiral acquisition matched the Cartesian scan for scan time, geometry, and contrast. Nine neuroradiologists independently reviewed each subject, with the matching pair of spiral and Cartesian scans compared side-by-side, and scored on 10 image-quality metrics (5-point Likert scale) focused on intracranial assessment. The Wilcoxon signed rank test evaluated relative performance of spiral versus Cartesian, while the Kruskal-Wallis test assessed interprotocol differences. RESULTS: Spiral was superior to Cartesian in 7 of 10 metrics (flow artifact mitigation, SNR, GM/WM contrast, image sharpness, lesion conspicuity, preference for diagnosing abnormal enhancement, and overall intracranial image quality), comparable in 1 of 10 metrics (motion artifacts), and inferior in 2 of 10 metrics (susceptibility artifacts, overall extracranial image quality) related to magnetic susceptibility (P < .05). Interprotocol comparison confirmed relatively higher SNR and GM/WM contrast for partial Fourier and TSE protocol groups, respectively (P < .05). CONCLUSIONS: Spiral 2D T1 spin-echo for routine structural brain MR imaging is feasible in the clinic with conventional scanners and was preferred by neuroradiologists for overall postcontrast intracranial evaluation.

A Spiral Spin-Echo MR Imaging Technique for Improved Flow Artifact Suppression in T1-Weighted Postcontrast Brain Imaging: A Comparison with Cartesian Turbo Spin-Echo.

BACKGROUND AND PURPOSE: A challenge with the T1-weighted postcontrast Cartesian spin-echo and turbo spin-echo brain MR imaging is the presence of flow artifacts. Our aim was to develop a rapid 2D spiral spin-echo sequence for T1-weighted MR imaging with minimal flow artifacts and to compare it with a conventional Cartesian 2D turbo spin-echo sequence. MATERIALS AND METHODS: T1-weighted brain imaging was performed in 24 pediatric patients. After the administration of intravenous gadolinium contrast agent, a reference Cartesian TSE sequence with a scanning time of 2 minutes 30 seconds was performed, followed by the proposed spiral spin-echo sequence with a scanning time of 1 minutes 18 seconds, with similar spatial resolution and volumetric coverage. The results were reviewed independently and blindly by 3 neuroradiologists. Scores from a 3-point scale were assigned in 3 categories: flow artifact reduction, subjective preference, and lesion conspicuity, if any. The Wilcoxon signed rank test was performed to evaluate the reviewer scores. The t test was used to evaluate the SNR. The Fleiss κ coefficient was calculated to examine interreader agreement. RESULTS: In 23 cases, spiral spin-echo was scored over Cartesian TSE in flow artifact reduction (P < .001). In 21 cases, spiral spin-echo was rated superior in subjective preference (P < .001). Ten patients were identified with lesions, and no statistically significant difference in lesion conspicuity was observed between the 2 sequences. There was no statistically significant difference in SNR between the 2 techniques. The Fleiss κ coefficient was 0.79 (95% confidence interval, 0.65-0.93). CONCLUSIONS: The proposed spiral spin-echo pulse sequence provides postcontrast images with minimal flow artifacts at a faster scanning time than its Cartesian TSE counterpart.

Direct magnetic resonance determination of aortic distensibility in essential hypertension: relation to age, abdominal visceral fat, and in situ intracellular free magnesium.

To investigate the contribution of vascular compliance to essential hypertension (EH), we developed magnetic resonance imaging (MRI) techniques to directly measure aortic distensibility (AD) in the ascending and descending thoracic and abdominal aorta of fasting normal (n= 10) and EH (n=20) subjects. These results were compared with concurrent MR-based measurements of left ventricular mass index (LVMI) and abdominal subcutaneous and visceral fat and with 31P-MR spectroscopic measurement of in situ intracellular free magnesium levels (Mgi) in brain and skeletal muscle. Aortic distensibility in EH was consistently and significantly reduced at all measured sites (2.5+/-0.4, 2.2+/-0.4, 2.3+/-0.4 versus 7.0+/-1.6, 5.1+/-0.3, 7.3+/-0.8 mm Hg(-1) x 10(-3), P<.05), as was Mgi in the brain (284+/-22 versus 383+/-34 micromol/L, P<.05) and skeletal muscle (397+/-10 versus 527+/-36 micromol/L, P<.05). For all subjects, systolic blood pressure (r=-.662, P<.0001) and LVMI (r=-.484, P<.01) were inversely related to AD. AD and brain Mgi were inversely related to age (AD, r=-.792, P<.0001; brain Mgi: r=-.673, P<.05). AD was inversely related to fasting blood glucose (r=-.413, P<.05) and to abdominal visceral fat (r=-.416, P<.05) but not to body mass index (BMI: r=-.328, P=NS) or subcutaneous fat (r=-.157, P=NS). AD was also significantly and positively related to in situ Mgi, both in the brain and skeletal muscle (brain: r=.712, P<.01; skeletal muscle: r=.632, P<.01). We conclude that (1) MR techniques can be used to coordinately and noninvasively assess cardiac, vascular, metabolic, and ionic aspects of hypertensive disease in humans; (2) increased systolic blood pressure and LVMI in EH may at least in part result from decreased AD; (3) decreased Mgi contributes to arterial stiffness in hypertension and may help to explain the characteristic age-related decreases in AD; and (4) decreased AD may be one mechanism by which abdominal visceral fat contributes to cardiovascular risk.

Pulse waveform analysis of arterial compliance: relation to other techniques, age, and metabolic variables.

To assess the physiologic and clinical relevance of newer noninvasive measures of vascular compliance, computerized arterial pulse waveform analysis (CAPWA) of the radial pulse was used to calculate two components of compliance, C1 (capacitive) and C2 (oscillatory or reflective), in 87 normotensive (N1BP, n = 20), untreated hypertensive (HiBP, n = 21), and treated hypertensive (HiBP-Rx, n = 46) subjects. These values were compared with two other indices of compliance, the ratio of stroke volume to pulse pressure (SV/PP) and magnetic resonance imaging (MRI)-based aortic distensibility; and were also correlated with demographic and biochemical values. The HiBP subjects displayed lower C1 (1.34 +/- 0.09 v. 1.70 +/- 0.11 mL/mm Hg, significance [sig] = .05) and C2 (0.031 +/- 0.003 v 0.073 +/- 0.02 mL/mm Hg, sig = .005) than N1BP subjects. This was not true for C1 (1.64 +/- 0.08 mL/mm Hg) and C2 (0.052 +/- 0.005 mL/mm Hg) values in HiBP-Rx subjects. The C1 (r = 0.917, P < .0001) and C2 (r = 0.677, P < .0001) were both closely related to SV/PP, whereas C1 (r = 0.748, P = .002), but not C2, was significantly related to MRI-determined aortic distensibility. Among other factors measured, age exerted a strong negative influence on both C1 (r = -0.696, P < .0001) and C2 (r = -0.611, P < .0001) compliance components. Positive correlations were observed between C1 (r = 0.863, P = .006), aortic distensibility (r = 0.597, P = .19) and 24-h urinary sodium excretion, and between C1- and MR spectroscopy-determined in situ skeletal muscle intracellular free magnesium (r = 0.827, P = .006), whereas C2 was inversely related to MRI-determined abdominal visceral fat area (r = -0.512, P = .042) and fasting blood glucose (r = -0.846, P = .001). Altogether, the close correspondence between CAPWA, other compliance techniques, and known cardiovascular risk factors suggests the clinical relevance of CAPWA in the assessment of altered vascular function in hypertension.

Neonatal hypoxic-ischemic encephalopathy: detection with diffusion-weighted MR imaging.

BACKGROUND AND PURPOSE: Although diffusion-weighted imaging has been shown to be highly sensitive in detecting acute cerebral infarction in adults, its use in detecting neonatal hypoxic-ischemic encephalopathy (HIE) has not been fully assessed. We examined the ability of this technique to detect cerebral changes of acute neonatal HIE in different brain locations. METHODS: Fifteen MR examinations were performed in 14 neonates with HIE (median age, 6.5 days; range, 2-11 days). Imaging comprised conventional T1-weighted, proton density-weighted, and T2-weighted sequences and echo-planar diffusion-weighted sequences. The location, extent, and image timing of ischemic damage on conventional and diffusion-weighted sequences and apparent diffusion coefficient (ADC) maps were compared. RESULTS: Although conventional sequences showed cerebral changes consistent with ischemia on all examinations, diffusion-weighted imaging showed signal hyperintensity associated with decreased ADC values in only seven subjects (47%). All subjects with isolated cortical infarction on conventional sequences had corresponding hyperintensity on diffusion-weighted images and decreased ADC values, as compared with 14% of subjects with deep gray matter/perirolandic cortical damage. The timing of imaging did not significantly alter diffusion-weighted imaging findings. CONCLUSION: Diffusion-weighted imaging, performed with the technical parameters in this study, may have a lower correlation with clinical evidence of HIE than does conventional MR imaging. The sensitivity of diffusion-weighted imaging in detecting neonatal HIE appears to be affected by the pattern of ischemic damage, with a lower sensitivity if the deep gray matter is affected as compared with isolated cerebral cortex involvement.

Evidence for cytotoxic edema in the pathogenesis of cerebral venous infarction.

BACKGROUND AND PURPOSE: The pathogenesis of cerebral venous infarction (CVI) remains controversial, with uncertainty over whether cytotoxic edema plays a role. Recent animal studies have shown that cytotoxic edema reliably occurs in acute CVI and precedes the onset of vasogenic edema. Our hypothesis was that cytotoxic edema would also occur in acute human CVI and would be detectable as an area of restricted diffusion on diffusion-weighted images. METHODS: Twelve subjects with acute cerebral venous thrombosis confirmed by MR venography underwent both conventional MR and echo-planar diffusion-weighted imaging (maximum diffusion sensitivity [b=1000 s/mm(2)]). Images were examined for areas of CVI that were identified as T2 hyperintensity, diffusion hyperintensity, or hemorrhage. The percent change in apparent diffusion coefficient (ADC) and T2 signal as well as the T2/diffusion volume were calculated within areas of edematous CVI. Regression techniques were used to examine the relationship of these variables to symptom duration. RESULTS: Ten regions of CVI were detected in seven subjects, all showing T2 hyperintensity. Two of these regions were predominantly hemorrhagic and did not display diffusion hyperintensity. The remaining eight regions displayed diffusion hyperintensity that was associated with a decreased ADC. ADC values increased with symptom duration (r(2) = 0.96; P <.006). Both T2 hyperintensity and T2/diffusion volume peaked approximately 2 days after symptom onset. CONCLUSION: Restricted water diffusion suggesting cytotoxic edema is commonly found in subjects with acute CVI and decreases over time. This supports an important etiologic role for cytotoxic edema in the pathogenesis of CVI.

In vivo MR determination of water diffusion coefficients and diffusion anisotropy: correlation with structural alteration in gliomas of the cerebral hemispheres.

PURPOSE: To determine whether a relationship exists between water diffusion coefficients or diffusion anisotropy and MR-defined regions of normal or abnormal brain parenchyma in patients with cerebral gliomas. METHODS: In 40 patients with cerebral gliomas, diffusion was characterized in a single column of interest using a motion-insensitive spin-echo sequence that was applied sequentially at two gradient strength settings in three orthogonal directions. Apparent diffusion coefficients (ADCs) were derived for the three orthogonal axes at 128 points along the column. An average ADC and an index of diffusion anisotropy (IDA = diffusion coefficientmax-min/diffusionmean) was than calculated for any of nine MR-determined regions of interest within the tumor or adjacent parenchyma. RESULTS: In cerebral edema, mean ADC (all ADCs as 10(-7) cm2/s) was 138 +/- 24 (versus 83 +/- 6 for normal white matter) with mean IDA of 0.26 +/- 0.14 (versus 0.45 +/- 0.17 for normal white matter). Solid enhancing central tumor mean ADC was 131 +/- 25 with mean IDA of 0.15 +/- 0.10. Solid enhancing tumor margin mean ADC was 131 +/- 25, with IDA of 0.25 +/- 0.20. Cyst or necrosis mean ADC was 235 +/- 35 with IDA of 0.07 +/- 0.04. CONCLUSION: In cerebral gliomas ADC and IDA determinations provide information not available from routine MR imaging. ADC and IDA determinations allow distinction between normal white matter, areas of necrosis or cyst formation, regions of edema, and solid enhancing tumor. ADCs can be quickly and reliably characterized within a motion-insensitive column of interest with standard MR hardware.

Magnetic-resonance imaging techniques for detection of elasticity variation.

The relative success of manual palpation in the detection of breast cancer would suggest that a method for remote palpation resulting in a measurement of tissue elasticity could provide a diagnostic tool for detecting cancerous lesions deeper within the breast. This presumption is based in part on the excellent contrast between neoplastic and normal tissue due to the large (orders of magnitude) relative variation in the shear elastic modulus. By comparison, the bulk deformational modulus maintains the same value to within 20% for most soft tissues. A specific method of magnetic-resonance imaging (MRI) which measures tissue displacements has been used in experiments with a phantom containing regions of increased Young's modulus as a demonstration. The spatial modulation of magnetization technique uses the displacement of a spatial grid pattern caused by spin saturation to track regional motion. Mathematical reconstruction of the distribution of elastic moduli is shown for select examples. Any modality, e.g., MRI, ultrasound, etc., which can detect local tissue motion with sufficient spatial resolution can be used and therefore the results presented here should give an indication of the utility of such motion tracking techniques to future measurement of tissue elasticity.

Retrospective correction of intensity inhomogeneities in MRI.

Medical imaging data sets are often corrupted by multiplicative inhomogeneities, often referred to as nonuniformities or intensity variations, that hamper the use of quantitative analyses. The authors describe an automatic technique that not only improves the worst situations, such as those encountered with magnetic resonance imaging (MRI) surface coils, but also corrects typical inhomogeneities encountered in routine volume data sets, such as MRI head scans, without generating additional artifact. Because the technique uses only the patient data set, the technique can be applied retrospectively to all data sets, and corrects both patient independent effects, such as rf coil design, and patient dependent effects, such as attenuation of overlying tissue experienced both in high field MRI and X-ray computed tomography (CT). The authors show results for several MRI imaging situations including thorax, head, and breast. Following such corrections, region of interest analyses, volume histograms, and thresholding techniques are more meaningful. The value of such correction algorithms may increase dramatically with increased use of high field strength magnets and associated patient-dependent rf attenuation in overlying tissues.

Limits of time-of-flight magnetic resonance angiography.

Many of the limits to current time-of-flight (TOF) magnetic resonance (MR) angiographic methods, including flow voids from turbulent flow, flow artifacts from pulsatile flow, and oblique flow displacement, are not inherent to the TOF enhancement mechanism and will be eliminated with technological advancements. Slowly flowing blood and physiological motion will remain an obstacle to these methods, although technological advancements will improve on current methods. Future TOF MR angiographic methods will prove to be a cost-effective competitor to MR angiographic methods requiring contrast agents in many applications.

Basic spin physics.

Magnetic resonance imaging is fundamentally a measurement of the magnetism inherent in some nuclear isotopes; of these the proton, or hydrogen atom, is of particular interest for clinical applications. The magnetism in each nucleus is often referred to as spin. A strong, static magnetic field B0 is used to align spins, forming a magnetic density within the patient. A second, rotating magnetic field B1 (RF pulse) is applied for a short duration, which rotates the spins away from B0 in a process called excitation. After the spins are rotated away from B0, the RF pulse is turned off, and the spins precess about B0. As long as the spins are all pointing in the same direction at any one time (have phase coherence), they act in concert to create rapidly oscillating magnetic fields. These fields in turn create a current in an appropriately placed receiver coil, in a manner similar to that of an electrical generator. The precessing magnetization decays rapidly in a duration roughly given by the T2 time constant. At the same time, but at a slower rate, magnetization forms again along the direction of B0; the duration of this process is roughly expressed by the T1 time constant. The precessional frequency of each spin is proportional to the magnetic field experienced at the nucleus. Small variations in this magnetic field can have dramatic effects on the MR image, caused in part by loss of phase coherence. These magnetic field variations can arise because of magnet design, the magnetic properties (susceptibility) of tissues and other materials, and the nuclear environment unique to various sites within any given molecule. The loss of phase coherence can be effectively eliminated by the use of RF refocusing pulses. Conventional MR imaging experiments can be characterized as either gradient echo or spin echo, the latter indicating the use of a RF refocusing pulse, and by the parameters TR, TE, and flip angle alpha. Tissues, in turn, are characterized by their individual spin density, M0, and by the T1, T2, and T2* time constants. Knowledge of these parameters allows one to calculate the resulting signal from a given tissue for a given MR imaging experiment.

Spatial encoding and reconstruction in MRI with quadratic phase profiles.

Application of a slice-selective frequency modulated radiofrequency excitation pulse in a magnetic resonance (MR) imaging experiment creates a quadratic phase profile along the direction of slice selection. This quadratic phase profile inherently localizes the signal contribution to its vertex, which can be shifted with the application of a linear magnetic field gradient. Different methods for reconstruction of the spatial profile are discussed. The point spread functions of these reconstructions are similar to that of conventional Fourier transforms; one important difference is the elimination of aliasing at the expense of MR signal amplitude when performing 'local,' or limited, reconstruction. Limited reconstruction together with spatially limited excitation combines some of the advantages of both three-dimensional phase-encoded and two-dimensional multislice techniques in appropriate situations. Applications discussed are three-dimensional gradient echo experiments applied to time of flight MR angiography and T2(+)-weighted data collection.

Analysis of localized quadratic encoding and reconstruction.

Localized quadratic (LQ) encoding is a method of collecting multislice MRI data sets with greatly overlapping excited slices in such a way that the slice overlap can be deconvolved. This results in reconstructed data with resolution equal to the center-to-center slice spacing, regardless of the amount of excited slice overlap. LQ encoding is analyzed using the modulation transfer function of the encoding and reconstruction process. This allows analysis of many aspects of the technique in a well established theoretical framework. Many different characteristics of the method are explored, including excited slice profiles, required RF magnitudes and specific absorption rate, signal to noise ratio, signal dynamic range, reconstruction artifacts, sensitivity to motion, saturation and inflow effects, modulation transfer function shifting, and off-resonance artifacts. It is suggested that this technique is best suited for applications currently using multiple thin-slab three-dimensional encoding.

Reconstructing MR images from undersampled data: data-weighting considerations.

Data which are sampled more densely than the Nyquist limit in k-space are weighted prior to reconstruction by the inverse of the local sampling density. This work considers the effects of weighting data that are sampled less densely than the Nyquist limit. It specifically analyzes azimuthally undersampled projection reconstruction, variable density spirals, and variable density phase encoding. Effects on resolution, aliasing, and SNR are given. Higher resolution is obtained by weighting undersampled data according to the inverse of sampling density, while better SNR and less aliasing artifact are obtained by weighting undersampled data uniformly. Magn Reson Med 43:867-875, 2000.

An optimized center-out k-space trajectory for multishot MRI: comparison with spiral and projection reconstruction.

A method for collecting MRI data on a set of rotated trajectories that begin at the center of k-space is outlined. It is theoretically slightly faster, slightly less susceptible to off-resonance and motion-induced phase, and produces images with slightly better signal-to-noise ratio than methods using Archimedean spiral trajectories, particularly for a short sampling duration. It also produces more accurate images than those of projection reconstruction methods, which are significantly undersampled azimuthally. This method may be most useful when imaging areas with large inhomogeneities (e.g., near metallic implants), short T(2) species, or high turbulence (e.g., gas imaging). Magn Reson Med 42:714-720, 1999.

Flow effects in localized quadratic, partial Fourier MRA.

A pulse sequence for inflow-enhanced magnetic resonance angiography, including localized quadratic encoding, partial-Fourier slice selection, and spiral in-plane encoding, is analyzed. The through-plane encoding method is discussed in a space-spatial frequency context to illustrate some of its properties. This pulse sequence has the advantages of being faster and more robust to turbulent flow than conventional inflow-enhanced methods. Simulations show the effect of different parameters on the modulation-transfer function of the resulting images. A flow phantom is used to verify some of the simulation results.

Asymmetric sampling along k(slice-select) in two-dimensional multislice MRI.

Reduction of the slice-select refocusing gradient in two-dimensional multislice imaging results in asymmetry of the k-space representation of collected data along the slice-select direction. Standard methods of partial Fourier reconstruction developed for other methods of asymmetric k-space sampling can be used to reconstruct these data with final through-plane resolution smaller than the collected slice thickness. This method can be used for reducing scan time in the same manner as asymmetric sampling in the phase-encoded direction. In addition, the reduced refocusing gradient reduces minimum TE and motion artifacts in the same manner as for asymmetric sampling in the frequency-encoded direction (fractional echoes). Results using a resolution phantom and a flow phantom illustrate these concepts.

Motion correction with PROPELLER MRI: application to head motion and free-breathing cardiac imaging.

A method for motion correction, involving both data collection and reconstruction, is presented. The PROPELLER MRI method collects data in concentric rectangular strips rotated about the k-space origin. The central region of k-space is sampled for every strip, which (a) allows one to correct spatial inconsistencies in position, rotation, and phase between strips, (b) allows one to reject data based on a correlation measure indicating through-plane motion, and (c) further decreases motion artifacts through an averaging effect for low spatial frequencies. Results are shown in which PROPELLER MRI is used to correct for bulk motion in head images and respiratory motion in nongated cardiac images. Magn Reson Med 42:963-969, 1999.