Intracardiac MR imaging (ICMRI) guiding-sheath with amplified expandable-tip imaging and MR-tracking for navigation and arrythmia ablation monitoring: Swine testing at 1.5 and 3T.

PURPOSE: Develop a deflectable intracardiac MR imaging (ICMRI) guiding-sheath to accelerate imaging during MR-guided electrophysiological (EP) interventions for radiofrequency (500 kHz) ablation (RFA) of arrythmia. Requirements include imaging at three to five times surface-coil SNR in cardiac chambers, vascular insertion, steerable-active-navigation into cardiac chambers, operation with ablation catheters, and safe levels of MR-induced heating. METHODS: ICMRI's 6 mm outer-diameter (OD) metallic-braided shaft had a 2.6 mm OD internal lumen for ablation-catheter insertion. Miniature-Baluns (MBaluns) on ICMRI's 1 m shaft reduced body-coil-induced heating. Distal section was a folded "star"-shaped imaging-coil mounted on an expandable frame, with an integrated miniature low-noise-amplifier overcoming cable losses. A handle-activated movable-shaft expanded imaging-coil to 35 mm OD for imaging within cardiac-chambers. Four MR-tracking micro-coils enabled navigation and motion-compensation, assuming a tetrahedron-shape when expanded. A second handle-lever enabled distal-tip deflection. ICMRI with a protruding deflectable EP catheter were used for MR-tracked navigation and RFA using a dedicated 3D-slicer user-interface. ICMRI was tested at 3T and 1.5T in swine to evaluate (a) heating, (b) cardiac-chamber access, (c) imaging field-of-view and SNR, and (d) intraprocedural RFA lesion monitoring. RESULTS: The 3T and 1.5T imaging SNR demonstrated >400% SNR boost over a 4 × 4 × 4 cm3 FOV in the heart, relative to body and spine arrays. ICMRI with MBaluns met ASTM/IEC heating limits during navigation. Tip-deflection allowed navigating ICMRI and EP catheter into atria and ventricles. Acute-lesion long-inversion-time-T1-weighted 3D-imaging (TWILITE) ablation-monitoring using ICMRI required 5:30 min, half the time needed with surface arrays alone. CONCLUSION: ICMRI assisted EP-catheter navigation to difficult targets and accelerated RFA monitoring.

Fully automated segmentation of clinical target volume in cervical cancer from magnetic resonance imaging with convolutional neural network.

PURPOSE: Contouring clinical target volume (CTV) from medical images is an essential step for radiotherapy (RT) planning. Magnetic resonance imaging (MRI) is used as a standard imaging modality for CTV segmentation in cervical cancer due to its superior soft-tissue contrast. However, the delineation of CTV is challenging as CTV contains microscopic extensions that are not clearly visible even in MR images, resulting in significant contour variability among radiation oncologists depending on their knowledge and experience. In this study, we propose a fully automated deep learning-based method to segment CTV from MR images. METHODS: Our method begins with the bladder segmentation, from which the CTV position is estimated in the axial view. The superior-inferior CTV span is then detected using an Attention U-Net. A CTV-specific region of interest (ROI) is determined, and three-dimensional (3-D) blocks are extracted from the ROI volume. Finally, a CTV segmentation map is computed using a 3-D U-Net from the extracted 3-D blocks. RESULTS: We developed and evaluated our method using 213 MRI scans obtained from 125 patients (183 for training, 30 for test). Our method achieved (mean ± SD) Dice similarity coefficient of 0.85 ± 0.03 and the 95th percentile Hausdorff distance of 3.70 ± 0.35 mm on test cases, outperforming other state-of-the-art methods significantly (p-value < 0.05). Our method also produces an uncertainty map along with the CTV segmentation by employing the Monte Carlo dropout technique to draw physician's attention to the regions with high uncertainty, where careful review and manual correction may be needed. CONCLUSIONS: Experimental results show that the developed method is accurate, fast, and reproducible for contouring CTV from MRI, demonstrating its potential to assist radiation oncologists in alleviating the burden of tedious contouring for RT planning in cervical cancer.

MR-Tracked Deflectable Stylet for Gynecologic Brachytherapy.

Brachytherapy is a radiation based treatment that is implemented by precisely placing focused radiation sources into tumors. In advanced interstitial cervical cancer bracytherapy treatment, this is performed by placing a metallic rod ("stylet") inside a hollow cylindrical tube ("catheter") and advancing the pair to the desired target. The stylet is removed once the target is reached, followed by the insertion of radiation sources into the catheter. However, manually advancing an initially straight stylet into the tumor with millimeter spatial accuracy has been a long-standing challenge, which requires multiple insertions and retractions, due to the unforeseen stylet deflection caused by the stiff muscle tissue that is traversed. In this paper, we develop a novel tendon-actuated deflectable stylet equipped with MR active-tracking coils that may enhance brachytherapy treatment outcomes by allowing accurate stylet trajectory control. Herein we present the design concept and fabrication method, followed by the kinematic and mechanics models of the deflectable stylet. The hardware and theoretical models are extensively validated via benchtop and MRI-guided characterization. At insertion depths of 60 mm, benchtop phantom targeting tests provided a targeting error of 1. 23 ± 0. 47 mm, and porcine tissue targeting tests provided a targeting error of 1. 65 ± 0. 64 mm, after only a single insertion. MR-guided experiments indicate that the stylet can be safely and accurately located within the MRI environment.

Acute enhancement of necrotic radio-frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non-contrast-enhanced T1 -weighted MRI.

PURPOSE: To evaluate non-contrast-enhanced MRI of acute radio-frequency ablation (RFA) lesions in the left atrium (LA) and pulmonary vein (PV) ostia. The goal is to provide a method for discrimination between necrotic (permanent) lesions and reversible injury, which is associated with recurrence after treatment of atrial fibrillation. METHODS: Fifteen normal swine underwent RFA around the right-superior PV ostia. Electrical pulmonary vein isolation (PVI) was verified by electro-anatomic mapping (EAM) and pacing. MRI was carried out using a 3D respiratory-gated T1 -weighted long inversion time (TWILITE) sequence without contrast agent. Key settings were: inversion time 700 ms, triggering over 2 cardiac cycles, pixel size 1.1 mm3 . Contrast-enhanced imaging and T2 -weighted imaging were carried out for comparison. Six animals were sacrificed on ablation day for TTC-stained gross pathology, 9 animals were sacrificed after 2-3 mo after repeat EAM and MRI. Image intensity ratio (IIR) was used to measure lesion enhancement, and gross pathology was used to validate image enhancement patterns and compare lesion widths. RESULTS: RFA lesions exhibited unambiguous enhancement in acute TWILITE imaging (IIR = 2.34 ± 0.49 at 1.5T), and the enhancement patterns corresponded well with gross pathology. Lesion widths in MRI correlated well with gross pathology (R2 = 0.84), with slight underestimation by 0.9 ± 0.5 mm. Lesion enhancement subsided chronically. CONCLUSION: TWILITE imaging allowed acute detection of permanent RFA lesions in swine LA and PV ostia, without the need for contrast agent. Lesion enhancement pattern showed good correspondence to gross pathology and was well visualized by volume rendering. This method may provide valuable intra- or post-procedural assessment of RFA treatment.

Comparison of outcomes for MR-guided versus CT-guided high-dose-rate interstitial brachytherapy in women with locally advanced carcinoma of the cervix.

OBJECTIVE: The purpose was to compare local control (LC), overall survival (OS) and dose to the organs at risk (OAR) in women with locally advanced cervical cancer treated with MR-guided versus CT-guided interstitial brachytherapy (BT). METHODS: 56 patients (29 MR, 27 CT) were treated with high-dose-rate (HDR) interstitial BT between 2005-2015. The MR patients had been prospectively enrolled on a Phase II clinical trial. Data were analyzed using Kaplan-Meier (K-M) and Cox proportional hazards statistical modeling in JMP® & R®. RESULTS: Median follow-up time was 19.7months (MR group) and 18.4months (CT group). There were no statistically significant differences in patient age at diagnosis, histology, percent with tumor size >4cm, grade, FIGO stage or lymph node involvement between the groups. Patients in the MR group had more lymphovascular involvement compared to patients in the CT group (p<0.01). When evaluating plans generated, there were no statistically significant differences in median cumulative dose to the high-risk clinical target volume or the OAR. 2-year K-M LC rates for MR-based and CT-based treatments were 96% and 87%, respectively (log-rank p=0.65). At 2years, OS was significantly better in the MR-guided cohort (84% vs. 56%, p=0.036). On multivariate analysis, squamous histology was associated with longer OS (HR 0.23, 95% CI 0.07-0.72) in a model with MR BT (HR 0.35, 95% CI 0.08-1.18). There was no difference in toxicities between CT and MR BT. CONCLUSION: In this population of locally advanced cervical-cancer patients, MR-guided HDR BT resulted in estimated 96% 2-year local control and excellent survival and toxicity rates.

Gradient-induced voltages on 12-lead ECGs during high duty-cycle MRI sequences and a method for their removal considering linear and concomitant gradient terms.

PURPOSE: To restore 12-lead electrocardiographic (ECG) signal fidelity inside MRI by removing magnetic field gradient-induced voltages during high gradient duty cycle sequences. THEORY AND METHODS: A theoretical equation was derived to provide first- and second-order electrical fields induced at individual ECG electrodes as a function of gradient fields. Experiments were performed at 3T on healthy volunteers using a customized acquisition system that captured the full amplitude and frequency response of ECGs, or a commercial recording system. The 19 equation coefficients were derived via linear regression of data from accelerated sequences and were used to compute induced voltages in real-time during full resolution sequences to remove ECG artifacts. Restored traces were evaluated relative to ones acquired without imaging. RESULTS: Measured induced voltages were 0.7 V peak-to-peak during balanced steady state free precession (bSSFP) with the heart at the isocenter. Applying the equation during gradient echo sequencing, three-dimensional fast spin echo, and multislice bSSFP imaging restored nonsaturated traces and second-order concomitant terms showed larger contributions in electrodes further from the magnet isocenter. Equation coefficients are evaluated with high repeatability (ρ = 0.996) and are dependent on subject, sequence, and slice orientation. CONCLUSION: Close agreement between theoretical and measured gradient-induced voltages allowed for real-time removal. Prospective estimation of sequence periods in which large induced voltages occur may allow hardware removal of these signals.

Design and Fabrication of MR-Tracked Metallic Stylet for Gynecologic Brachytherapy.

Active magnetic resonance (MR) tracking for gynecologic brachytherapy was made possible by attaching the micro radiofrequency coils to the brachytherapy applicator. The rectangular planar micro coil was fabricated using flexible printed circuits with dimensions of 8mm×1.5mm. A 5-Fr (1.6mm) tungsten brachytherapy stylet was custom-machined to incorporate the micro coils. The finite element analysis and the phantom tissue studies show that the proposed device enables in situ, real-time guidance of access routes to the target anatomy safely and accurately. The setup was tested in a Siemens 3T MR scanner. The micro coils can be localized rapidly (up to 40 Hz) and precisely (resolution: 0.6×0.6×0.6mm3) using an MR-tracking sequence.

Real-time active MR-tracking of metallic stylets in MR-guided radiation therapy.

PURPOSE: To develop an active MR-tracking system to guide placement of metallic devices for radiation therapy. METHODS: An actively tracked metallic stylet for brachytherapy was constructed by adding printed-circuit micro-coils to a commercial stylet. The coil design was optimized by electromagnetic simulation, and has a radio-frequency lobe pattern extending ∼5 mm beyond the strong B0 inhomogeneity region near the metal surface. An MR-tracking sequence with phase-field dithering was used to overcome residual effects of B0 and B1 inhomogeneities caused by the metal, as well as from inductive coupling to surrounding metallic stylets. The tracking system was integrated with a graphical workstation for real-time visualization. The 3 Tesla MRI catheter-insertion procedures were tested in phantoms and ex vivo animal tissue, and then performed in three patients during interstitial brachytherapy. RESULTS: The tracking system provided high-resolution (0.6 × 0.6 × 0.6 mm(3) ) and rapid (16 to 40 frames per second, with three to one phase-field dithering directions) catheter localization in phantoms, animals, and three gynecologic cancer patients. CONCLUSION: This is the first demonstration of active tracking of the shaft of metallic stylet in MR-guided brachytherapy. It holds the promise of assisting physicians to achieve better targeting and improving outcomes in interstitial brachytherapy.

3DQRS: a method to obtain reliable QRS complex detection within high field MRI using 12-lead electrocardiogram traces.

PURPOSE: To develop a technique that accurately detects the QRS complex in 1.5 Tesla (T), 3T, and 7T MRI scanners. METHODS: During early systole, blood is rapidly ejected into the aortic arch, traveling perpendicular to the MRI's main field, which produces a strong voltage (V(MHD)) that eclipses the QRS complex. Greater complexity arises in arrhythmia patients, since V(MHD) varies between sinus-rhythm and arrhythmic beats. The 3DQRS method uses a kernel consisting of 6 electrocardiogram (ECG) precordial leads (V1-V6), compiled from a 12-lead ECG performed outside the magnet. The kernel is cross-correlated with signals acquired inside the MRI to identify the QRS complex in real time. The 3DQRS method was evaluated against a vectorcardiogram (VCG)-based approach in two premature ventricular contraction (PVC) and two atrial fibrillation (AF) patients, a healthy exercising athlete, and eight healthy volunteers, within 1.5T and 3T MRIs, using a prototype MRI-conditional 12-lead ECG system. Two volunteers were recorded at 7T using a Holter recorder. RESULTS: For QRS complex detection, 3DQRS subject-averaged sensitivity levels, relative to VCG were: 1.5T (100% versus 96.7%), 3T (98.9% versus 92.2%), and 7T (96.2% versus 77.7%). CONCLUSION: The 3DQRS method was shown to be more effective in cardiac gating than a conventional VCG-based method.

A 1.5T MRI-conditional 12-lead electrocardiogram for MRI and intra-MR intervention.

PURPOSE: High-fidelity 12-lead electrocardiogram (ECG) is important for physiological monitoring of patients during MR-guided intervention and cardiac MRI. Issues in obtaining noncorrupted ECGs inside MRI include a superimposed magneto-hydro-dynamic voltage, gradient switching-induced voltages, and radiofrequency heating. These problems increase with magnetic field. The aim of this study is to develop and clinically validate a 1.5T MRI-conditional 12-lead ECG system. METHODS: The system was constructed with transmission lines to reduce radiofrequency induction and switching circuits to remove induced voltages. Adaptive filters, trained by 12-lead measurements outside MRI and in two orientations inside MRI, were used to remove the magneto-hydro-dynamic voltage. The system was tested on 10 (one exercising) volunteers and four arrhythmia patients. RESULTS: Switching circuits removed most imaging-induced voltages (residual noise <3% of the R-wave). Magneto-hydro-dynamic voltage removal provided intra-MRI ECGs that varied by <3.8% from those outside the MRI, preserving the true S-wave to T-wave segment. In premature ventricular contraction (PVC) patients, clean ECGs separated premature ventricular contraction and sinus rhythm beats. Measured heating was <1.5°C. The system reliably acquired multiphase (steady-state free precession) wall-motion-cine and phase-contrast-cine scans, including subjects in whom 4-lead gating failed. The system required a minimum repetition time of 4 ms to allow robust ECG processing. CONCLUSION: High-fidelity intra-MRI 12-lead ECG is possible.

Voltage-based device tracking in a 1.5 Tesla MRI during imaging: initial validation in swine models.

PURPOSE: Voltage-based device-tracking (VDT) systems are commonly used for tracking invasive devices in electrophysiological cardiac-arrhythmia therapy. During electrophysiological procedures, electro-anatomic mapping workstations provide guidance by integrating VDT location and intracardiac electrocardiogram information with X-ray, computerized tomography, ultrasound, and MR images. MR assists navigation, mapping, and radiofrequency ablation. Multimodality interventions require multiple patient transfers between an MRI and the X-ray/ultrasound electrophysiological suite, increasing the likelihood of patient-motion and image misregistration. An MRI-compatible VDT system may increase efficiency, as there is currently no single method to track devices both inside and outside the MRI scanner. METHODS: An MRI-compatible VDT system was constructed by modifying a commercial system. Hardware was added to reduce MRI gradient-ramp and radiofrequency unblanking pulse interference. VDT patches and cables were modified to reduce heating. Five swine cardiac VDT electro-anatomic mapping interventions were performed, navigating inside and thereafter outside the MRI. RESULTS: Three-catheter VDT interventions were performed at >12 frames per second both inside and outside the MRI scanner with <3 mm error. Catheters were followed on VDT- and MRI-derived maps. Simultaneous VDT and imaging was possible in repetition time >32 ms sequences with <0.5 mm errors, and <5% MRI signal-to-noise ratio (SNR) loss. At shorter repetition times, only intracardiac electrocardiogram was reliable. Radiofrequency heating was <1.5°C. CONCLUSION: An MRI-compatible VDT system is feasible.

Navigated DENSE strain imaging for post-radiofrequency ablation lesion assessment in the swine left atria.

AIMS: Prior work has demonstrated that magnetic resonance imaging (MRI) strain can separate necrotic/stunned myocardium from healthy myocardium in the left ventricle (LV). We surmised that high-resolution MRI strain, using navigator-echo-triggered DENSE, could differentiate radiofrequency ablated tissue around the pulmonary vein (PV) from tissue that had not been damaged by radiofrequency energy, similarly to navigated 3D myocardial delayed enhancement (3D-MDE). METHODS AND RESULTS: A respiratory-navigated 2D-DENSE sequence was developed, providing strain encoding in two spatial directions with 1.2 × 1.0 × 4 mm(3) resolution. It was tested in the LV of infarcted sheep. In four swine, incomplete circumferential lesions were created around the right superior pulmonary vein (RSPV) using ablation catheters, recorded with electro-anatomic mapping, and imaged 1 h later using atrial-diastolic DENSE and 3D-MDE at the left atrium/RSPV junction. DENSE detected ablation gaps (regions with >12% strain) in similar positions to 3D-MDE (2D cross-correlation 0.89 ± 0.05). Low-strain (<8%) areas were, on average, 33% larger than equivalent MDE regions, so they include both injured and necrotic regions. Optimal DENSE orientation was perpendicular to the PV trunk, with high shear strain in adjacent viable tissue appearing as a sensitive marker of ablation lesions. CONCLUSIONS: Magnetic resonance imaging strain may be a non-contrast alternative to 3D-MDE in intra-procedural monitoring of atrial ablation lesions.

MR-Safe Cartesian Platform for Active Cardiac Shimming: Preliminary Validation.

OBJECTIVE: Implanted Cardioverter Defibrillators (ICDs) induce a large (100 parts per million) inhomogeneous magnetic field in the magnetic resonance imaging (MRI) scanner which cannot be corrected by the scanner's built-in shim coils, leading to significant image artifacts that can make portions of the heart unreadable. To compensate for the field inhomogeneity, an active shim coil capable of countering the field deviation in user-defined regions was designed that must be optimally placed at patient-specific locations. We aim to develop and evaluate an MR-safe robotic solution for automated shim coil positioning. METHODS: We designed and fabricated an MR-safe Cartesian platform that holds the shim coil inside the scanner. The platform consists of three lead screw stages actuated by pneumatic motors, achieving decoupled translations of 140 mm in each direction. The platform is made of plastics and fiberglass with the control electronics placed outside the scanner room, ensuring MR safety. Mechanical modeling was derived to provide design specifications. RESULTS: Experiments show that the platform achieves less than 2 mm average motion error and 0.5 mm repeatability in all directions, and reduces the adjustment time from 5 min to a few seconds. Phantom and animal trials were conducted, showing that the proposed system is able to position a heavy shim coil ( kg) for improved ICD artifact suppression. CONCLUSION: This robotic platform provides an effective method for reliable shim coil positioning inside the scanner. SIGNIFICANCE: This work contributes to improving cardiac MRI quality that could facilitate accurate diagnosis and treatment planning for patients with implanted ICDs.

Balanced-force shim system for correcting magnetic-field inhomogeneities in the heart due to implanted cardioverter defibrillators.

Background: In the US, 1.4 million people have implanted ICDs for reducing the risk of sudden death due to ventricular arrhythmias. Cardiac MRI (cMR) is of particular interest in the ICD patient population as cMR is the optimal imaging modality for distinguishing cardiac conditions that predispose to sudden death, and it is the best method to plan and guide therapy. However, all ICDs contain a ferromagnetic transformer which imposes a large inhomogeneous magnetic field in sections of the heart, creating large image voids that can mask important pathology. A shim system was devised to resolve these ICD issues. A shim coil system (CSS) that corrects ICD artifacts over a user-selected Region-of-Interest (ROI), was constructed and validated. Methods: A shim coil was constructed that can project a large magnetic field for distances of ~15 cm. The shim-coil can be positioned safely anywhere within the scanner bore. The CSS includes a cantilevered beam to hold the shim coil. Remotely controlled MR-conditional motors allow 2 mm-accuracy three-dimensional shim-coil position. The shim coil is located above the subjects and the imaging surface-coils. Interaction of the shim coil with the scanner's gradients was eliminated with an amplifier that is in a constant current mode. Coupling with the scanners' radio-frequency (rf) coils, was reduced with shielding, low-pass filters, and cable shield traps. Software, which utilizes magnetic field (B0) mapping of the ICD inhomogeneity, computes the optimal location for the shim coil and its corrective current. ECG gated single- and multiple-cardiac-phase 2D GRE and SSFP sequences, as well as 3D ECG-gated respiratory-navigated IR-GRE (LGE) sequences were tested in phantoms and N = 3 swine with overlaid ICDs. Results: With all cMR sequences, the system reduced artifacts from >100 ppm to <25 ppm inhomogeneity, which permitted imaging of the entire left ventricle in swine with ICD-related voids. Continuously acquired Gradient recalled echo or Steady State Free Precession images were used to interactively adjust the shim current and coil location. Conclusion: The shim system reduced large field inhomogeneities due to implanted ICDs and corrected most ICD-related image distortions. Externally-controlled motorized translation of the shim coil simplified its utilization, supporting an efficient cardiac MRI workflow.

Prospective motion correction using tracking coils.

Intracavity imaging coils provide higher signal-to-noise than surface coils and have the potential to provide higher spatial resolution in shorter acquisition times. However, images from these coils suffer from physiologically induced motion artifacts, as both the anatomy and the coils move during image acquisition. We developed prospective motion-correction techniques for intracavity imaging using an array of tracking coils. The system had <50 ms latency between tracking and imaging, so that the images from the intracavity coil were acquired in a frame of reference defined by the tracking array rather than by the system's gradient coils. Two-dimensional gradient-recalled and three-dimensional electrocardiogram-gated inversion-recovery-fast-gradient-echo sequences were tested with prospective motion correction using ex vivo hearts placed on a moving platform simulating both respiratory and cardiac motion. Human abdominal tests were subsequently conducted. The tracking array provided a positional accuracy of 0.7 ± 0.5 mm, 0.6 ± 0.4 mm, and 0.1 ± 0.1 mm along the X, Y, and Z directions at a rate of 20 frames-per-second. The ex vivo and human experiments showed significant image quality improvements for both in-plane and through-plane motion correction, which although not performed in intracavity imaging, demonstrates the feasibility of implementing such a motion-correction system in a future design of combined tracking and intracavity coil.

Comparison of wideband steady-state free precession and T2-weighted fast spin echo in spine disorder assessment at 1.5 and 3 T.

Wideband steady-state free precession (WB-SSFP) is a modification of balanced steady-state free precession utilizing alternating repetition times to reduce susceptibility-induced balanced steady-state free precession limitations, allowing its use for high-resolution myelographic-contrast spinal imaging. Intertissue contrast and spatial resolution of complete-spine-coverage 3D WB-SSFP were compared with those of 2D T2-weighted fast spin echo, currently the standard for spine T2-imaging. Six normal subjects were imaged at 1.5 and 3 T. The signal-to-noise ratio efficiency (SNR per unit-time and unit-volume) of several tissues was measured, along with four intertissue contrast-to-noise ratios; nerve-ganglia:fat, intradural-nerves:cerebrospinal fluid, nerve-ganglia:muscle, and muscle:fat. Patients with degenerative and traumatic spine disorders were imaged at both MRI fields to demonstrate WB-SSFP clinical advantages and disadvantages. At 3 T, WB-SSFP provided spinal contrast-to-noise ratios 3.7-5.2 times that of fast spin echo. At 1.5 T, WB-SSFP contrast-to-noise ratio was 3-3.5 times that of fast spin echo, excluding a 1.7 ratio for intradural-nerves:cerebrospinal fluid. WB-SSFP signal-to-noise ratio efficiency was also higher. Three-dimensional WB-SSFP disadvantages relative to 2D fast spin echo are reduced edema hyperintensity, reduced muscle signal, and higher motion sensitivity. WB-SSFP's high resolution and contrast-to-noise ratio improved visualization of intradural nerve bundles, foraminal nerve roots, and extradural nerve bundles, improving detection of nerve compression in radiculopathy and spinal-stenosis. WB-SSFP's high resolution permitted reformatting into orthogonal planes, providing distinct advantages in gauging fine spine pathology.

Free-breathing 3D whole-heart black-blood imaging with motion sensitized driven equilibrium.

PURPOSE: To assess the efficacy and robustness of motion sensitized driven equilibrium (MSDE) for blood suppression in volumetric 3D whole-heart cardiac MR. MATERIALS AND METHODS: To investigate the efficacy of MSDE on blood suppression and myocardial signal-to-noise ratio (SNR) loss on different imaging sequences, seven healthy adult subjects were imaged using 3D electrocardiogram (ECG)-triggered MSDE-prep T(1) -weighted turbo spin echo (TSE), and spoiled gradient echo (GRE), after optimization of MSDE parameters in a pilot study of five subjects. Imaging artifacts, myocardial and blood SNR were assessed. Subsequently, the feasibility of isotropic spatial resolution MSDE-prep black-blood was assessed in six subjects. Finally, 15 patients with known or suspected cardiovascular disease were recruited to be imaged using a conventional multislice 2D double inversion recovery (DIR) TSE imaging sequence and a 3D MSDE-prep spoiled GRE. RESULTS: The MSDE-prep yielded significant blood suppression (75%-92%), enabling a volumetric 3D black-blood assessment of the whole heart with significantly improved visualization of the chamber walls. The MSDE-prep also allowed successful acquisition of black-blood images with isotropic spatial resolution. In the patient study, 3D black-blood MSDE-prep and DIR resulted in similar blood suppression in left ventricle and right ventricle walls but the MSDE-prep had superior myocardial signal and wall sharpness. CONCLUSION: MSDE-prep allows volumetric black-blood imaging of the heart.

Reduced motion external defibrillation: Reduced subject motion with equivalent defibrillation efficiency validated in swine.

BACKGROUND: External defibrillators are used for arrhythmia cardioversion and for defibrillating during cardiac arrest. During defibrillation, short-duration biphasic pulses cause intense motion due to rapid chest-wall muscle contraction. A reduced motion external defibrillator (RMD) was constructed by integrating a commercial defibrillator with a Tetanizing-waveform generator. A long-duration, low-amplitude, tetanizing waveform slowly stimulated the chest musculature before the biphasic pulse, reducing muscle contraction during the shock. OBJECTIVE: The purpose of this study was to evaluate RMD defibrillation in swine for subject motion during defibrillation pulses and for defibrillation effectiveness. RMD defibrillation can reduce the duration of arrhythmia ablation therapy or simplify cardioversion procedures. METHODS: The tetanizing unit delivered a triangular 1-kHz pulse of 0.25- to 2.0-second duration and 10- to 100-V peak amplitude, subsequently triggering the conventional defibrillator to output standard 1- to 200-J energy biphasic pulses at the next R wave. Forward limb motion was evaluated by measuring peak acceleration and limb work during RMD (tetanizing + biphasic) or biphasic pulse-only waveforms at 10-3-second sampling rate. Seven swine were arrested electrically and subsequently defibrillated. Biphasic pulse-only and RMD defibrillations were repeated 25-35 times per swine, varying tetanizing parameters and biphasic pulse energy. Defibrillation thresholds (DFTs) were established by measuring the minimum energy required to restore sinus rhythm with biphasic pulse-only or RMD defibrillations. RESULTS: Two forward-limb acceleration peaks occurred during both the tetanizing waveform and biphasic pulse, indicating rapid and slower nociceptic (pain sensation) nerve fiber activation. Optimal RMD tetanizing parameters (25-35 V, 0.25- to 0.75-second duration), relative to biphasic pulse-only defibrillations, resulted in 74% ± 10% smaller peak accelerations and 85% ± 10% reduced limb work. DFT energies were identical when comparing RMD to biphasic pulse-only defibrillations. CONCLUSION: Relative to conventional defibrillations, RMD defibrillations maintain rhythm restoration efficiency with drastically reduced subject motion.

Fully automated multiorgan segmentation of female pelvic magnetic resonance images with coarse-to-fine convolutional neural network.

PURPOSE: Brachytherapy combined with external beam radiotherapy (EBRT) is the standard treatment for cervical cancer and has been shown to improve overall survival rates compared to EBRT only. Magnetic resonance (MR) imaging is used for radiotherapy (RT) planning and image guidance due to its excellent soft tissue image contrast. Rapid and accurate segmentation of organs at risk (OAR) is a crucial step in MR image-guided RT. In this paper, we propose a fully automated two-step convolutional neural network (CNN) approach to delineate multiple OARs from T2-weighted (T2W) MR images. METHODS: We employ a coarse-to-fine segmentation strategy. The coarse segmentation step first identifies the approximate boundary of each organ of interest and crops the MR volume around the centroid of organ-specific region of interest (ROI). The cropped ROI volumes are then fed to organ-specific fine segmentation networks to produce detailed segmentation of each organ. A three-dimensional (3-D) U-Net is trained to perform the coarse segmentation. For the fine segmentation, a 3-D Dense U-Net is employed in which a modified 3-D dense block is incorporated into the 3-D U-Net-like network to acquire inter and intra-slice features and improve information flow while reducing computational complexity. Two sets of T2W MR images (221 cases for MR1 and 62 for MR2) were taken with slightly different imaging parameters and used for our network training and test. The network was first trained on MR1 which was a larger sample set. The trained model was then transferred to the MR2 domain via a fine-tuning approach. Active learning strategy was utilized for selecting the most valuable data from MR2 to be included in the adaptation via transfer learning. RESULTS: The proposed method was tested on 20 MR1 and 32 MR2 test sets. Mean ± SD dice similarity coefficients are 0.93 ± 0.04, 0.87 ± 0.03, and 0.80 ± 0.10 on MR1 and 0.94 ± 0.05, 0.88 ± 0.04, and 0.80 ± 0.05 on MR2 for bladder, rectum, and sigmoid, respectively. Hausdorff distances (95th percentile) are 4.18 ± 0.52, 2.54 ± 0.41, and 5.03 ± 1.31 mm on MR1 and 2.89 ± 0.33, 2.24 ± 0.40, and 3.28 ± 1.08 mm on MR2, respectively. The performance of our method is superior to other state-of-the-art segmentation methods. CONCLUSIONS: We proposed a two-step CNN approach for fully automated segmentation of female pelvic MR bladder, rectum, and sigmoid from T2W MR volume. Our experimental results demonstrate that the developed method is accurate, fast, and reproducible, and outperforms alternative state-of-the-art methods for OAR segmentation significantly (p < 0.05).