Quantitative and qualitative evaluation of high-quality hepatobiliary phase imaging with shortened timing and utility in patients with compromised liver function.

PURPOSE: To compare high flip angle (FA) hepatobiliary-phase (hHBP) imaging with variable time intervals to conventional HBP (cHBP) to assess the impact of increased FA on image quality in shortened HBP imaging. METHODS: Data from 218 patients, divided into normal liver group (n = 184) and decompensated liver group (n = 34), who underwent liver magnetic resonance imaging (MRI) including 10-min, 15-min, 20-min hHBP, and cHBP were analyzed. Signal-to-noise ratio (SNR), contrast-ratio (CR), contrast-to-noise ratio (CNR), signal intensity ratios (SIRs), and relative enhancement (RE) of the liver were calculated for quantitative analysis. Sharpness, noise, and artifacts of the image, contrast media visibility, overall image quality, and lesion conspicuity were evaluated by two abdominal radiologists. RESULTS: Quantitative analysis showed that SNR, RE, SIR for liver/muscle, liver/spleen, and CR of all hHBP images demonstrated a significantly higher value compared to cHBP images in the normal liver group (p < 0.001). These values were also superior in the normal liver group compared to the decompensated liver group (p < 0.01). In qualitative analysis, both normal and decompensated liver groups exhibited significantly superior image sharpness in all hHBP images compared to cHBP images and the overall image quality of the 15-min and 20-min hHBP did not show significant difference compared to cHBP. All values tended to be better in the normal liver group than the decompensated liver group with statistical significance except for lesion conspicuity (p < 0.01). CONCLUSION: High-FA HBP has proven to be a valuable image acquisition method, potentially shortening liver MR imaging time while maintaining acceptable image quality.

Non-Invasive Imaging Methods to Evaluate Non-Alcoholic Fatty Liver Disease with Fat Quantification: A Review.

Hepatic steatosis without specific causes (e.g., viral infection, alcohol abuse, etc.) is called non-alcoholic fatty liver disease (NAFLD), which ranges from non-alcoholic fatty liver (NAFL) to non-alcoholic steatohepatitis (NASH), fibrosis, and NASH-related cirrhosis. Despite the usefulness of the standard grading system, liver biopsy has several limitations. In addition, patient acceptability and intra- and inter-observer reproducibility are also concerns. Due to the prevalence of NAFLD and limitations of liver biopsies, non-invasive imaging methods such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) that can reliably diagnose hepatic steatosis have developed rapidly. US is widely available and radiation-free but cannot examine the entire liver. CT is readily available and helpful for detection and risk classification, significantly when analyzed using artificial intelligence; however, it exposes users to radiation. Although expensive and time-consuming, MRI can measure liver fat percentage with magnetic resonance imaging proton density fat fraction (MRI-PDFF). Specifically, chemical shift-encoded (CSE)-MRI is the best imaging indicator for early liver fat detection. The purpose of this review is to provide an overview of each imaging modality with an emphasis on the recent progress and current status of liver fat quantification.

Improved Single Breath-Hold SSFSE Sequence for Liver MRI Based on Compressed Sensing: Evaluation of Image Quality Compared with Conventional T2-Weighted Sequences.

The purpose of this study was to evaluate the image quality of compressed-sensing accelerated single-shot fast spin-echo (SSFSECS) sequences acquired within a single breath-hold in comparison with conventional SSFSE (SSFSECONV) and multishot TSE (mTSE). A total of 101 patients who underwent liver MRI at 3 T, including SSFSECONV (acquisition time (TA) = 58−62 s), mTSE (TA = 108 s), and SSFSECS (TA = 18 s), were included in this retrospective study. Two radiologists assessed the three sequences with respect to artifacts, organ sharpness, small structure visibility, overall image quality, and conspicuity of main lesions of liver and pancreas using a five-point evaluation scale system. Descriptive statistics and the Wilcoxon signed-rank test were used for statistical analysis. SSFSECS was significantly better than SSFSECONV and mTSE for artifacts, small structure visibility, overall image quality, and conspicuity of main lesions (p < 0.005). Regarding organ sharpness, mTSE and SSFSECS did not significantly differ (p = 0.554). Conspicuity of liver lesion did not significantly differ between SSFSECONV and mTSE (p = 0.404). SSFSECS showed superior image quality compared with SSFSECONV and mTSE despite a more than three-fold reduction in TA, suggesting a remarkable potential for saving time in liver imaging.

Intraindividual comparison of MRI-derived liver surface nodularity score at 1.5 T and 3 T.

PURPOSE: To compare the MRI-derived liver surface nodularity (LSN) scores acquired on both 1.5 T and 3 T. MATERIALS AND METHODS: Forty chronic liver disease patients who underwent gadoxetic acid-enhanced MRI at both 1.5 and 3 T were included. Axial hepatobiliary phase images with the same voxel size were used to calculate the LSN score in both liver lobes with a quantitative software. Rank correlation, Wilcoxon test, and Bland-Altman limits of agreement were used for statistical analysis. RESULTS: There was a weak correlation between the right and left liver lobe on 1.5 T (rs = 0.331, p = 0.037) and 3 T (rs = 0.381, p = 0.015). The correlation between 1.5 T and 3 T on both liver lobes showed a very strong correlation (right, rs = 0.927, p < 0.001; left, rs = 0.845, p < 0.001). LSN scores differed significantly between both lobes on 1.5 T (median, 1.201 vs. 0.674, right vs. left) and 3 T (1.076 vs. 0.592) (all p < 0.001). LSN scores differed significantly between 1.5 T and 3 T on both lobes (all p < 0.001). The Bland-Altman plot comparing 1.5 T and 3 T on right and left liver lobes showed a systemic bias of 0.08 and 0.07, respectively. CONCLUSIONS: LSN scores differed significantly on 1.5 T vs. 3 T and right vs. left liver lobe. Caution should be made when comparing LSN scores derived from different field strengths or the hepatic lobe. Interplatform, interlobar reproducibility should be resolved to use LSN scores, which is relatively easy to perform without additional hardware or images.

Noninvasive staging of liver fibrosis: review of current quantitative CT and MRI-based techniques.

Liver fibrosis features excessive protein accumulation in the liver interstitial space resulting from repeated tissue injury due to chronic liver disease. Liver fibrosis eventually proceeds to cirrhosis and associated complications. So, early diagnosis and staging of liver fibrosis are of vital importance for clinical treatment. Liver biopsy remains the gold standard for the diagnosing and staging of fibrosis, but it is suboptimal due to various limitations. Recently, efforts have been made to migrate toward noninvasive techniques for assessing liver fibrosis. CT is relatively easy to perform, relatively standardized for different scanners, and does not require additional hardware in liver fibrosis staging. MRI is frequently performed to characterize indeterminate liver lesions. Because it does not use ionizing radiation and features high image contrast, its role has increased in the staging of liver fibrosis. More recently, several studies on liver fibrosis staging using deep learning algorithms in CT or MRI have been proposed and have shown meaningful results. In this review, we summarize the basic concept, diagnostic performance, and advantages and limitations of each technique to noninvasively stage liver fibrosis.

Comparison of Compressed Sensing and Gradient and Spin-Echo in Breath-Hold 3D MR Cholangiopancreatography: Qualitative and Quantitative Analysis.

While magnetic resonance cholangiopancreatography (MRCP) is routinely used, compressed sensing MRCP (CS-MRCP) and gradient and spin-echo MRCP (GRASE-MRCP) with breath-holding (BH) may allow sufficient image quality with shorter acquisition times. This study qualitatively and quantitatively compared BH-CS-MRCP and BH-GRASE-MRCP and evaluated their clinical effectiveness. Data from 59 consecutive patients who underwent both BH-CS-MRCP and BH-GRASE-MRCP were qualitatively analyzed using a five-point Likert-type scale. The signal-to-noise ratio (SNR) of the common bile duct (CBD), contrast-to-noise ratio (CNR) of the CBD and liver, and contrast ratio between periductal tissue and the CBD were measured. Paired t-test, Wilcoxon signed-rank test, and McNemar's test were used for statistical analysis. No significant differences were found in overall image quality or duct visualization of the CBD, right and left 1st level intrahepatic duct (IHD), cystic duct, and proximal pancreatic duct (PD). BH-CS-MRCP demonstrated higher background suppression and better visualization of right (p = 0.004) and left 2nd level IHD (p < 0.001), mid PD (p = 0.003), and distal PD (p = 0.041). Image quality degradation was less with BH-GRASE-MRCP than BH-CS-MRCP (p = 0.025). Of 24 patients with communication between a cyst and the PD, 21 (87.5%) and 15 patients (62.5%) demonstrated such communication on BH-CS-MRCP and BH-GRASE-MRCP, respectively. SNR, contrast ratio, and CNR of BH-CS-MRCP were higher than BH-GRASE-MRCP (p < 0.001). Both BH-CS-MRCP and BH-GRASE-MRCP are useful imaging methods with sufficient image quality. Each method has advantages, such as better visualization of small ducts with BH-CS-MRCP and greater time saving with BH-GRASE-MRCP. These differences allow diverse choices for visualization of the pancreaticobiliary tree in clinical practice.

Comparison of diffusion-weighted imaging and MR elastography in staging liver fibrosis: a meta-analysis.

PURPOSE: To compare the diagnostic performance of diffusion-weighted imaging (DWI), gradient-recalled echo-based magnetic resonance elastography (GRE-MRE), and spin-echo echo-planar imaging-based MRE (SE-EPI-MRE) in liver fibrosis staging. METHODS: A systematic literature search was done to collect studies on the performance of DWI, GRE-MRE, and SE-EPI-MRE for diagnosing liver fibrosis. Pooled sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood ratio, and a summary receiver operating characteristic (ROC) curve were estimated with a bivariate random effects model. Subgroup analyses on various study characteristics were performed. RESULTS: Sixty studies with a total of 6620 patients were included in the meta-analysis. Pooled sensitivity and specificity of GRE-MRE and SE-EPI-MRE showed high diagnostic accuracy and did not differ significantly. The area under the summary ROC curve for all stages of fibrosis differed significantly between DWI (0.83-0.88) and either GRE-MRE (0.95-0.97) or SE-EPI-MRE (0.95-0.99). Substantial heterogeneity was detected for all three imaging methods. CONCLUSIONS: Both GRE-MRE and SE-EPI-MRE are highly accurate for detection of each liver fibrosis stage, with high potential to replace liver biopsy. Although DWI had a moderate accuracy in distinguishing liver fibrosis, it could be regarded as an alternative to MRE, since it is widely available and easily implemented in routine liver MRI.

[Uterine Cervical Cancer: Emphasis on Revised FIGO Staging 2018 and MRI]. / 자궁경부암: ê°œì •ëœ 2018 FIGO 병기와 ìžê¸°ê³µëª ì˜ìƒì„ 중심으로.

Uterine cervical cancer is a common gynecological cancer prevalent in Korea. Early detection, precise diagnosis, and appropriate treatment can affect its prognosis. Imaging approaches play an important role in staging, treatment planning, and follow-up. MRI specifically provides the advantage of assessing tumor size and disease severity with high soft tissue contrast. The revised version of the International Federation of Gynecology and Obstetrics (FIGO) staging system has been introduced in 2018, which incorporates subdivided primary tumor size and lymph node metastasis. In this review, the staging of uterine cervical cancer based on previous studies, the recently revised FIGO staging, and various post-treatment images are primarily described using MRI.

Intra-individual comparison of conventional and simultaneous multislice-accelerated diffusion-weighted imaging in upper abdominal solid organs: value of ADC normalization using the spleen as a reference organ.

PURPOSE: To compare the apparent diffusion coefficient (ADC) value of conventional diffusion-weighted imaging (cDWI) to simultaneous multislice-accelerated DWI (sDWI) and to evaluate the possibility of ADC normalization using the spleen as a reference organ. METHODS: We retrospectively evaluated 92 patients (68 men, 24 women; mean age 60.0 years) who underwent liver magnetic resonance imaging (MRI) including both cDWI and sDWI. sDWI was obtained with an acceleration factor of 2. ADC values were measured from the right liver lobe, left liver lobe, spleen, pancreas, right kidney, and left kidney. ADC values of the spleen were used for normalization. Paired sample t test, Pearson's correlation coefficient, and Bland-Altman method were used for statistical analysis. RESULTS: ADC values of cDWI were significantly lower than sDWI in all six anatomic regions (p < 0.001). The mean difference in ADC value between cDWI and sDWI ranged from 0.048 to 0.125 × 10-3 mm2/s. ADC values from cDWI and sDWI showed a moderate to very high positive correlation (p < 0.001). After ADC normalization using the spleen as a reference organ, there was no significant difference between normalized ADC of cDWI and sDWI in all 5 anatomic regions (p = 0.11 - 0.74). CONCLUSIONS: Normalization of ADC using the spleen could be useful for comparing upper abdominal organs acquired with either cDWI or sDWI in longitudinal and follow-up studies.

[A case of acute hepatitis E].

Hepatitis E is an infectious viral disease with clinical and morphologic features of acute hepatitis. Although HEV infection is endemic in the Indian subcontinent, Southeast and Central Asia, a large outbreak of hepatitis E was identified in China. Smaller outbreaks have been observed in the Middle East, northern and western parts of Africa, and Mexico. Sporadic hepatitis E also has been observed in several countries. In nonendemic regions, the sporadic cases of hepatitis E are almost always associated with travel to HEV-endemic regions. In Korea, there has been no report on hepatitis E. Recently, we experienced a case of acute icteric hepatitis in which serologic study showed seroconversion of IgM anti-HEV. The patient did not have any travel history to an HEV-endemic area. We report this as an initial case of acute hepatitis E in Korea.

A Case of Acute Hepatitis E / 대한간학회지

Hepatitis E is an infectious viral disease with clinical and morphologic features of acute hepatitis. Although HEV infection is endemic in the Indian subcontinent, Southeast and Central Asia, a large outbreak of hepatitis E was identified in China. Smaller outbreaks have been observed in the Middle East, northern and western parts of Africa, and Mexico. Sporadic hepatitis E also has been observed in several countries. In nonendemic regions, the sporadic cases of hepatitis E are almost always associated with travel to HEV-endemic regions. In Korea, there has been no report on hepatitis E. Recently, we experienced a case of acute icteric hepatitis in which serologic study showed seroconversion of IgM anti-HEV. The patient did not have any travel history to an HEV-endemic area. We report this as an initial case of acute hepatitis E in Korea.

A case of eosinophilic panniculitis diagnosed in the lower extremity skin lesions with tenderness / 천식및알레르기

Eosinophilic panniculitis is characterized by prominent infiltration of eosinophils in the subcutaneous fat. Clinically it may be considered as a reactive process because most patients have an associated systemic condition. We report a case of tender subcutaneous nodules and plaques with erythema on the lower legs in a 30-year-old man with blood eosinophilia. The histologic features were characterized by massive eosinophilic infiltration in the septae and lobule in the parenchymal area of subcutaneous tissues. Despite exhaustive investigation, no obvious trigger of the panniculitis could be identified. The cutaneous lesions regressed and the eosinophil count became normal during the seven days course of treatment with intravenous corticosteroid. Another flare-up occurred about one month after treatment. The patient is presently being treated with prolonged use of alternate-day steroid without recurrence.

A case of Churg-Strauss syndrome associated with zafirlukast / 천식및알레르기

Churg-Strauss syndrome (CSS) is an eosinophil associated disease, characterized by vaculitis and granulomatosis on small vessel, asthma and eosinophil tissue infiltration. Several cases of CSS have been reported in patients treated with cysteinyl leukotriene receptor antagonist and weaned-off systemic or inhaled corticosteroids. A 39-year-old man with a history of childhood allergic rhinitis was diagnosed with bronchial asthma and his symptoms were well controlled with fluticasone propinate, salmeterol and zafirlukast. However four months later, he was admitted again with prominent skin lesions, tingling sensation on both extremities and fever. We diagnosed CSS with a history of sinusitis and bronchial asthma, marked peripheral eosinophilia, vasculitis and neuropathy. His symptoms and laboratory findings promptly improved after ten days of intravenous corticosteroid and cessation of zafirlukast without recurrence for six months during the follow-up period. We conclude that zafirlukast may cause CSS and attention should be taken when using zafirlukast.

Clinical Study of Post-Traumatic Seizure in Childhood and Adolescence

PURPOSE: As morbidity and mortality resulting from physical trauma have significantly increased, the importance of trauma concerning medical, legal, and socioeconomic issues has been widely documented. Studies of post-traumatic seizure after head trauma have been reported, but mostly in adults. So this study was performed to analyse clinical findings on head trauma patients under 20 years of age. METHODS: The medical records of 230 patients under 20 years of age, who were admitted as head trauma to Chung Ang University hospital from January 1993 till May 1997, were reviewed. RESULTS: The overall incidence of Post-traumatic seizure was 32 of 230 patients in this study. The incidence per age was 16.7% in less than 5 year, 12.2% in 6-10 year, 11.4% in 11-15 year, and 14.9% in 16-20 year. We found incidences of Post-traumatic seizure in cases with depressed skull fracture(44.4%), subdural hematoma(28.6%), subarachnoid hemorrhage(28.6%) and intracerebral hemorrhage(21.1%). Of the 230 patients with head trauma, 2.2% had an immediate-onset seizure, 2.6% an early-onset seizure and 9.1% a late-onset seizure. Of the patients with post-traumatic seizure, abnormal EEG findings were found in 50%. EEG abnormalities were slowing (46.2%) and spike(3.8%). Recurrence rate of post-traumatic seizure was 21.9% in this study. We found a high incidence of recurrence in cases of depressed skull fracture, subdural hematoma and epidural hematoma. CONCLUSION: Considering the great influence of seizure on a child's development and long-term prognosis, prevention based on post-traumatic seizure risk assessment is important and antiepileptic prophylaxis should be considered as disk factors.

The Effect of Small Dose of Nondepolarizing Muscle Relaxant Administered Prior to Succinylcholine on Intubating Condition / 대한마취과학회지

Subparalyzing dose of nodepolarizing relaxants prior to injection of succinylcholine has been used to prevent various adverse effects induced after succinylcholine. For investigating interactions between succinylcholine and small doses of four non-depolar-izing agents, the 112 subjects that were ASA class 1-2 and no existing neuromuscular conduction system disorder were divided into 5 groups that were control group(only succinylcholine 1 mg/kg) and pretreated group d-tubocurarine 0.5 mg/kg, atracurium 0.08 mg/kg, vecuronium 0.01 mg/kg and pancuronium 0.01 mg/kg. In each group, the plasma concentration of K+ and PChE before and after use of succinylcholine, fasciculation, onset and recovery time of succinylcholine block and intubating conditon were observed. The results are as follows; In the pretreated group, there were no significant changes of plasma concentration of K+ and plasma cholinesterase(Table 3) but diminished the incidence of fascieulation, delayed the onset time and shorted the recovery time of succinylcholine block(Table 4), and worse in intubating condition(Table 5) except pancuronium treated group. It was concluded that these seem to make worse condition of intubation, while small doses of nondepolarizing muscle relaxants except pancuronium antagonize depolarizing muscle relaxant.

The Effect of Small Dose of Nondepolarizing Muscle Relaxant Administered Prior to Succinylcholine on Intubating Condition / 대한마취과학회지

Subparalyzing dose of nodepolarizing relaxants prior to injection of succinylcholine has been used to prevent various adverse effects induced after succinylcholine. For investigating interactions between succinylcholine and small doses of four non-depolar-izing agents, the 112 subjects that were ASA class 1-2 and no existing neuromuscular conduction system disorder were divided into 5 groups that were control group(only succinylcholine 1 mg/kg) and pretreated group d-tubocurarine 0.5 mg/kg, atracurium 0.08 mg/kg, vecuronium 0.01 mg/kg and pancuronium 0.01 mg/kg. In each group, the plasma concentration of K+ and PChE before and after use of succinylcholine, fasciculation, onset and recovery time of succinylcholine block and intubating conditon were observed. The results are as follows; In the pretreated group, there were no significant changes of plasma concentration of K+ and plasma cholinesterase(Table 3) but diminished the incidence of fascieulation, delayed the onset time and shorted the recovery time of succinylcholine block(Table 4), and worse in intubating condition(Table 5) except pancuronium treated group. It was concluded that these seem to make worse condition of intubation, while small doses of nondepolarizing muscle relaxants except pancuronium antagonize depolarizing muscle relaxant.

The Effect of Small Dose of Hydrocortisone to the Recovery Index from Neuromuscular Blockade Induced with Vecuronium / 대한마취과학회지

Several investigators have described an interaction between muscle relaxants and hydrocortisones which have showed different results. The exact mechanism of this action is not clear and ther conflicting results have further confusion. The experimental methods were two ways. In the one of method, a group that vecuronium 0.1mg/kg was given intravenously is control and a group that hydrocortisones of various doses(0.3, 0.5 and 1 mg/kg) were administered into vein when T1 was appeared is compared. In the another of method, a control group was anticholinesterase(pyridostigmine 0.12 mg/kg, robinul 0.004mg/kg) were given at the time when T1 reached 25% and a group treated with hydrocortisone 0.5 mg/kg when T1 was appeared is compared. Neuromuscular blockade was measured by recording the twitch response following ulnar nerve stimulation by EMG(ABM, Datex Co. 2Hz 30mA supramaximal voltage). The recovery time from 25% to 75% recovery of twitch height was measured according to recovery index(RI). The results obtained were as follows: `) The RI of control group treated with vecuronium 0.1mg/kg alone was 40.32+/-20.24 minutes and the group which hydrocortisone 0.5mg/kg was combined, was shorten to 18.79+/-5.17 minutes, but in the group combined with hydrocortisone 1.0mg/kg and 0.3mg/kg, the RI was also tended to short, but not significant. 2) In the RI of vecuronium 0.1mg/kg, anticholinesterases were given, was 8.46+/-5.06 minutes and the group combined with hydrocortisone 0.5mg/kg was shorten to 4.77+/-1.82 minutes significantly. Conclusively, in the small doses of hydrocortisone, there is a effect of antagonism to the vecuronium induced blockade and a potentiated effect to the anticholinesterase activity to the vecuronium.