Magnetic Resonance Neurography of the Brachial Plexus Using 3D SHINKEI: Comparative Evaluation with Conventional Magnetic Resonance Sequences for the Visualization of Anatomy and Detection of Nerve Injury at 1.5T.

BACKGROUND AND PURPOSE: This work aims at optimizing and studying the feasibility of imaging the brachial plexus at 1.5T using 3D nerve-SHeath signal increased with INKed rest-tissue RARE imaging (3D SHINKEI) neurography sequence by comparing with routine sequences. MATERIALS AND METHODS: The study was performed on a 1.5T Achieva scanner. It was designed in two parts: (a) Optimization of SHINKEI sequence at 1.5T; and (b) Feasibility study of the optimized SHINKEI sequence for generating clinical quality magnetic resonance neurography images at 1.5T. Simulations and volunteer experiments were conducted to optimize the T2 preparation duration for optimum nerve-muscle contrast at 1.5T. Images from the sequence under study and other routine sequences from 24 patients clinically referred for brachial plexus imaging were scored by a panel of radiologists for diagnostic quality. Injury detection efficacy of these sequences were evaluated against the surgical information available from seven patients. RESULTS: T2 preparation duration of 50 ms gives the best contrast to noise between nerve and muscle. The images of 3D SHINKEI and short-term inversion recovery turbo spin-echo sequences are of similar diagnostic quality but significantly better than diffusion weighted imaging with background signal suppression. In comparison with the surgical findings, 3D SHINKEI has the lowest specificity; however, it had the highest sensitivity and predictive efficacy compared to other routine sequences. CONCLUSION: 3D SHINKEI sequence provides a good nerve-muscle contrast and has high predictive efficacy of nerve injury, indicating that it is a potential screening sequence candidate for brachial plexus scans at 1.5T also.

MR Neurography of Brachial Plexus at 3.0 T with Robust Fat and Blood Suppression.

Purpose To develop and evaluate magnetic resonance (MR) neurography of the brachial plexus with robust fat and blood suppression for increased conspicuity of nerves at 3.0 T in clinically feasible acquisition times. Materials and Methods This prospective study was HIPAA compliant, with institutional review board approval and written informed consent. A low-refocusing-flip-angle three-dimensional (3D) turbo spin-echo (TSE) sequence was modified to acquire both in-phase and out-of-phase echoes, required for chemical shift (Dixon) reconstruction, in the same repetition by using partial echoes combined with modified homodyne reconstruction with phase preservation. This multiecho TSE modified Dixon (mDixon) sequence was optimized by using simulations and phantom studies and in three healthy volunteers. The sequence was tested in five healthy volunteers and was evaluated in 10 patients who had been referred for brachial plexopathy at 3.0 T. The images were evaluated against the current standard of care, images acquired with a 3D TSE short inversion time inversion recovery (STIR) sequence, qualitatively by using the Wilcoxon signed-rank test and quantitatively by using the Friedman two-way analysis of variance, with P < .05 considered to indicate a statistically significant difference. Results Multiecho TSE-mDixon involving partial-echo and homodyne reconstruction with phase preservation achieved uniform fat suppression in half the imaging time compared with multiacquisition TSE-mDixon. Compared with 3D TSE STIR, fat suppression, venous suppression, and nerve visualization were significantly improved (P < .05), while arterial suppression was better but not significantly so (P = .06), with increased apparent signal-to-noise ratio in the dorsal nerve root ganglion and C6 nerve (P < .001) with the multiecho TSE-mDixon sequence. Conclusion The multiecho 3D TSE-mDixon sequence provides robust fat and blood suppression, resulting in increased conspicuity of the nerves, in clinically feasible imaging times and can be used for MR neurography of the brachial plexus at 3.0 T. © RSNA, 2016 Online supplemental material is available for this article.

Application of Modified Spin-Echo-based Sequences for Hepatic MR Elastography: Evaluation, Comparison with the Conventional Gradient-Echo Sequence, and Preliminary Clinical Experience.

Purpose To (a) evaluate modified spin-echo (SE) magnetic resonance (MR) elastographic sequences for acquiring MR images with improved signal-to-noise ratio (SNR) in patients in whom the standard gradient-echo (GRE) MR elastographic sequence yields low hepatic signal intensity and (b) compare the stiffness values obtained with these sequences with those obtained with the conventional GRE sequence. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board; the requirement to obtain informed consent was waived. Data obtained with modified SE and SE echo-planar imaging (EPI) MR elastographic pulse sequences with short echo times were compared with those obtained with the conventional GRE MR elastographic sequence in two patient cohorts, one that exhibited adequate liver signal intensity and one that exhibited low liver signal intensity. Shear stiffness values obtained with the three sequences in 130 patients with successful GRE-based examinations were retrospectively tested for statistical equivalence by using a 5% margin. In 47 patients in whom GRE examinations were considered to have failed because of low SNR, the SNR and confidence level with the SE-based sequences were compared with those with the GRE sequence. Results The results of this study helped confirm the equivalence of SE MR elastography and SE-EPI MR elastography to GRE MR elastography (P = .0212 and P = .0001, respectively). The SE and SE-EPI MR elastographic sequences provided substantially improved SNR and stiffness inversion confidence level in 47 patients in whom GRE MR elastography had failed. Conclusion Modified SE-based MR elastographic sequences provide higher SNR MR elastographic data and reliable stiffness measurements; thus, they enable quantification of stiffness in patients in whom the conventional GRE MR elastographic sequence failed owing to low signal intensity. The equivalence of the three sequences indicates that the current diagnostic thresholds are applicable to SE MR elastographic sequences for assessing liver fibrosis. © RSNA, 2016.

Estimation of the absolute shear stiffness of human lung parenchyma using (1) H spin echo, echo planar MR elastography.

PURPOSE: To develop a rapid proton MR elastography (MRE) technique that can quantify the absolute shear stiffness of lung parenchyma, to investigate the ability to differentiate respiration-dependent stiffness variations of the lung, and to demonstrate clinical feasibility. MATERIALS AND METHODS: A spin-echo echo planar imaging MRE sequence (SE-EPI MRE) with a very short echo time was developed and tested in a series of five healthy volunteers at three different lung volumes: (i) residual volume (RV), (ii) total lung capacity (TLC), (iii) and midway between RV and TLC (MID). At each volume, lung density was quantified using a MR-based density mapping sequence. For reference, data were acquired using the previously described spin-echo lung MRE sequence (SE-MRE). MRE data were also acquired in a patient with proven Idiopathic Pulmonary Fibrosis (IPF) to test clinical feasibility. RESULTS: The SE-EPIMRE sequence reduced total acquisition time by a factor of 2 compared with the SE-MRE sequence. Lung parenchyma median shear stiffness for the 5 volunteers quantified with the SE-EPI MRE sequence was 0.9 kPa, 1.1 kPa, and 1.6 kPa at RV, MID, and TLC, respectively. The corresponding values obtained with the SE-MRE sequence were 0.9 kPa, 1.1 kPa, and 1.5 kPa. Absolute shear stiffness was also successfully measured in the IPF patient. CONCLUSION: The results indicate that stiffness variations due to respiration could be measured with the SE-EPIMRE technique and were equivalent to values generated by the previously described SE-MRE approach. Preliminary data obtained from the patient demonstrate clinical feasibility.

MR elastography derived shear stiffness--a new imaging biomarker for the assessment of early tumor response to chemotherapy.

PURPOSE: The overall goal is to develop magnetic resonance elastography derived shear stiffness as a biomarker for the early identification of chemotherapy response, allowing dose, agent type and treatment regimen to be tailored on a per patient basis, improving therapeutic outcome and minimizing normal tissue toxicity. The specific purpose of this study is to test the feasibility of this novel biomarker to measure the treatment response in a well-known chemotherapy model. METHODS: Tumors were grown in the right flank of genetically modified mice by subcutaneous injection of DoHH2 (non-Hodgkin's lymphoma) cells. Magnetic resonance elastography was used to quantify tumor stiffness before and after injection of a chemotherapeutic agent or saline. Histological tests were also performed on the tumors. RESULTS: A significant decrease (P < 0.0001) in magnetic resonance elastography-derived tumor shear stiffness was observed within 4 days of chemotherapy treatment, while no appreciable change was observed in saline-treated tumors. No significant change in volume occurred at this early stage, but there were decreased levels of cellular proliferation in chemotherapy-treated tumors. CONCLUSION: These results demonstrate that magnetic resonance elastography-derived estimates of shear stiffness reflect an initial response to cytotoxic therapy and suggest that this metric could be an early and sensitive biomarker of tumor response to chemotherapy.

Magnetic resonance imaging of pediatric muscular disorders: recent advances and clinical applications.

This review describes various quantitative magnetic resonance imaging techniques that can be used to objectively analyze the composition (T2 relaxation time mapping, Dixon imaging, and diffusion-weighted imaging), architecture (diffusion tensor imaging), mechanical properties (magnetic resonance elastography), and function (magnetic resonance spectroscopy) of normal and pathologic skeletal muscle in the pediatric population.

Magnetic resonance assessment of parenchymal elasticity in normal and edematous, ventilator-injured lung.

Magnetic resonance elastography (MRE) is a MR imaging method capable of spatially resolving the intrinsic mechanical properties of normal lung parenchyma. We tested the hypothesis that the mechanical properties of edematous lung exhibit local properties similar to those of a fluid-filled lung at transpulmonary pressures (P(tp)) up to 25 cm H(2)O. Pulmonary edema was induced in anesthetized female adult Sprague-Dawley rats by mechanical ventilation to a pressure of 40 cm H(2)O for ≈ 30 min. Prior to imaging the wet weight of each ex vivo lung set was measured. MRE, high-resolution T(1)-weighted spin echo and T(2)* gradient echo data were acquired at each P(tp) for both normal and injured ex vivo lungs. At P(tp)s of 6 cm H(2)O and greater, the shear stiffness of normal lungs was greater than injured lungs (P ≤ 0.0003). For P(tp)s up to 12 cm H(2)O, shear stiffness was equal to 1.00, 1.07, 1.16, and 1.26 kPa for the injured and 1.31, 1.89, 2.41, and 2.93 kPa for normal lungs at 3, 6, 9, and 12 cm H(2)O, respectively. For injured lungs MRE magnitude signal and shear stiffness within regions of differing degrees of alveolar flooding were calculated as a function of P(tp). Differences in shear stiffness were statistically significant between groups (P < 0.001) with regions of lower magnitude signal being stiffer than those of higher signal. These data demonstrate that when the alveolar space filling material is fluid, MRE-derived parenchymal shear stiffness of the lung decreases, and the lung becomes inherently softer compared with normal lung.

Magnetic resonance elastography of the lung parenchyma in an in situ porcine model with a noninvasive mechanical driver: correlation of shear stiffness with trans-respiratory system pressures.

Quantification of the mechanical properties of lung parenchyma is an active field of research due to the association of this metric with normal function, disease initiation and progression. A phase contrast MRI-based elasticity imaging technique known as magnetic resonance elastography is being investigated as a method for measuring the shear stiffness of lung parenchyma. Previous experiments performed with small animals using invasive drivers in direct contact with the lungs have indicated that the quantification of lung shear modulus with (1) H based magnetic resonance elastography is feasible. This technique has been extended to an in situ porcine model with a noninvasive mechanical driver placed on the chest wall. This approach was tested to measure the change in parenchymal stiffness as a function of airway opening pressure (P(ao) ) in 10 adult pigs. In all animals, shear stiffness was successfully quantified at four different P(ao) values. Mean (±STD error of mean) pulmonary parenchyma density corrected stiffness values were calculated to be 1.48 (±0.09), 1.68 (±0.10), 2.05 (±0.13), and 2.23 (±0.17) kPa for P(ao) values of 5, 10, 15, and 20 cm H2O, respectively. Shear stiffness increased with increasing P(ao) , in agreement with the literature. It is concluded that in an in situ porcine lung shear stiffness can be quantitated with (1) H magnetic resonance elastography using a noninvasive mechanical driver and that it is feasible to measure the change in shear stiffness due to change in P(ao) .

Magnetic Resonance Elastography.

Often compared to the practice of manual palpation, magnetic resonance elastography is an emerging technology for quantitatively assessing the mechanical properties of tissue as a basis for characterizing disease. The potential of MRE as a diagnostic tool is rooted in the fact that normal and diseased tissues often differ significantly in terms of their intrinsic mechanical properties. MRE uses magnetic resonance imaging (MRI) in conjunction with the application of mechanical shear waves to probe tissue mechanics. This process can be broken down into three essential steps: inducing shear waves in the tissue,imaging the propagating shear waves with MRI, andanalyzing the wave data to generate quantitative images of tissue stiffness MRE has emerged as a safe, reliable and noninvasive method for staging hepatic liver fibrosis, and is now used in some locations as an alternative to biopsy. MRE is also being used in the ongoing investigations of numerous other organs and tissues, including, for example, the spleen, kidney, pancreas, brain, heart, breast, skeletal muscle, prostate, vasculature, lung, spinal cord, eye, bone, and cartilage. In the article that follows, some fundamental techniques and applications of MRE are summarized.

MR elastography of human lung parenchyma: technical development, theoretical modeling and in vivo validation.

PURPOSE: To develop a novel MR-based method for visualizing the elastic properties of human lung parenchyma in vivo and to evaluate the ability of this method to resolve differences in parenchymal stiffness at different respiration states in healthy volunteers. MATERIALS AND METHODS: A spin-echo MR Elastography (MRE) pulse sequence was developed to provide both high shear wave motion sensitivity and short TE for improved visualization of lung parenchyma. The improved motion sensitivity of this approach was modeled and tested with phantom experiments. In vivo testing was then performed on 10 healthy volunteers at the respiratory states of residual volume (RV) and total lung capacity (TLC). RESULTS: Shear wave propagation was visualized within the lungs of all volunteers and was processed to provide parenchymal shear stiffness maps for all 10 subjects. Density corrected stiffness values at TLC (1.83 ± 0.22 kPa) were higher than those at the RV (1.14 ± 0.14 kPa) with the difference being statistically significant (P < 0.0001). CONCLUSION: (1)H-based MR elastography can noninvasively measure the shear stiffness of human lung parenchyma in vivo and can quantitate the change in shear stiffness due to respiration. The values obtained were consistent with previously reported in vitro assessments of cadaver lungs. Further work is required to increase the flexibility of the current acquisition and to investigate the clinical potential of lung MRE.

MR elastography of the ex vivo bovine globe.

PURPOSE: To evaluate the feasibility of using MR elastography (MRE) to assess the mechanical properties of the eye. MATERIALS AND METHODS: The elastic properties of the corneoscleral shell of an intact, enucleated bovine globe specimen were estimated using MRE and finite element modeling (FEM), assuming linear, isotropic behavior. The two-dimensional (2D), axisymetric model geometry was derived from a segmented 2D MR image, and estimations of the Young's modulus in both the cornea and sclera were made at various intraocular pressures using an iterative flexural wave speed matching algorithm. RESULTS: Estimated values of the Young's moduli of the cornea and sclera varied from 40 to 185 kPa and 1 to 7 MPa, respectively, over an intraocular pressure range of 0.85 to 9.05 mmHg (1.2 to 12.3 cmH(2)O). They also varied exponentially as functions of both wave speed and intraocular dP/dV, an empirical measure of "ocular rigidity." CONCLUSION: These results show that it is possible to estimate the intrinsic elastic properties of the corneoscleral shell in an ex vivo bovine globe, suggesting that MRE may provide a useful means to assess the mechanical properties of the eye and its anatomy. Further development of the technique and modeling process will enhance its potential, and further investigations are needed to determine its clinical potential.

Vibration imaging for localization of functional compartments of the extrinsic flexor muscles of the hand.

PURPOSE: To develop and test an MRI-based imaging technique for the localization of the functional compartments of the functionally finger-specific, yet anatomically indistinct, flexor muscles of the hand. MATERIALS AND METHODS: A total of six normal healthy volunteers were involved in five studies in which individual fingers were vibrated with mechanical actuators and the resultant motion within the corresponding functional compartments of the flexor muscles, mechanically transferred through the structurally connected tendons, was imaged with a phase-contrast MR imaging technique that is highly sensitive to cyclic motion. The motion amplitude and relative phase relationship between the functional compartments of various muscles and fingers were obtained and analyzed from these images as a means to differentiate the various subcompartments. RESULTS: The results show that this technique provides a detailed mapping of the regions of the complex flexor muscle compartments that correspond to each digit for both the flexor digitorum profundus and the flexor digitorum superficialis. The results also demonstrate the presence of mechanical interdependence between the flexor muscles. CONCLUSION: It is concluded from the results that localization of the finger-specific subcompartments of the forearm flexor muscles can be performed with this technique.

Magnetic resonance elastography: a review.

Magnetic resonance elastography (MRE) is a rapidly developing technology for quantitatively assessing the mechanical properties of tissue. The technology can be considered to be an imaging-based counterpart to palpation, commonly used by physicians to diagnose and characterize diseases. The success of palpation as a diagnostic method is based on the fact that the mechanical properties of tissues are often dramatically affected by the presence of disease processes, such as cancer, inflammation, and fibrosis. MRE obtains information about the stiffness of tissue by assessing the propagation of mechanical waves through the tissue with a special magnetic resonance imaging technique. The technique essentially involves three steps: (1) generating shear waves in the tissue, (2) acquiring MR images depicting the propagation of the induced shear waves, and (3) processing the images of the shear waves to generate quantitative maps of tissue stiffness, called elastograms. MRE is already being used clinically for the assessment of patients with chronic liver diseases and is emerging as a safe, reliable, and noninvasive alternative to liver biopsy for staging hepatic fibrosis. MRE is also being investigated for application to pathologies of other organs including the brain, breast, blood vessels, heart, kidneys, lungs, and skeletal muscle. The purpose of this review article is to introduce this technology to clinical anatomists and to summarize some of the current clinical applications that are being pursued.

High-frequency mode conversion technique for stiff lesion detection with magnetic resonance elastography (MRE).

A novel imaging technique is described in which the mode conversion of longitudinal waves is used for the qualitative detection of stiff lesions within soft tissue using magnetic resonance elastography (MRE) methods. Due to the viscoelastic nature of tissue, high-frequency shear waves attenuate rapidly in soft tissues but much less in stiff tissues. By introducing minimally-attenuating longitudinal waves at a significantly high frequency into tissue, shear waves produced at interfaces by mode conversion will be detectable in stiff regions, but will be significantly attenuated and thus not detectable in the surrounding soft tissue. This contrast can be used to detect the presence of stiff tissue. The proposed technique is shown to readily depict hard regions (mimicking tumors) present in tissue-simulating phantoms and ex vivo breast tissue. In vivo feasibility is demonstrated on a patient with liver metastases in whom the tumors are readily distinguished. Preliminary evidence also suggests that quantitative stiffness measurements of stiff regions obtained with this technique are more accurate than those from conventional MRE because of the short shear wavelengths. This rapid, qualitative technique may lend itself to applications in which the localization of stiff, suspicious neoplasms is coupled with more sensitive techniques for thorough characterization.

Cyclic motion encoding for enhanced MR visualization of slip interfaces.

PURPOSE: To develop and test a magnetic resonance imaging-based method for assessing the mechanical shear connectivity across tissue interfaces with phantom experiments and in vivo feasibility studies. MATERIALS AND METHODS: External vibrations were applied to phantoms and tissue and the differential motion on either side of interfaces within the media was mapped onto the phase of the MR images using cyclic motion encoding gradients. The phase variations within the voxels of functional slip interfaces reduced the net magnitude signal in those regions, thus enhancing their visualization. A simple two-compartment model was developed to relate this signal loss to the intravoxel phase variations. In vivo studies of the abdomen and forearm were performed to visualize slip interfaces in healthy volunteers. RESULTS: The phantom experiments demonstrated that the proposed technique can assess the functionality of shear slip interfaces and they provided experimental validation for the theoretical model developed. Studies of the abdomen showed that the slip interface between the small bowel and the peritoneal wall can be visualized. In the forearm, this technique was able to depict the slip interfaces between the functional compartments of the extrinsic forearm muscles. CONCLUSION: Functional shear slip interfaces can be visualized sensitively using cyclic motion encoding of externally applied tissue vibrations.

Magnetic resonance elastography with a phased-array acoustic driver system.

Dynamic MR elastography (MRE) quantitatively maps the stiffness of tissues by imaging propagating shear waves in the tissue. These waves can be produced from intrinsic motion sources (e.g., due to cardiac motion), from external motion sources that produce motion directly at depth in tissue (e.g., amplitude-modulated focused ultrasound), and from external actuators that produce motion at the tissue surface that propagates into the tissue. With external actuator setups, typically only a single transducer is used to create the shear waves, which in some applications might have limitations due to shadowing and attenuation of the waves. To address these limitations, a phased-array acoustic driver system capable of applying independently controlled waveforms to each channel was developed and tested. It was found that the system produced much more uniform illumination of the object, improving the quality of the elastogram. It was also found that the accuracy of the stiffness value of any arbitrary region of interest could be improved by obtaining maximal shear wave illumination with the phased array capability of the system.