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Objectives: Optimal contrast within the pulmonary artery is achieved by the maximum amount of contrast-enhanced blood flowing through the superior vena cava (SVC), while minimum amounts of non-contrasted blood should originate from the inferior vena cava (IVC). This study aims to clarify whether "suction against resistance" might optimise this ratio., Methods: Phase-contrast pulse sequences on a 1.5T MRI magnet were used for flow quantification (mean flow (mL/s), stroke volume (Vol) in the SVC and IVC in volunteers. Different breathing manoeuvers were analysed repeatedly: free breathing; inspiration; expiration; suction against resistance, and Valsalva. To standardise breathing commands, volunteers performed suction and Valsalva manoeuvers with an MR-compatible manometer., Results: Suction against resistance was associated with a significant drop of the IVC/SVC flow quotient (1.63 [range 1.3-2.0] p < 0.05 at -10 mmHg and 1.48 [1.1-1.9] p < 0.01 at -20 mmHg) corresponding to increased blood flow from SVC and diminished flow originating from the IVC. The remaining breathing commands (free breathing 2.2; inspiration 2.4; expiration 2.4; Valsalva 10 mmHg 2.3; Valsalva 20 mmHg 2.6; and Valsalva 30 mmHg 2.2) showed no differences (p > 0.05)., Conclusions: Suction against resistance caused a significant drop in the IVC/SVC quotient. Theoretically, this breathing manoeuver might significantly improve the enhancement characteristics of CT angiography., Key Points: Suction provokes reduction in blood flow in the inferior vena cava. Ratio between the inferior and superior vena cava blood flow diminished during suction. Manometer used during breathing standardises MR phase-contrast blood flow measurements.

Objective: The aim of this study was to prospectively evaluate the feasibility of monitoring treatment response to chemotherapy in patients with non-small cell lung carcinoma using functional diffusion maps (fDMs)., Materials and Methods: This study was approved by the Cantonal Research Ethics Committee and informed written consent was obtained from all patients. Nine patients (mean age = 66 years; range = 53-76 years, 5 females, 4 males) with overall 13 lesions were included. Imaging was performed within two weeks before initiation of chemotherapy and at one, two, and six weeks after initiation of chemotherapy. Imaging included a respiratory-triggered diffusion-weighted sequence including three b-factors (100, 600, and 800 s/mm2). Treatment response was defined by change in tumor diameter on computed tomography (CT) after two cycles of chemotherapy. Changes in the apparent diffusion coefficient (ADC) on a per-lesion basis and the percentages of voxel with significantly increased or decreased ADCs on fDMs were analyzed using repeated measures analysis of variance (ANOVA). Changes in tumor size were used as covariate to examine the ability of ADCs and fDM parameters to predict treatment response., Results: Repeated measures ANOVA revealed that the percentage of voxels with increased ADCs on fDMs (p = 0.002) as well as the mean ADC increase (p = 0.011) were significantly higher in good responders with a large reduction in tumor size on CT., Conclusion: Our results indicate that the percentage of voxels with significantly increased ADCs on fDMs seems to be a promising biomarker for early prediction of treatment response in patients with non-small cell lung carcinoma. Contrary to averaged values, this approach allows the spatial heterogeneity of treatment response to be resolved.

Introduction: The purpose of this prospective study was to compare a 21G micropuncture needle with a regular 19G access needle for direct superficial femoral artery (SFA) access., Methods: A total of 100 consecutive patients were randomized to each group. Ultrasound-guided antegrade puncture of the SFA was performed using either a 21G or 19G needle. The time between injection of local anesthesia and flushing of the inserted sheath was measured. For hemostasis, either manual compression for 20 min or a closure device was used. All patients received an ultrasound exam 6 h after the procedure to assess the puncture site., Results: Successful access was achieved in 49 of 50 (98%) in the 21G group and 50 of 50 (100%) in the 19G group. In one patient, access with the 21G failed due to severe calcification. Access was successful after switching to the 19G needle. Immediate hemostasis was achieved in all patients. Overall, 22 complications were observed: 10 pseudoaneurysms (4 using the 21G and 6 with the 19G) and 12 hematomas (9 with the 21G and 3 with the 19G). The differences were not statistically significant (p > 0.05). Time to access was significantly faster for the 19G needle (median time 205 s; range: 94-2,160 s) compared with the 21G needle (median time 330 s; range: 93-1,140 s; p = 0.002)., Conclusions: The rate of pseudoaneurysms after SFA access was slightly lower using a 21G needle compared with a 19G needle; however, this was without statistical significance. On the other hand, there was an increase in access time and hematomas with the 21G needle.

Lemierre's syndrome is characterized by anaerobic septicemia, internal jugular vein thrombosis, and septic emboli associated with infections of the head and neck. We describe an unusual and clinically confusing case of a young woman with an acute paresis of the abducens nerve and partial paresis of the right oculomotor nerve. After an extensive imaging diagnostic procedure, we also documented a peritonsillar abscess and various types of thromboses in intracranial and extracranial veins. Furthermore, we found brain and lung abscesses, which led us to establish the diagnosis of Lemierre's syndrome. Despite intensive anti-coagulation and antibiotic therapy, the patient developed a mycotic aneurysm in the right internal carotid artery directly adjacent to the previously thrombosed cavernous sinus. In summary, we were able to confirm that Lemierre's syndrome may occur in conjunction with uncharacteristic symptoms. Due to the sometimes confusing clinical symptoms as well as clinical and radiological specialties, we had to work on an interdisciplinary basis to minimize the delay prior to establishing the diagnosis and therapy.

Mesothelioma is the most common malignant primary tumor of the pleura and usually associated with inhalation of asbestos fibers. In contrast, peritoneal mesothelioma is a rare entity whose pathomechanism is not yet fully understood. The coexistence of pleural mesothelioma with secondary involvement of the abdominal cavity has not been addressed in the literature. In this case report, we describe secondary malignant mesothelioma of the greater omentum. A 69-year-old man with histologically proven pleural mesothelioma on the right side and no past medical history of asbestos exposure received palliative treatment consisting of a talc pleurodesis. After a 6-month interval of stable disease, a local progressive tumor of the right pleura was seen on a CT scan. Eleven months later, during follow-up, the patient presented at our emergency department with a sudden onset of diffuse abdominal pain. Abdominal ultrasound revealed a mass within the greater omentum and the coexistence of free fluid. Subsequent abdominal CT scans demonstrated tumor infiltration from the right pleura by a transdiaphragmatic route into the abdomen, where diffuse infiltration of the greater omentum was observed. Aspiration of the ascites and the biopsy of the greater omentum confirmed the diagnosis of secondary malignant mesothelioma of the peritoneum. In conclusion, we present the extremely rare diagnosis of secondary malignant mesothelioma of the abdomen, which arose as a result of local progression from the right pleura into the abdomen.

Bootstrap methods have recently been introduced to diffusion-weighted magnetic resonance imaging to estimate the measurement uncertainty of ensuing diffusion parameters directly from the acquired data without the necessity to assume a noise model. These methods have been previously combined with deterministic streamline tractography algorithms to allow for the assessment of connection probabilities in the human brain. Thereby, the local noise induced disturbance in the diffusion data is accumulated additively due to the incremental progression of streamline tractography algorithms. Graph based approaches have been proposed to overcome this drawback of streamline techniques. For this reason, the bootstrap method is in the present work incorporated into a graph setup to derive a new probabilistic fiber tractography method, called BootGraph. The acquired data set is thereby converted into a weighted, undirected graph by defining a vertex in each voxel and edges between adjacent vertices. By means of the cone of uncertainty, which is derived using the wild bootstrap, a weight is thereafter assigned to each edge. Two path finding algorithms are subsequently applied to derive connection probabilities. While the first algorithm is based on the shortest path approach, the second algorithm takes all existing paths between two vertices into consideration. Tracking results are compared to an established algorithm based on the bootstrap method in combination with streamline fiber tractography and to another graph based algorithm. The BootGraph shows a very good performance in crossing situations with respect to false negatives and permits incorporating additional constraints, such as a curvature threshold. By inheriting the advantages of the bootstrap method and graph theory, the BootGraph method provides a computationally efficient and flexible probabilistic tractography setup to compute connection probability maps and virtual fiber pathways without the drawbacks of streamline tractography algorithms or the assumption of a noise distribution. Moreover, the BootGraph can be applied to common DTI data sets without further modifications and shows a high repeatability. Thus, it is very well suited for longitudinal studies and meta-studies based on DTI., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The aim of this study was to clarify whether addiction-specific neurometabolic reaction patterns occur in the insular cortex during acute nicotine withdrawal in tobacco smokers in comparison to nonsmokers. Fourteen male smokers and 10 male nonsmokers were included. Neurometabolites of the right and the left insular cortices were quantified by magnetic resonance spectroscopy (MRS) on a 3-Tesla scanner. Three separate MRS measurements were performed in each subject: among the smokers, the first measurement was done during normal smoking behavior, the second measurement during acute withdrawal (after 24 h of smoking abstinence), and the third shortly after administration of an oral nicotine substitute. Simultaneously, craving, withdrawal symptoms, and CO levels in exhaled air were determined during the three phases. The participants in the control group underwent the same MR protocol. In the smokers, during withdrawal, the insular cortex showed a significant increase in glutamine (Gln; p = 0.023) as well as a slight increase not reaching significance for glutamine/glutamate (Glx; p = 0.085) and a nonsignificant drop in myoinositol (mI; p = 0.381). These values tended to normalize after oral nicotine substitution treatment, even though differences were not significant: Gln (p = 0.225), Glx (p = 0.107) and mI (p = 0.810). Overall, the nonsmokers (control group) did not show any metabolic changes over all three phases (p > 0.05). In smokers, acute nicotine withdrawal produces a neurometabolic reaction pattern that is partly reversed by the administration of an oral nicotine substitute. The results are consistent with the expression of an addiction-specific neurometabolic shift in the brain and confirm the fact that the insular cortex seems to play a possible role in nicotine dependence., (Copyright © 2012 S. Karger AG, Basel.)

Purpose: To optimize the diagnostic accuracy of the functional diffusion map for monitoring tumor treatment response in cancer patients., Materials and Methods: Using Monte Carlo simulations, measurement precision of the apparent diffusion coefficient (ADC), and particularly accuracy of threshold determination from healthy reference tissue, are evaluated by investigating the repeatability limit of the ADC as a function of different degrees of diffusion weighting of the sequence. Phantom and in-vivo experiments are performed to verify and illustrate the results of the simulations., Results: While diagnostic accuracy of the functional diffusion map is hardly diminished by differing values of the T(2) relaxation time in tumor and reference tissue, it is shown to be impaired by differing ADCs, resulting in erroneously determined segmentation thresholds. This problem can be addressed by decreasing the maximum b-factor and increasing the number of signal averages at the maximum b-factor or, alternatively, the number of b-factors while favoring schemes with higher b-factors. Phantom experiments confirm the results of the simulations. In-vivo data are presented to illustrate the effect of sequence optimization on the diagnostic accuracy of the functional diffusion map., Conclusion: The present work demonstrates that the diagnostic accuracy of the functional diffusion map can be impaired by inaccurate segmentation thresholds and derives means for its optimization that will increase the fidelity of future clinical studies., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: To determine the precision for in vivo applications of model and non-model-based bootstrap algorithms for estimating the measurement uncertainty of diffusion parameters derived from diffusion tensor imaging data., Materials and Methods: Four different bootstrap methods were applied to diffusion datasets acquired during 10 repeated imaging sessions. Measurement uncertainty was derived in eight manually selected regions of interest and in the entire brain white matter and gray matter. The precision of the bootstrap methods was analyzed using coefficients of variation and intra-class correlation coefficients. Comprehensive simulations were performed to validate the results., Results: All bootstrap algorithms showed similar precision which slightly varied in dependence of the selected region of interest. The averaged coefficient of variation in the selected regions of interest was 13.81%, 12.35%, and 17.93% with respect to the apparent diffusion coefficient, the fractional anisotropy value, and the cone of uncertainty, respectively. The repeated measurements showed a very high similarity with intraclass-correlation coefficients larger than 0.96. The simulations confirmed most of the in vivo findings., Conclusion: All investigated bootstrap methods perform with a similar, high precision in deriving the measurement uncertainty of diffusion parameters. Thus, the time-efficient model-based bootstrap approaches should be the method of choice in clinical practice., (Copyright © 2012 Wiley Periodicals, Inc.)

The potential signal-to-noise ratio (SNR) gain at ultrahigh field strengths offers the promise of higher image resolution in single-shot diffusion-weighted echo-planar imaging the challenge being reduced T(2) and T(2) * relaxation times and increased B(0) inhomogeneity which lead to geometric distortions and image blurring. These can be addressed using parallel imaging (PI) methods for which a greater range of feasible reduction factors has been predicted at ultrahigh field strengths-the tradeoff being an associated SNR loss. Using comprehensive simulations, the SNR of high-resolution diffusion-weighted echo-planar imaging in combination with spin-echo and stimulated-echo acquisition is explored at 7 T and compared to 3 T. To this end, PI performance is simulated for coil arrays with a variable number of circular coil elements. Beyond that, simulations of the point spread function are performed to investigate the actual image resolution. When higher PI reduction factors are applied at 7 T to address increased image distortions, high-resolution imaging benefits SNR-wise only at relatively low PI reduction factors. On the contrary, it features generally higher image resolutions than at 3 T due to smaller point spread functions. The SNR simulations are confirmed by phantom experiments. Finally, high-resolution in vivo images of a healthy volunteer are presented which demonstrate the feasibility of higher PI reduction factors at 7 T in practice., (Copyright © 2011 Wiley Periodicals, Inc.)

Purpose: To prospectively investigate and monitor the response to antiandrogen treatment of bone metastases in patients with prostate cancer by using diffusion-weighted (DW) magnetic resonance (MR) imaging with the apparent diffusion coefficient (ADC) and functional diffusion maps (DMs)., Materials and Methods: This study had institutional review board approval; informed consent was obtained from all patients. Nine treatment-naive men (mean age, 73 years; range, 66-86 years) with 20 pelvic bone metastases were included. Imaging was performed before antiandrogen treatment and at 1, 2, and 3 months afterward. Imaging included a DW MR imaging sequence with five b factors (0-800 sec/mm²). Serum prostate-specific antigen (PSA) levels and mean ADCs of each metastasis were measured over time and analyzed by using the general linear model. Pairwise comparisons (paired-samples t tests) of PSA levels and ADCs before and after therapy were performed with the significance level set at P < .017 (Bonferroni correction). To determine the relationship between serum PSA level and the averaged mean ADCs in each patient, the two parameters were correlated across time. In addition, an analysis with functional DMs was performed to evaluate ADC response to treatment on a per-voxel basis., Results: Serum PSA levels decreased by more than 90% during therapy. The mean ADCs of metastases were increased significantly at 1 (P < .001), 2 (P = .002), and 3 (P = .011) months after therapy compared with pretreatment values. Heterogeneous response was revealed at functional DM analysis. After 1 month of therapy, 47.3% of all analyzed tumor voxels showed significantly increased ADCs, while 46.5% were unchanged and 6.2% exhibited decreased ADCs in comparison to the pretreatment values. At 3 months after therapy, the proportion of voxels showing ADC decrease was higher (13.7%) than that at 1 month., Conclusion: DW MR imaging allows monitoring of antiandrogen therapy in bone metastases. PSA level decrease corresponded well with an increase in mean tumor ADC. Heterogeneity of tumor response to therapy was demonstrated by functional DM analysis., (© RSNA, 2010.)

Several observations suggest that the transmission of myocardial forces is influenced in part by the spatial arrangement of the myocytes aggregated together within ventricular mass. Our aim was to assess, using diffusion tensor magnetic resonance imaging (DT-MRI), any differences in the three-dimensional arrangement of these myocytes in the normal heart compared with the hypertrophic murine myocardium. We induced ventricular hypertrophy in seven mice by infusion of angiotensin II through a subcutaneous pump, with seven other mice serving as controls. DT-MRI of explanted hearts was performed at 3.0 Tesla. We used the primary eigenvector in each voxel to determine the three-dimensional orientation of aggregated myocytes in respect to their helical angles and their transmural courses (intruding angles). Compared with controls, the hypertrophic hearts showed significant increases in myocardial mass and the outer radius of the left ventricular chamber (P < 0.05). In both groups, a significant change was noted from positive intruding angles at the base to negative angles at the ventricular apex (P < 0.01). Compared with controls, the hypertrophied hearts had significantly larger intruding angles of the aggregated myocytes, notably in the apical and basal slices (P < 0.001). In both groups, the helical angles were greatest in midventricular sections, albeit with significantly smaller angles in the mice with hypertrophied myocardium (P < 0.01). The use of DT-MRI revealed significant differences in helix and intruding angles of the myocytes in the mice with hypertrophied myocardium.

Purpose: To construct a temperature-controlled diffusion phantom with known diffusion properties and geometry in order to facilitate the comparison and optimization of diffusion sequences with the objective of increasing the precision of experimentally derived diffusion parameters., Materials and Methods: A temperature-stabilized diffusion phantom made up of two crossing strands of hydrophobic polyethylene fibers was constructed. Reproducibility and temperature dependence of several diffusion parameters was investigated and compared with computer simulations. Furthermore, in order to stimulate actual use, the precision of measurement of different diffusion-encoding schemes was compared using bootstrap analysis., Results: The measured values of the diffusion parameters are highly reproducible and feature strong temperature dependence which is reproduced in simulations, underlining the necessity of a temperature-stabilized environment for quality control. The exemplary application presented here demonstrates that the phantom allows comparing and optimizing different diffusion sequences with regard to their measurement precision., Conclusion: The present work demonstrates that the diffusion phantom facilitates and improves the comparison and quality control of diffusion sequences and the ensuing parameters. The results show that an accurate temperature control is a vital prerequisite for highly reproducible calibration measurements. As such, the phantom might provide a valuable calibration tool for clinical studies., (Copyright (c) 2009 Wiley-Liss, Inc.)

Purpose: To apply and to evaluate the newly developed advanced fast marching algorithm (aFM) in vivo by reconstructing the human visual pathway, which is characterized by areas of extensive fiber crossing and branching, i.e., the optic chiasm and the lateral geniculate nucleus (LGN)., Materials and Methods: Diffusion tensor images were acquired in 10 healthy volunteers. Due to the proximity to bony structures and air-filled spaces of the optic chiasm, a high sensitivity encoding (SENSE) reduction factor was applied to reduce image distortions in this area. To reconstruct the visual system, three different seed areas were chosen separately. The results obtained by the aFM tracking algorithm were compared and validated with known anatomy., Results: The visual system could be reconstructed reproducibly in all subjects and the reconstructed fiber pathways are in good agreement with known anatomy., Conclusion: The present work shows that the advanced aFM, which is especially designed for overcoming tracking limitations within areas of extensive fiber crossing, handles the fiber crossing and branching within the optic chiasm and the LGN correctly, thus allowing the reconstruction of the entire human visual fiber pathway, from the intraorbital segment of the optic nerves to the visual cortex., ((c) 2007 Wiley-Liss, Inc.)