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PURPOSE: The purpose of this study was to develop a spiral-based combined spin- and gradient-echo (spiral-SAGE) method for simultaneous dynamic contrast-enhanced (DCE-MRI) and dynamic susceptibility contrast MRI (DSC-MRI). METHODS: Using this sequence, we obtained gradient-echo TEs of 1.69 and 26 ms, a SE TE of 87.72 ms, with a TR of 1663 ms. Using an iterative SENSE reconstruction followed by deblurring, spiral-induced image artifacts were minimized. Healthy volunteer images are shown to demonstrate image quality using the optimized reconstruction, as well as for comparison with EPI-based SAGE. A bioreactor phantom was used to compare dynamic-contrast time courses with both spiral-SAGE and EPI-SAGE. A proof-of-concept cohort of patients with brain tumors shows the range of hemodynamic maps available using spiral-SAGE. RESULTS: Comparison of spiral-SAGE images with conventional EPI-SAGE images illustrates substantial reductions of image distortion and artifactual image intensity variations. Bioreactor phantom data show similar dynamic contrast time courses between standard EPI-SAGE and spiral-SAGE for the second and third echoes, whereas first-echo data show improvements in quantifying T(1) changes with shorter echo times. In a cohort of patients with brain tumors, spiral-SAGE-based perfusion and permeability maps are shown with comparison with the standard single-echo EPI perfusion map. CONCLUSION: Spiral-SAGE provides a substantial improvement for the assessment of perfusion and permeability by mitigating artifacts typically encountered with EPI and by providing a shorter echo time for improved characterization of permeability. Spiral-SAGE enables quantification of perfusion, permeability, and vessel architectural parameters, as demonstrated in brain tumors.

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

PURPOSE Magnetic resonance imaging (MRI) is commonly used in treatment planning for stereotactic radiosurgery (SRS) of trigeminal neuralgia (TN). With current MRI techniques, the delineation of the trigeminal nerve root entry zone (REZ) may be degraded due to poor contrast and artifacts. The purpose of this work is to develop an MRI technique with better delineation of the trigeminal nerve REZ to improve SRS treatment planning for TN. METHODS A spiral fluid-attenuated inversion recovery (FLAIR) MRI technique was developed to improve image quality by improving tissue contrast, fluid suppression, artifact reduction, and signal-to-noise ratio (SNR). A concomitant-phase compensation method based on spiral gradient waveforms was implemented to minimize artifacts due to magnetic field change induced by the metal frame used in Gamma Knife treatment planning. The image quality of spiral FLAIR was assessed in four healthy volunteers. The geometric accuracy was quantitatively evaluated by registering spiral FLAIR to computed tomography (CT) images and comparing it with existing MRI techniques. RESULTS The spiral FLAIR technique demonstrated better delineation of the trigeminal nerve REZ, improved tissue contrast of the brain stem, and minimized flow artifacts, compared to steady-state free precession (SSFP) MRI. Spiral FLAIR also improved fluid suppression, SNR, and artifacts, which contributed to better delineation of the trigeminal nerve REZ compared to conventional Cartesian FLAIR. The measured mean (± standard deviation) distance between spiral FLAIR and CT images is 0.98 ± 0.56 mm, comparable to 0.40 ± 0.26 mm in 3T T1 spoiled gradient echo (T1-SPGR), 0.59 ± 0.25 mm in 3T SSFP, 0.66 ± 0.38 mm in 1.5T T1-SPGR, and 0.61 ± 0.25 mm in 1.5T Cartesian FLAIR. CONCLUSION A spiral FLAIR technique with improved image quality and good geometric accuracy provides a potential alternative for treatment planning in SRS for TN patients.

Right atrial (RA) masses are rare, challenging to diagnose, and potentially life-threatening with high mortality if untreated. We present a patient presenting with diffuse large B-cell lymphoma in the brain that was incidentally found to have a large RA mass. For a better definition of the RA mass, extensive workup using multimodality imaging including chest computed tomography, transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance imaging, and left heart catheterization was warranted. The imaging demonstrated a large RA mass extending through the tricuspid valve into the right ventricle and superior and inferior vena cava without a mobile component. The mass was then successfully resected, and further histology examination was performed to rule out lymphoma and rare subtypes of diffuse large B-cell lymphoma. The comprehensive workup proved the RA mass to be a calcified thrombus rather than a direct metastatic spread of lymphoma.

Traumatic injuries of the brain and spinal cord are a significant source of mortality and long-term disability. A recent systematic study in a rat model of spinal cord injury (SCI) indicates severe, destructive, and very protracted inflammation as the key mechanism initiated by the massive injury involving the white matter. Although the severe inflammation is localized and counteracted by astrogliosis, it has a damaging effect on the blood vessels in the surrounding spinal cord, leading to persistent vasogenic edema. Evaluation of these injuries with imaging of the brain and spinal cord plays a crucial role in the acute trauma work-up, allowing clinicians to quickly identify abnormalities that require immediate medical or surgical intervention or to exclude them from the workup. Recently, anti-inflammatory agents have been shown to inhibit and accelerate the elimination of post-SCI inflammation in preclinical studies, and an exciting potential has arisen for the use of antiinflammatory drugs in clinical studies to achieve neuroprotection (i.e., inhibition of destruction caused by inflammation) and to inhibit vasogenic edema in SCI, traumatic brain injury, and stroke. In both subacute and chronic settings, imaging can guide therapy and provide important prognostic information. In this review, we discuss the imaging workup and evolving imaging findings of neurotrauma in the acute and chronic setting, including conventional and advanced imaging techniques. As neuroimaging is the primary mode of diagnostic analysis in neurotrauma, it is a critical component in future clinical trials evaluating neuroprotective therapies.

INTRODUCTION: We examined patient outcomes after Gamma Knife stereotactic radiosurgery (GKSRS) salvage therapy for recurrent high-grade gliomas (HGGs) to determine whether tumor grade or lesion size affected overall survival (OS) and progression-free survival (PFS). METHODS: This single-center retrospective study assessed radiographic response and clinical outcomes following GKSRS salvage treatment of recurrent malignant gliomas (January 2005–March 2014). RESULTS: A total of 121 patients (67 female) with 132 tumors were treated. Median (range) PFS was 4.7 (3.9-5.4) months for the cohort, 6.8 (4.6-8.9) months for initial grade 2 tumors, 4.2 (1.9-6.5) months for initial grade 3 tumors, and 4.3 (3.7-4.9) months for initial grade 4 tumors. Patients with small lesions (≤6.7 cm(3); n = 53) had significantly longer median (range) PFS (6.8 [4.8-8.8], P=0.02). CONCLUSIONS: GKSRS offers meaningful salvage therapy with minimal morbidity in appropriately selected patients with focally recurrent HGGs.

The pathogenesis of spinal cord injury (SCI) remains poorly understood and treatment remains limited. Emerging evidence indicates the severity of post-SCI inflammation and an ongoing controversy in the roles of astrocytes with studies identifying astrocytes as associated both with ongoing inflammation and damage as well as potentially having a protective role. We have completed an extensive systematic study with MRI, histopathology, proteomics and ELISA analyses designed to further define the severe protracted and damaging inflammation after SCI in a rat model. We have identified 3 distinct phases of SCI: acute (first 2 days), inflammatory (starting day 3) and resolution (>3 months) in 16 weeks follow up. Actively phagocytizing, CD68+/CD163- macrophages infiltrate myelin-rich necrotic areas converting them into cavities of injury (COI) when deep in the spinal cord. Alternatively, superficial SCI areas are infiltrated by granulomatous tissue, or arachnoiditis where glial cells are obliterated. In the COI, CD68+/CD163- macrophage numbers reach a maximum in the first 4 weeks and then decline. Myelin phagocytosis is present at 16 weeks indicating ongoing inflammatory damage. The COI and arachnoiditis are defined by a wall of progressively hypertrophied astrocytes. MR imaging indicates persistent spinal cord edema that is linked to the severity of inflammation. Microhemorrhages in the spinal cord around the lesion are eliminated, presumably by reactive astrocytes within the first week post-injury. Acutely increased levels of TNF-α, IL-1β, IFN-γ and other pro-inflammatory cytokines, chemokines and proteases decrease and anti-inflammatory cytokines increase in later phases. In this study we elucidated a number of fundamental mechanisms in pathogenesis of SCI and have demonstrated a close association between progressive astrogliosis and reduction in the severity of inflammation.

BACKGROUND AND PURPOSE: Coccidioides immitis is a dimorphic fungus endemic to the Southwest United States and Mexico, and at our institution, it is a relatively common pathogen presenting with a broad spectrum of associated spine diseases. We describe the various spinal manifestations resulting from coccidioidal infection and provide MR imaging examples from 41 pathologically proved cases. MATERIALS AND METHODS: Retrospective electronic medical record and PACS searches were performed. Patients found to have both MR imaging findings positive for infection and confirmative biopsy and/or CSF studies were included. Abnormal MR imaging findings were identified, categorized, and quantified. Patient demographics and associated intracranial involvement if present were also recorded. RESULTS: Forty-one patients were included. Positive findings were categorized as leptomeningeal enhancement (26 patients, 63%), arachnoiditis (22 patients, 54%), osteomyelitis-discitis (14 patients, 34%), cord edema (11 patients, 27%), and true syrinx (3 patients, 7%). Thirty patients had documented brain involvement (73%), most commonly in the form of basilar meningitis. Four patients were positive for HIV (10%). Fifteen patients had pulmonary manifestations at presentation (37%). CONCLUSIONS: C immitis results in various spinal manifestations, most commonly leptomeningeal enhancement and arachnoiditis/adhesive disease followed by osteomyelitis, which may resemble tuberculous or pyogenic infection on MR imaging.

Use of advanced imaging in the emergency department has been increasing in the United States during the past 2 decades. This trend has been most notable in CT, which has increased concern over the effects of increasing levels of medical ionizing radiation. MR imaging offers a safe, nonionizing alternative to CT and is diagnostically superior in many neurologic conditions encountered in the emergency department. Herein, we describe the process of developing and installing a dedicated MR imaging scanner in the Neuroscience Emergency Department at the Barrow Neurological Institute and its effects on neuroradiology and the emergency department in general.

Proton magnetic resonance spectroscopy (1H-MRS) has shown promise in distinguishing recurrent high-grade glioma from posttreatment radiation effect (PTRE). The purpose of this study was to establish objective 1H-MRS criteria based on metabolite peak height ratios to distinguish recurrent tumor (RT) from PTRE. A retrospective analysis of magnetic resonance imaging and 1H-MRS data was performed. Spectral metabolites analyzed included N-acetylaspartate, choline (Cho), creatine (Cr), lactate (Lac), and lipids (Lip). Quantitative 1H-MRS criteria to differentiate RT from PTRE were identified using 81 biopsy-matched spectral voxels. A receiver operating characteristic curve analysis was conducted for all metabolite ratio combinations with the pathology diagnosis as the classification variable. Forward discriminant analysis was used to identify ratio variables that maximized the correct classification of RT versus PTRE. Our results were applied to 205 records without biopsy-matched voxels to examine the percent agreement between our criteria and the radiologic diagnoses. Five ratios achieved an acceptable balance [area under the curve (AUC) ≥ 0.700] between sensitivity and specificity for distinguishing RT from PTRE, and each ratio defined a criterion for diagnosing RT. The ratios are as follows: Cho/Cr > 1.54 (sensitivity 66%, specificity 79%), Cr/Cho ≤ 0.63 (sensitivity 65%, specificity 79%), Lac/Cho ≤ 2.67 (sensitivity 85%, specificity 58%), Lac/Lip ≤ 1.64 (sensitivity 54%, specificity 95%), and Lip/Lac > 0.58 (sensitivity 56%, specificity 95%). Application of our ratio criteria in prospective studies may offer an alternative to biopsy or visual spectral pattern recognition to distinguish RT from PTRE in patients with gliomas.

Purpose Fluid-attenuated inversion recovery (FLAIR) nulls the CSF signal and is widely used in neuro MRI exams. A 3D scan can provide high SNR, contiguous coverage, and reduced sensitivity to through-plane CSF flow. In this work, a 3D spiral FLAIR technique is proposed to improve the image quality of conventional 3D Cartesian FLAIR. Methods The 3D spiral FLAIR sequence incorporated a spiral-in/out readout to preserve higher scan efficiency and eliminate off resonance-induced artifacts observed with a commonly implemented spiral-out readout, a compensation approach to minimize phase errors due to the concomitant fields accompanying the spiral gradient, and an adapted variable flip angle scheme to preserve scan efficiency and maintain a long and stable echo train. 3D Cartesian and spiral FLAIR (~6 min each) were acquired on a 3 Tesla scanner from 6 subjects (age range: 31-64 years; mean: 39.5). Two neuroradiologists rated the images in a blinded fashion on a 5-point scale. The noise performance was assessed quantitatively. Results Compared to 3D Cartesian FLAIR, 3D spiral FLAIR exhibits greater reduction of artifacts from CSF, especially anterior to the brain stem (rated better in 4 cases), artifacts attributed to blood/flow in the deep brain (better or much better in all 6 cases), and superior overall image quality (much better in 5 cases) despite residual susceptibility artifacts near the nasal cavity. Quantitative assessment demonstrates ~1.5× higher average SNR than Cartesian data. Conclusion 3D spiral FLAIR achieves higher SNR, reduced CSF, and blood/flow artifacts, providing an alternative to 3D Cartesian FLAIR for neurological exams.

BACKGROUND: MRI-based modeling of tumor cell density (TCD) can significantly improve targeted treatment of Glioblastoma (GBM). Unfortunately, interpatient variability limits the predictive ability of many modeling approaches. We present a Transfer Learning (TL) method that generates individualized patient models, grounded in the wealth of population data, while also detecting and adjusting for interpatient variabilities based on each patient’s own histologic data. METHODS: We recruited primary GBM patients undergoing image-guided biopsies and preoperative imaging including contrast-enhanced MRI (CE-MRI), Dynamic-Susceptibility-Contrast (DSC)-MRI, and Diffusion Tensor Imaging (DTI). We calculated relative cerebral blood volume (rCBV) from DSC-MRI and mean diffusivity (MD) and fractional anisotropy (FA) from DTI. Following image coregistration, we assessed TCD for each biopsy and identified corresponding localized MRI measurements. We then explored a range of univariate and multivariate predictive models of TCD based on MRI measurements in a generalized one-model-fits-all (OMFA) approach. We then implemented both univariate and multivariate individualized TL predictive models, which harness the available population level data but allow for individual variability in their predictions. Finally, we compared Pearson correlation coefficients and mean absolute error between the individualized TL versus generalized OMFA models. RESULTS: TCD significantly correlated with rCBV (r=0.33,p

Background Glioblastoma (GBM) exhibits profound intratumoral genetic heterogeneity. Each tumor comprises multiple genetically distinct clonal populations with different therapeutic sensitivities. This has implications for targeted therapy and genetically informed paradigms. Contrast-enhanced (CE)-MRI and conventional sampling techniques have failed to resolve this heterogeneity, particularly for nonenhancing tumor populations. This study explores the feasibility of using multiparametric MRI and texture analysis to characterize regional genetic heterogeneity throughout MRI-enhancing and nonenhancing tumor segments. Methods We collected multiple image-guided biopsies from primary GBM patients throughout regions of enhancement (ENH) and nonenhancing parenchyma (so called brain-around-tumor, [BAT]). For each biopsy, we analyzed DNA copy number variants for core GBM driver genes reported by The Cancer Genome Atlas. We co-registered biopsy locations with MRI and texture maps to correlate regional genetic status with spatially matched imaging measurements. We also built multivariate predictive decision-tree models for each GBM driver gene and validated accuracies using leave-one-out-cross-validation (LOOCV). Results We collected 48 biopsies (13 tumors) and identified significant imaging correlations (univariate analysis) for 6 driver genes: EGFR, PDGFRA, PTEN, CDKN2A, RB1, and TP53. Predictive model accuracies (on LOOCV) varied by driver gene of interest. Highest accuracies were observed for PDGFRA (77.1%), EGFR (75%), CDKN2A (87.5%), and RB1 (87.5%), while lowest accuracy was observed in TP53 (37.5%). Models for 4 driver genes (EGFR, RB1, CDKN2A, and PTEN) showed higher accuracy in BAT samples (n = 16) compared with those from ENH segments (n = 32). Conclusion MRI and texture analysis can help characterize regional genetic heterogeneity, which offers potential diagnostic value under the paradigm of individualized oncology.

OBJECTIVEThe authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm.METHODSIn the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist.RESULTSThere was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 178 clip-assigned patients with saccular aneurysms, 1 (< 1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow-up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time.CONCLUSIONSThere was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

Background Deep brain stimulation (DBS) is well-established, evidence-based therapy for Parkinson disease, essential tremor, and primary dystonia. Clinical outcome studies have recently shown that "asleep" DBS lead placement, performed using intraoperative imaging with stereotactic accuracy as the surgical endpoint, has motor outcomes comparable to traditional "awake" DBS using microelectrode recording (MER), but with shorter case times and improved speech fluency. Objective To identify procedural variables in DBS surgery associated with improved surgical efficiency and stereotactic accuracy. Methods Retrospective review of 323 cases with 546 leads placed (August 2011-October 2014). In 52% (n = 168) of cases, patients were asleep under general anesthesia without MER. Multivariate regression identified independent predictors of reduced surgery time and improved stereotactic accuracy. Results MER was an independent contributor to increased procedure time (+44 min; P = .03). Stereotactic accuracy was better in asleep patients. Accuracy was improved with frame-based stereotaxy at head of bed 0° vs frameless stereotaxy at head of bed 30°. Improved accuracy was also associated with shorter procedures (r = 0.17; P = .049). Vector errors were evenly distributed around the planned target for the globus pallidus internus, but directionally skewed for the subthalamic (medial-posterior) and ventral intermediate nuclei (medial-anterior). Conclusion Distinct procedural variables in DBS surgery are associated with reduced case times and improved stereotactic accuracy.

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

Purpose The three-dimensional (3D) spiral turbo spin echo (TSE) sequence is one of the preferred readout methods for arterial spin labeled (ASL) perfusion imaging. Conventional spiral TSE collects the data using a spiral-out readout on a stack of spirals trajectory. However, it may result in suboptimal image quality and is not flexible in protocol design. The goal of this study is to provide a more robust readout technique without such limitation. Methods The proposed technique incorporates a spiral-in/out readout into 3D TSE, and collects the data on a distributed spirals trajectory. The data set is split into the spiral-in and -out subsets that are reconstructed separately and combined after image deblurring. Results The volunteer results acquired with the proposed technique show no geometric distortion or signal pileup, as is present with GRASE, and no signal loss, as is seen with conventional spiral TSE. Examples also demonstrate the flexibility in changing the imaging parameters to satisfy various criteria. Conclusion The 3D TSE with a distributed spiral-in/out trajectory provides a robust readout technique and allows for easy protocol design, thus is a promising alternative to GRASE or conventional spiral TSE for ASL perfusion imaging. Magn Reson Med, 2015. © 2015 Wiley Periodicals, Inc.

Purpose To study how sensitivity encoding (SENSE) impacts periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) image quality, including signal-to-noise ratio (SNR), robustness to motion, precision of motion estimation, and image quality. Methods Five volunteers were imaged by three sets of scans. A rapid method for generating the g-factor map was proposed and validated via Monte Carlo simulations. Sensitivity maps were extrapolated to increase the area over which SENSE can be performed and therefore enhance the robustness to head motion. The precision of motion estimation of PROPELLER blades that are unfolded with these sensitivity maps was investigated. An interleaved R-factor PROPELLER sequence was used to acquire data with similar amounts of motion with and without SENSE acceleration. Two neuroradiologists independently and blindly compared 214 image pairs. Results The proposed method of g-factor calculation was similar to that provided by the Monte Carlo methods. Extrapolation and rotation of the sensitivity maps allowed for continued robustness of SENSE unfolding in the presence of motion. SENSE-widened blades improved the precision of rotation and translation estimation. PROPELLER images with a SENSE factor of 3 outperformed the traditional PROPELLER images when reconstructing the same number of blades. Conclusion SENSE not only accelerates PROPELLER but can also improve robustness and precision of head motion correction, which improves overall image quality even when SNR is lost due to acceleration. The reduction of SNR, as a penalty of acceleration, is characterized by the proposed g-factor method. Magn Reson Med, 2014. © 2014 Wiley Periodicals, Inc.

Purpose 2D turbo-spin-echo (TSE) is widely used in the clinic for neuroimaging. However, the long refocusing radiofrequency pulse train leads to high specific absorption rate (SAR) and alters the contrast compared to conventional spin-echo. The purpose of this work is to develop a robust 2D spiral TSE technique for fast T2 -weighted imaging with low SAR and improved contrast. Methods A spiral-in/out readout is incorporated into 2D TSE to fully take advantage of the acquisition efficiency of spiral sampling while avoiding potential off-resonance-related artifacts compared to a typical spiral-out readout. A double encoding strategy and a signal demodulation method are proposed to mitigate the artifacts because of the T2 -decay-induced signal variation. An adapted prescan phase correction as well as a concomitant phase compensation technique are implemented to minimize the phase errors. Results Phantom data demonstrate the efficacy of the proposed double encoding/signal demodulation, as well as the prescan phase correction and concomitant phase compensation. Volunteer data show that the proposed 2D spiral TSE achieves fast scan speed with high SNR, low SAR, and improved contrast compared to conventional Cartesian TSE. Conclusion A robust 2D spiral TSE technique is feasible and provides a potential alternative to conventional 2D Cartesian TSE for T2 -weighted neuroimaging.

Dynamic susceptibility contrast (DSC) MRI measures of brain tumor cerebral blood volume (CBV) are able to predict grade, overall survival and response to treatment. Wide-spread acceptance of DSC-MRI has been challenged by the need to balance contrast agent dose and CBV accuracy. The goal of this study was to identify and validate single-dose, BTIP compliant, DSC-MRI protocols. Using a validated, patient-based DRO, we evaluated CBV accuracy across a range of acquisition parameters (field strength, TR, TE, flip angle, multi-echo acquisitions, dosing protocols) and post-processing steps. To validate the optimal protocols, we next collected DSC-MRI data following ASFNR’s recommended “double – dose” approach, where a single-dose preload (to minimize T1 effects) is given prior to a second bolus injection (for DSC-MRI data acquisition). The single-dose DSC-MRI data was collected during the preload bolus injection. Consistency of the derived CBV data, visual agreement and data characteristics (e.g. CNR) was statistically evaluated. When using a single-dose and routine single-echo pulse sequence, the DRO analysis found that a low flip angle (LFA = 30o) and 30ms TE provided the highest CBV accuracy (concordance correlation coefficient (CCC) = 0.92) and precision (coefficient of variation (CV) = 8.2%)). For comparison, the maximum accuracy found with the DRO utilizes a double-dose injection protocol and yielded a CCC of 0.98 and CV of 6.8%. Single-dose, multi-echo acquisitions provided higher accuracy than the LFA data and matched that found with the double-dose approach. In patients (data collection ongoing), the agreement between single-dose LFA (n > 40) or multi-echo (n > 40) based CBV values and the reference double-dose approach was very high (CCC > 0.94) and were statistically equivalent. Optimized single-dose DSC-MRI protocols provide highly accurate CBV data, use lower doses of contrast agent, and simplify scan procedures, indicating their potential for robust use in clinical practice and trials.

Purpose To introduce a new algorithm for estimating data shifts (used for both rotation and translation estimates) for motion-corrected PROPELLER MRI. The method estimates shifts for all blades jointly, emphasizing blade-pair correlations that are both strong and more robust to noise. Theory and Methods The heads of three volunteers were scanned using a PROPELLER acquisition while they exhibited various amounts of motion. All data were reconstructed twice, using motion estimates from the original and new algorithm. Two radiologists independently and blindly compared 216 image pairs from these scans, ranking the left image as substantially better or worse than, slightly better or worse than, or equivalent to the right image. Results In the aggregate of 432 scores, the new method was judged substantially better than the old method 11 times, and was never judged substantially worse. Conclusion The new algorithm compared favorably with the old in its ability to estimate bulk motion in a limited study of volunteer motion. A larger study of patients is planned for future work. Magn Reson Med 72:430–437, 2014. © 2013 Wiley Periodicals, Inc.

Proton magnetic resonance spectroscopy (

As drug discovery programs search for new treatment strategies to improve the survival of patients with glioblastoma multiforme (GBM), the need for a timely and accurate end point to judge treatment efficacy has never been greater.1 Overall survival (OS) represents the benchmark measure of outcome but has clear disadvantages for clinical trial assessment. Clinical trials that use OS are lengthened because of the time needed to observe mortality,1,2 and correlations between OS and initial treatment are modified by subsequent salvage therapies.2,3 These limitations have led to the use of progression-free survival (PFS) as a surrogate marker for OS. However, PFS requires accurate estimates of tumor growth based on MRI, and such estimates are not always readily made, nor does PFS correlate well with OS.2,3 Contrast-enhanced MRI (CE-MRI) represents the best available method for measuring treatment response and predicting survival after standard first-line therapy and is used to define PFS.2–4 Currently, decisions about treatment are guided by criteria (Macdonald, RANO) that equate increasing size of CE-MRI enhancement with progressive tumor burden, treatment failure, and poor prognosis.5,6 Despite its widespread use, this approach has distinct limitations. First, CE-MRI cannot distinguish tumor growth from treatment-induced parenchymal injury, so called post-treatment radiation effect (PTRE), which exactly mimics tumor on CE-MRI. Two well documented forms of PTRE are pseudoprogression (pP) and radiation necrosis (RN). Unlike tumor, PTRE represents a positive response to treatment and, therefore, a good prognosis; however, PTRE-related enhancement underlies erroneous declaration of treatment failure in up to half of cases.7–10 In addition, tumor often coexists and variably admixes with PTRE in most patients.11 The histologic tumor fraction (i.e., tumor burden) therefore comprises a subcomponent of the total CE-MRI enhancement and represents a potentially useful predictor of survival in patients with recurrent brain tumor.12–14 In fact, studies suggest that histologically quantifying tumor burden provides more meaningful prognostic information than simply reporting the presence of tumor.12–15 Because CE-MRI cannot reliably distinguish the coexistence of PTRE and tumor burden, surgical biopsy and histologic evaluation remain the current benchmark.13 Unfortunately, surgery is not without medical risk, morbidity, and cost. These issues underscore a clear need to develop a noninvasive method to accurately estimate tumor burden as a potential alternative or adjunct to surgical biopsy. Perfusion MRI (pMRI) noninvasively detects GBM and PTRE microvascular characteristics, most commonly with the dynamic susceptibility-weighted contrast-enhanced (DSC) method. With use of pMRI, relative cerebral blood volume (rCBV) is measured on a voxel-wise basis across CE-MRI lesions, providing regionally specific estimates of tissue microvasculature and histologic identity.16–24 To date, several pMRI-based analytic methods have been proposed to estimate histologic tumor fraction, each with potential advantages and limitations. First, calculating mean rCBV across all CE-MRI lesion voxels is the easiest method but does not assess intervoxel variations that may reflect histologic heterogeneity.16,17 Second, histogram analysis contributes additional metrics, including mode, maximum, and histogram width, although these may be biased by spatial statistics.18,19 Finally, the voxel-based thresholding method applies predetermined rCBV criteria to classify individual voxels based on histologic identity, but requires that the accuracy of the threshold be prospectively validated.20,21 To date, no published studies support consensus regarding which pMRI-based analytic method best estimates histologic tumor fraction as a predictor of survival in recurrent GBM. Our hypothesis is that tumor burden and OS will correlate more strongly with those pMRI-based methods that use a voxel-based approach to assess histologic heterogeneity. We here report a study in a cohort of patients with recurrent GBM with CE-MRI evidence of tumor progression. Our goals were to (1) determine the strengths of correlation between histologic tumor fraction and previously published pMRI-based metrics (rCBV mean, mode, maximum, and histogram width) and a new voxel-based thresholding metric, called pMRI fractional tumor burden (pMRI-FTB), and (2) identify which pMRI-based metric best correlates with OS.

Diffusion-weighted imaging (DWI) has shown great benefits in clinical MR exams. However, current DWI techniques have shortcomings of sensitivity to distortion or long scan times or combinations of the two. Diffusion-weighted echo-planar imaging (EPI) is fast but suffers from severe geometric distortion. Periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted imaging (PROPELLER DWI) is free of geometric distortion, but the scan time is usually long and imposes high Specific Absorption Rate (SAR) especially at high fields. TurboPROP was proposed to accelerate the scan by combining signal from gradient echoes, but the off-resonance artifacts from gradient echoes can still degrade the image quality. In this study, a new method called X-PROP is presented. Similar to TurboPROP, it uses gradient echoes to reduce the scan time. By separating the gradient and spin echoes into individual blades and removing the off-resonance phase, the off-resonance artifacts in X-PROP are minimized. Special reconstruction processes are applied on these blades to correct for the motion artifacts. In vivo results show its advantages over EPI, PROPELLER DWI, and TurboPROP techniques.

BACKGROUND: MRI-based modeling can help characterize the intratumoral genetic heterogeneity of Glioblastoma (GBM). Yet, published models to date have neglected the potential impact of sex-differences on the accuracy of MRI-genetic correlations. Specifically, there is growing awareness that female GBM patients can display different genetic/molecular aberrations and phenotypic expression compared to male counterparts. In this exploratory study, we compare MRI signal and key GBM driver alterations across a cohort of male and female GBM patients, using image-guided biopsies and spatially matched multi-parametric MRI. METHODS: We collected 61 image-guided biopsies from 18 primary GBM patients (9/9 male/female). For each biopsy, we analyzed DNA copy number variants (CNV) for 6 core GBM driver genes reported by TCGA: amplifications (++) for EGFR and PDGFRA and deletions (--) for PTEN, CDKN2A, RB1, TP53. We compared regional CNV status with spatially matched MRI texture measurements from co-registered biopsy locations. Advanced MRI features included relative cerebral blood volume (rCBV) on DSC-perfusion, mean diffusivity (MD) and fractional anisotropy (FA) on diffusion tensor imaging. We identified univariate correlations for combined and sex-specific (male, female) subgroups. We also built multivariate predictive decision-tree models for each GBM driver gene and used leave-one-out-cross-validation (LOOCV) to determine area-under-curve (AUC) on ROC analysis to compare accuracies across combined and sex-specific models. RESULTS: We identified multiple univariate correlations between regional CNV status and spatially matched MRI texture features that were specific to either male or female GBM tumors. For instance, EGFR++ specifically correlated with T2W image textures in male biopsies but rCBV textures in female biopsies. In general, sex-specific analyses on decision-tree modeling improved predictive accuracies (AUC) compared to combined (male+female) modeling, particularly for EGFR++ (p

Split-blade diffusion-weighted periodically rotated overlapping parallel lines with enhanced reconstruction (DW-PROPELLER) was proposed to address the issues associated with diffusion-weighted echo planar imaging such as geometric distortion and difficulty in high-resolution imaging. The major drawbacks with DW-PROPELLER are its high SAR (especially at 3T) and violation of the Carr-Purcell-Meiboom-Gill condition, which leads to a long scan time and narrow blade. Parallel imaging can reduce scan time and increase blade width; however, it is very challenging to apply standard k-space-based techniques such as GeneRalized Autocalibrating Partially Parallel Acquisitions (GRAPPA) to split-blade DW-PROPELLER due to its narrow blade. In this work, a new calibration scheme is proposed for k-space-based parallel imaging method without the need of additional calibration data, which results in a wider, more stable blade. The in vivo results show that this technique is very promising.

BACKGROUND AND PURPOSE: Relative cerebral blood volume (rCBV) accuracy can vary substantially depending on the dynamic susceptibility-weighted contrast-enhanced (DSC) acquisition and postprocessing methods, due to blood-brain barrier disruption and resulting T1-weighted leakage and T2- and/or T2*-weighted imaging (T2/T2*WI) residual effects. We set out to determine optimal DSC conditions that address these errors and maximize rCBV accuracy in differentiating posttreatment radiation effect (PTRE) and tumor. MATERIALS AND METHODS: We recruited patients with previously treated high-grade gliomas undergoing image-guided re-resection of recurrent contrast-enhancing MR imaging lesions. Thirty-six surgical tissue samples were collected from 11 subjects. Preoperative 3T DSC used 6 sequential evenly timed acquisitions, each by using a 0.05-mmol/kg gadodiamide bolus. Preload dosing (PLD) and baseline subtraction (BLS) techniques corrected T1-weighted leakage and T2/T2*WI residual effects, respectively. PLD amount and incubation time increased with each sequential acquisition. Corresponding tissue specimen stereotactic locations were coregistered to DSC to measure localized rCBV under varying PLD amounts, incubation times, and the presence of BLS. rCBV thresholds were determined to maximize test accuracy (average of sensitivity and specificity) in distinguishing tumor ( n = 21) and PTRE ( n = 15) samples under the varying conditions. Receiver operator characteristic (ROC) areas under the curve (AUCs) were statistically compared. RESULTS: The protocol that combined PLD (0.1-mmol/kg amount, 6-minute incubation time) and BLS correction methods maximized test AUC (0.99) and accuracy (95.2%) compared with uncorrected rCBV AUC (0.85) and accuracy (81.0%) measured without PLD and BLS ( P = .01). CONCLUSIONS: Combining PLD and BLS correction methods for T1-weighted and T2/T2*WI errors, respectively, enables highly accurate differentiation of PTRE and tumor growth.

Suppression of the fat signal in MRI is very important for many clinical applications. Multi-point water–fat separation methods, such as IDEAL (Iterative Decomposition of water and fat with Echo Asymmetry and Least-squares estimation), can robustly separate water and fat signal, but inevitably increase scan time, making separated images more easily affected by patient motions. PROPELLER (Periodically Rotated Overlapping ParallEL Lines with Enhanced Reconstruction) and Turboprop techniques offer an effective approach to correct for motion artifacts. By combining these techniques together, we demonstrate that the new TP-IDEAL method can provide reliable water–fat separation with robust motion correction. The Turboprop sequence was modified to acquire source images, and motion correction algorithms were adjusted to assure the registration between different echo images. Theoretical calculations were performed to predict the optimal shift and spacing of the gradient echoes. Phantom images were acquired, and results were compared with regular FSE-IDEAL. Both T1- and T2-weighted images of the human brain were used to demonstrate the effectiveness of motion correction. TP-IDEAL images were also acquired for pelvis, knee, and foot, showing great potential of this technique for general clinical applications. Magn Reson Med 61:188–195, 2009. © 2008 Wiley-Liss, Inc.

Background Genetic profiling represents the future of neuro-oncology but suffers from inadequate biopsies in heterogeneous tumors like Glioblastoma (GBM). Contrast-enhanced MRI (CE-MRI) targets enhancing core (ENH) but yields adequate tumor in only ~60% of cases. Further, CE-MRI poorly localizes infiltrative tumor within surrounding non-enhancing parenchyma, or brain-around-tumor (BAT), despite the importance of characterizing this tumor segment, which universally recurs. In this study, we use multiple texture analysis and machine learning (ML) algorithms to analyze multi-parametric MRI, and produce new images indicating tumor-rich targets in GBM. Methods We recruited primary GBM patients undergoing image-guided biopsies and acquired pre-operative MRI: CE-MRI, Dynamic-Susceptibility-weighted-Contrast-enhanced-MRI, and Diffusion Tensor Imaging. Following image coregistration and region of interest placement at biopsy locations, we compared MRI metrics and regional texture with histologic diagnoses of high- vs low-tumor content (≥80% vs

Background and purposeRelative cerebral blood volume, as measured by T2*-weighted dynamic susceptibility-weighted contrast-enhanced MRI, represents the most robust and widely used perfusion MR imaging metric in neuro-oncology. Our aim was to determine whether differences in modeling implementation will impact the correction of leakage effects (from blood-brain barrier disruption) and the accuracy of relative CBV calculations as measured on T2*-weighted dynamic susceptibility-weighted contrast-enhanced MR imaging at 3T field strength.Materials and methodsThis study included 52 patients with glioma undergoing DSC MR imaging. Thirty-six patients underwent both non-preload dose- and preload dose-corrected DSC acquisitions, with 16 patients undergoing preload dose-corrected acquisitions only. For each acquisition, we generated 2 sets of relative CBV metrics by using 2 separate, widely published, FDA-approved commercial software packages: IB Neuro and nordicICE. We calculated 4 relative CBV metrics within tumor volumes: mean relative CBV, mode relative CBV, percentage of voxels with relative CBV > 1.75, and percentage of voxels with relative CBV > 1.0 (fractional tumor burden). We determined Pearson (r) and Spearman (ρ) correlations between non-preload dose- and preload dose-corrected metrics. In a subset of patients with recurrent glioblastoma (n = 25), we determined receiver operating characteristic area under the curve for fractional tumor burden accuracy to predict the tissue diagnosis of tumor recurrence versus posttreatment effect. We also determined correlations between rCBV and microvessel area from stereotactic biopsies (n = 29) in 12 patients.ResultsWith IB Neuro, relative CBV metrics correlated highly between non-preload dose- and preload dose-corrected conditions for fractional tumor burden (r = 0.96, ρ = 0.94), percentage > 1.75 (r = 0.93, ρ = 0.91), mean (r = 0.87, ρ = 0.86), and mode (r = 0.78, ρ = 0.76). These correlations dropped substantially with nordicICE. With fractional tumor burden, IB Neuro was more accurate than nordicICE in diagnosing tumor versus posttreatment effect (area under the curve = 0.85 versus 0.67) (P < .01). The highest relative CBV-microvessel area correlations required preload dose and IB Neuro (r = 0.64, ρ = 0.58, P = .001).ConclusionsDifferent implementations of perfusion MR imaging software modeling can impact the accuracy of leakage correction, relative CBV calculation, and correlations with histologic benchmarks.

Purpose: Investigate the utility of patient-specific spatial predictions of tumor cell density from a bio-mathematical model. Introduction: Glioblastomas (GBMs) are the most malignant of all primary brain tumors. While it is known there is always a non-detectable portion of the tumor, current techniques of monitoring GBM progression, imaging and initial histological assessment, are not able to reliably estimate the tumor invasion past the enhancing region on T2-Weighted (T2W) imaging. Over the last two decades, a large effort has been made to create a simple patient-specific mathematical model of gliomas. The resulting model, referred to as the Proliferation-Invasion (PI) model, is based on two key parameters, the net growth rate, ρ, and the dispersal coefficient, D. In this model, the ratio of D/ρ is related to degree of invasion and the product D*ρ, is related to the speed of growth. The intuitive understanding provided by this model has been able to provide patient-specific understanding of disease kinetics enabling prediction of outcomes following surgical resection, radiation and the development of a prognostic response metric. Previous literature utilizing this model has been based on the assumption that what is seen on the pretreatment T1-Weighted contrast-enhanced (T1Gd) and T2W, images correspond to an 80% and 16% tumor cell density threshold respectively. This assumption allows for an estimate of D/ρ from a single time point of imaging. While these values were based on extensive experience, for ethical and technical reasons, they have never been rigorously investigated histologically. Recent technological advances have made it possible for surgeons to use an MRI to guide the acquisition of tissue making it possible to know with a good degree of accuracy where on the MR image the histological specimen comes from. Methods: Model Calibration : To estimate D/ρ for each patient, we assume abnormalities on the T1Gd and T2W images correspond to an 80% and 16% tumor cell density threshold respectively. We then utilize a Bayesian calibration approach based on adaptive grid refinement while holding the velocity constant to find the most likely value of D/ρ to match the observed radial measurements. Three-Dimensional Density Maps : Given a gray/white segmentation and an estimate for D/ρ, we can build a tumor cell density prediction in the patient's anatomy using the Eikonal equations and the modified Fast Marching Method (FMM) algorithm presented by Konukoglu et al. Patient Cohort : Eighteen patients were recruited with clinically suspected GBM undergoing preoperative stereotactic MRI for surgical resection with IRB approval Barrow Neurological Institute and Mayo Clinic in Arizona. Surgical Biopsy : Pre-operative conventional MRI, including T1Gd and T2W, was utilized to guide stereotactic biopsies. An average of 5–6 tissue specimens were acquired from each tumor by using stereotactic surgical localization, following the smallest possible diameter craniotomies to minimize brain shift. Histological Analysis : 4 μm tissue sections were stained with hematoxylin and eosin (H&E) for neuropathology review. H&E slides were reviewed by a neuropathologist. The percent tumor nuclei in the field was estimated. Results and Conclusion: Our analysis showed that the intuitive ordering of diffuse to nodular tumor profiles from the PI model is consistent with the histologic data. Further, utilizing the histologic data, limitations to a universal threshold cutoff of the T2/FLAIR region are specified and a better threshold cutoff value is suggested. We hope that this paper will lead to more studies of this kind resulting in more accurate ways to predict the spatial distribution of GBM tumor cells from medical imaging. Such advances could revolutionize surgical procedures and radiation therapy and may enable additional insights into tumor kinetic differences meaningful for treatment. Citation Format: Andrea Hawkins-Daarud, Lauren DeGirolamo, Joshua Jacobs, Kamala Clark-Swanson, Jennifer M. Eschbacher, Kris A. Smith, Peter Nakaji, Leslie C. Baxter, John P. Karis, Teresa Wu, J. Ross Mitchell, Jing Li, Leland Hu, Kristin R. Swanson. Histologic evidence for a bio-mathematical model of glioblastoma invasion. [abstract]. In: Proceedings of the AACR Special Conference on Engineering and Physical Sciences in Oncology; 2016 Jun 25-28; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2017;77(2 Suppl):Abstract nr A08.

Purpose T2-weighted imaging is of great diagnostic value in neuroimaging. Three-dimensional (3D) Cartesian turbo spin echo (TSE) scans provide high signal-to-noise ratio (SNR) and contiguous slice coverage. The purpose of this preliminary work is to implement a novel 3D spiral TSE technique with image quality comparable to 2D/3D Cartesian TSE. Methods The proposed technique uses multislab 3D TSE imaging. To mitigate the slice boundary artifacts, a sliding-slab method is extended to spiral imaging. A spiral-in/out readout is adopted to minimize the artifacts that may be present with the conventional spiral-out readout. Phase errors induced by B0 eddy currents are measured and compensated to allow for the combination of the spiral-in and spiral-out images. A nonuniform slice encoding scheme is used to reduce the truncation artifacts while preserving the SNR performance. Results Preliminary results show that each of the individual measures contributes to the overall performance, and the image quality of the results obtained with the proposed technique is, in general, comparable to that of 2D or 3D Cartesian TSE. Conclusion 3D sliding-slab TSE with a spiral-in/out readout provides good-quality T2-weighted images, and, therefore, may become a promising alternative to Cartesian TSE. Magn Reson Med, 2015. © 2015 Wiley Periodicals, Inc.

The three-dimensional (3D) spiral turbo spin echo (TSE) sequence is one of the preferred readout methods for arterial spin labeled (ASL) perfusion imaging. Conventional spiral TSE collects the data using a spiral-out readout on a stack of spirals trajectory. However, it may result in suboptimal image quality and is not flexible in protocol design. The goal of this study is to provide a more robust readout technique without such limitation.The proposed technique incorporates a spiral-in/out readout into 3D TSE, and collects the data on a distributed spirals trajectory. The data set is split into the spiral-in and -out subsets that are reconstructed separately and combined after image deblurring.The volunteer results acquired with the proposed technique show no geometric distortion or signal pileup, as is present with GRASE, and no signal loss, as is seen with conventional spiral TSE. Examples also demonstrate the flexibility in changing the imaging parameters to satisfy various criteria.The 3D TSE with a distributed spiral-in/out trajectory provides a robust readout technique and allows for easy protocol design, thus is a promising alternative to GRASE or conventional spiral TSE for ASL perfusion imaging.

To study how sensitivity encoding (SENSE) impacts periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) image quality, including signal-to-noise ratio (SNR), robustness to motion, precision of motion estimation, and image quality.Five volunteers were imaged by three sets of scans. A rapid method for generating the g-factor map was proposed and validated via Monte Carlo simulations. Sensitivity maps were extrapolated to increase the area over which SENSE can be performed and therefore enhance the robustness to head motion. The precision of motion estimation of PROPELLER blades that are unfolded with these sensitivity maps was investigated. An interleaved R-factor PROPELLER sequence was used to acquire data with similar amounts of motion with and without SENSE acceleration. Two neuroradiologists independently and blindly compared 214 image pairs.The proposed method of g-factor calculation was similar to that provided by the Monte Carlo methods. Extrapolation and rotation of the sensitivity maps allowed for continued robustness of SENSE unfolding in the presence of motion. SENSE-widened blades improved the precision of rotation and translation estimation. PROPELLER images with a SENSE factor of 3 outperformed the traditional PROPELLER images when reconstructing the same number of blades.SENSE not only accelerates PROPELLER but can also improve robustness and precision of head motion correction, which improves overall image quality even when SNR is lost due to acceleration. The reduction of SNR, as a penalty of acceleration, is characterized by the proposed g-factor method.

We previously reported that patients with tremor preponderant Parkinson disease (PD) displayed upward or lateral displacement of their more tremulous finger when they pointed both their index fingers at a target and closed their eyes for 15 seconds. In this study, we examined the phenomenon in 104 PD patients: 72 patients without tremor and 32 with minimal tremor to see if the displacement is related to the disease or the tremor. Sixty-eight of the 72 patients without tremor, 94%, exhibited finger displacement suggesting the phenomenon is related to the disease. None of the 104 patients were demented: mini-mental status examination (MMSE) score 29.0 ± 0. 75. Ninety patients displayed upward displacement (56 patients) or lateral or medial displacement (34 patients). MMSE score of the 90 patients: 29.2 ± 0.74 with no score < 28. Eight patients (6 without tremor) displayed downward displacement. MMSE score of the 8 patients: 27.5 ± 0.35 with 5 having MMSE score of 27. Although not significant the results suggest that patients with downward displacement and lower MMSE score may be evolving a dementia. Upward displacement with eyes closed for 15 seconds requires an ability to "remember" the position of the finger in space and to alter tone to overcome gravity. Downward displacement implies an inability to "remember" the position of the finger in space an inability to overcome the effects of gravity. This may be more likely in patients who are evolving a dementia. Two patients, with PD-like symptoms, and specific anatomical abnormalities are also presented as they illustrate the anatomy of finger displacement.

To introduce a new algorithm for estimating data shifts (used for both rotation and translation estimates) for motion-corrected PROPELLER MRI. The method estimates shifts for all blades jointly, emphasizing blade-pair correlations that are both strong and more robust to noise.The heads of three volunteers were scanned using a PROPELLER acquisition while they exhibited various amounts of motion. All data were reconstructed twice, using motion estimates from the original and new algorithm. Two radiologists independently and blindly compared 216 image pairs from these scans, ranking the left image as substantially better or worse than, slightly better or worse than, or equivalent to the right image.In the aggregate of 432 scores, the new method was judged substantially better than the old method 11 times, and was never judged substantially worse.The new algorithm compared favorably with the old in its ability to estimate bulk motion in a limited study of volunteer motion. A larger study of patients is planned for future work.

BACKGROUND AND PURPOSE: Quantifying MVA rather than MVD provides better correlation with survival in HGG. This is attributed to a specific “glomeruloid” vascular pattern, which is better characterized by vessel area than number. Despite its prognostic value, MVA quantification is laborious and clinically impractical. The DSC-MR imaging measure of rCBV offers the advantages of speed and convenience to overcome these limitations; however, clinical use of this technique depends on establishing accurate correlations between rCBV, MVA, and MVD, particularly in the setting of heterogeneous vascular size inherent to human HGG. MATERIALS AND METHODS: We obtained preoperative 3T DSC-MR imaging in patients with HGG before stereotactic surgery. We histologically quantified MVA, MVD, and vascular size heterogeneity from CD34-stained 10-μm sections of stereotactic biopsies, and we coregistered biopsy locations with localized rCBV measurements. We statistically correlated rCBV, MVA, and MVD under conditions of high and low vascular-size heterogeneity and among tumor grades. We correlated all parameters with OS by using Cox regression. RESULTS: We analyzed 38 biopsies from 24 subjects. rCBV correlated strongly with MVA (r = 0.83, P < .0001) but weakly with MVD (r = 0.32, P = .05), due to microvessel size heterogeneity. Among samples with more homogeneous vessel size, rCBV correlation with MVD improved (r = 0.56, P = .01). OS correlated with both rCBV (P = .02) and MVA (P = .01) but not with MVD (P = .17). CONCLUSIONS: rCBV provides a reliable estimation of tumor MVA as a biomarker of glioma outcome. rCBV poorly estimates MVD in the presence of vessel size heterogeneity inherent to human HGG.

Correlation of locations of sacral insufficiency fractures is made to regions of stress depicted by finite element analysis derived from biomechanical models of patient activities.Sacral insufficiency fractures occur at consistent locations. It was postulated that sacral anatomy and sites of stress within the sacrum with routine activities in the setting of osteoporosis are foundations for determining patterns for the majority of sacral insufficiency fractures.The predominant vertical components of sacral insufficiency fractures most frequently occur bilaterally through the alar regions of the sacrum, which are the thickest and most robust appearing portions of the sacrum instead of subjacent to the central sacrum, which bears the downward force of the spine.First, the exact locations of 108 cases of sacral insufficiency fractures were catalogued and compared to sacral anatomy. Second, different routine activities were simulated by pelvic models from CT scans of the pelvis and finite element analysis. Analyses were done to correlate sites of stress with activities within the sacrum and pelvis compared to patterns of sacral insufficiency fractures from 108 cases.The sites of stress depicted by the finite element analysis walking model strongly correlated with identical locations for most sacral and pelvic insufficiency fractures. Consistent patterns of sacral insufficiency fractures emerged from the 108 cases and a biomechanical classification system is introduced. Additionally, alteration of walking mechanics and asymmetric sacral stress may alter the pattern of sacral insufficiency fractures noted with hip pathology (P = 0.002).Locations of sacral insufficiency fractures are nearly congruous with stress depicted by walking biomechanical models. Knowledge of stress locations with activities, cortical bone transmission of stress, usual fracture patterns, intensity of sacral stress with different activities, and modifiers of walking mechanics may aid medical management, interventional, or surgical efforts.

BACKGROUND AND PURPOSE: Differentiating tumor growth from posttreatment radiation effect (PTRE) remains a common problem in neuro-oncology practice. To our knowledge, useful threshold relative cerebral blood volume (rCBV) values that accurately distinguish the 2 entities do not exist. Our prospective study uses image-guided neuronavigation during surgical resection of MR imaging lesions to correlate directly specimen histopathology with localized dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging (DSC) measurements and to establish accurate rCBV threshold values, which differentiate PTRE from tumor recurrence. MATERIALS AND METHODS: Preoperative 3T gradient-echo DSC and contrast-enhanced stereotactic T1-weighted images were obtained in patients with high-grade glioma (HGG) previously treated with multimodality therapy. Intraoperative neuronavigation documented the stereotactic location of multiple tissue specimens taken randomly from the periphery of enhancing MR imaging lesions. Coregistration of DSC and stereotactic images enabled calculation of localized rCBV within the previously recorded specimen locations. All tissue specimens were histopathologically categorized as tumor or PTRE and were correlated with corresponding rCBV values. All rCBV values were T1-weighted leakage-corrected with preload contrast-bolus administration and T2/T2*-weighted leakage-corrected with baseline subtraction integration. RESULTS: Forty tissue specimens were collected from 13 subjects. The PTRE group (n = 16) rCBV values ranged from 0.21 to 0.71, tumor (n = 24) values ranged from 0.55 to 4.64, and 8.3% of tumor rCBV values fell within the PTRE group range. A threshold value of 0.71 optimized differentiation of the histopathologic groups with a sensitivity of 91.7% and a specificity of 100%. CONCLUSIONS: rCBV measurements obtained by using DSC and the protocol we have described can differentiate HGG recurrence from PTRE with a high degree of accuracy.

✓Mannitol is widely considered the hyperosmolar therapy of choice in routine neurosurgical practice for the reduction of intracranial pressure (ICP). The authors present a unique case of a patient with a large meningioma treated with mannitol, in which mannitol accumulation within the tumor and its surrounding parenchyma was shown using in vivo magnetic resonance spectroscopy (MRS). This rare appearance of mannitol on MRS was characterized by a wide-based peak at 3.8 ppm, which remained detectable several hours after the last dose. These findings provide the first in vivo evidence in support of the prevailing theory that mannitol leakage into the peritumoral edematous region may contribute to rebound increases in ICP and suggest that this phenomenon has the potential to occur in extraaxial tumors. Judicious use of mannitol in the setting of elevated ICP due to tumor may be indicated to avoid potentially deleterious side effects caused by its accumulation.

Because radiographic visualization of a pituitary microadenoma is frequently difficult, we hypothesized that microadenomas associated with Cushing's disease may be better resolved and localized via acquisition with 3-Tesla (3T) compared with standard 1.5-Tesla (1.5T) magnetic resonance imaging (MRI). Five patients (four females, one male; age range, 14 to 50 years old) with endocrine and clinical confirmation of Cushing's disease underwent 1.5T and 3T MRI and corticotropin-releasing hormone stimulation/inferior petrosal sinus sampling (IPSS) as part of their preoperative evaluation. All patients underwent a transnasal trans-sphenoidal pituitary adenomectomy. In two cases, tumor could not be localized on either 1.5T or 3T MRI on the initial radiologist's review. In two other cases, the 1.5T images delineated the tumor location, but it was more clearly defined on 3T MRI. In a fifth case, the 1.5T MRI showed a probable right-sided adenoma. However, on both 3T MRI and at surgical exploration the tumor was localized on the left side. Therefore, in three of five cases, 3T MRI either more clearly defined tumors seen on 1.5T MRI or predicted the location of tumor contrary to the 1.5T images. IPSS identified the correct side of the tumor in two patients, an incorrect location in two patients, and was indeterminate in one patient. In certain cases 3T MRI is a new tool that may ameliorate imaging difficulties associated with adrenocorticotrophic hormone-secreting pituitary adenomas. Its role in the diagnostic evaluation of Cushing's disease will be better defined with further experience.

SUMMARY: We report the imaging features of 4 cases of patients with papillary tumor of the pineal region, a tumor newly recognized in the 2007 World Health Organization “Classification of Tumors of the Nervous System.” In each case, the tumor was intrinsically hyperintense on T1-weighted images with a characteristic location in the posterior commissure or pineal region. The pathologic hallmarks of the tumor are discussed, including a possible explanation for the MR imaging characteristics in our cases.

BACKGROUND AND PURPOSE: Periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER or PROP) is an effective means of compensating for head motion during MR imaging in adults. The aim of this study was to assess the value of this novel technique in unsedated children. METHODS: PROP T2-weighted fast spin-echo (FSE) imaging (TR/TE/NEX, 4000/83/2; 50 seconds) and T2-weighted single-shot FSE (SS-FSE) imaging (19,929/92/0.5; imaging time, 25 seconds) were performed in 35 unsedated children (mean age, 4.7 years ± 4.2) who were undergoing brain MR imaging. Two observers assessed unlabelled images for motion artifact, other artifacts, visibility of pathology, and the preferred image overall. Sequences were compared by using the χ(2) test and concordant data from both observers. RESULTS: Both PROP and the SS-FSE imaging offered equal degrees of motion correction. Metallic artifacts were worse on PROP imaging, likely because of a higher receiver bandwidth (P < .001, χ(2) test). Pathology was present in 28 subjects and equally well seen on PROP and SS-FSE images. Overall, PROP was preferred, largely because of its improvements in image contrast (P < .001, χ(2) test). CONCLUSION: SS-FSE imaging and PROP provide equal motion correction, although PROP enables better assessment of the brain parenchyma.

BACKGROUND AND PURPOSE: The aim of this study was to assess the effect of zero-filled interpolation (ZIP) on measurements of the cervical arteries because its benefits on the accuracy and precision of measurements in medium-sized arteries remains unknown. METHODS: Three observers measured 36 computer-simulated vessels (2–6.8 mm) and 130 normal cervical vessels (assessed with two-dimensional time-of-flight MR angiography) from 512–, 256–, and 256–ZIP matrix source images. The accuracy and precision of measurement was assessed for each matrix by using the Student t test and F test of variance, respectively. The effect of vessel size and matrix placement on measurement error was determined by means of linear regression and the Student t test, respectively. RESULTS: No significant difference was observed between simulated measurements obtained on the 512 matrix and their true value. The 256 matrix caused overestimation of vessel diameter compared with 512 matrix (mean bias, 0.3 mm for computer-simulated vessels and 0.1 mm for normal vessels). This effect was reduced with ZIP, by a mean of 0.1 mm for both groups (P < .03). Precision was not affected by the matrix size or ZIP, and vessel size and matrix placement did not alter the measurement error. CONCLUSION: Vessel diameter is overestimated on 256-matrix MR angiographic source images. ZIP reduces this overestimation; however, the effect is small and unlikely to be clinically important.

To compare periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) multishot fast spin-echo diffusion-weighted magnetic resonance (MR) imaging with single-shot echo-planar diffusion-weighted MR imaging for image quality and visualization of acute cerebral infarction.Seventy subjects (35 men, 35 women; mean age, 55 years +/- 24 [SD]) who were suspected of having acute cerebral infarction (symptom duration, 2.8 days +/- 2.7) underwent PROPELLER and echo-planar MR imaging (b = 1,000 sec/mm(2)). Two neuroradiologists compared unlabeled images for presence of artifacts, visualization of infarction, and their preference of images. Interobserver agreement and image comparison were assessed by using the kappa statistic and the chi(2) test, respectively.PROPELLER MR imaging reduced susceptibility artifacts (n = 70 subjects), which limited visualization of temporal (echo-planar, n = 64; PROPELLER, n = 0; P.01, chi(2) test), frontal (echo-planar, n = 58; PROPELLER, n = 1; P.01), and parietal lobes (echo-planar, n = 5; PROPELLER, n = 0; P.05) and cerebellum (echo-planar, n = 36; PROPELLER, n = 0; P.01) and brainstem (echo-planar, n = 23; PROPELLER, n = 0; P.01). Acute infarction (n = 31 subjects) was better demonstrated at PROPELLER MR imaging (PROPELLER better, n = 18; echo-planar better, n = 1; PROPELLER and echo-planar equal, n = 12; P.01, chi(2) test). PROPELLER MR imaging was preferred in all (n = 70) but one case in which the lesion lay within the intersection gap (PROPELLER preferred, n = 69; echo-planar preferred, n = 1; P.01, chi(2) test).With a short increase in imaging time, PROPELLER MR imaging offers better image quality and detection of acute cerebral infarction than does echo-planar MR imaging.