Prospective comparison of MR lung perfusion and lung scintigraphy

MR Perfusion Imaging of the Lung

Lung perfusion assessment is critical for diagnosing and monitoring a variety of respiratory conditions. MRI perfusion provides a radiation-free technique, making it an ideal choice for longitudinal imaging in younger populations. This review focuses on the techniques and applications of MRI perfusion, including contrast-enhanced (CE) MRI and non-CE methods such as arterial spin labeling (ASL), fourier decomposition (FD), and hyperpolarized 129-Xenon (129-Xe) MRI. ASL leverages endogenous water protons as tracers for a non-invasive measure of lung perfusion, while FD offers simultaneous measurements of lung perfusion and ventilation, enabling the generation of ventilation/perfusion mapsHyperpolarized 129-Xe MRI emerges as a novel tool for assessing regional gas exchange in the lungs. Despite the promise of MRI perfusion techniques, challenges persist, including competition with other imaging techniques and the need for additional validation and standardization. In conditions such as cystic fibrosis and lung cancer, MRI has displayed encouraging results, whereas in diseases like chronic obstructive pulmonary disease, further validation remains necessary. In conclusion, while MRI perfusion techniques hold immense potential for a comprehensive, non-invasive assessment of lung function and perfusion, their broader clinical adoption hinges on technological advancements, collaborative research, and rigorous validation.

Molecular and functional imaging in cancer-targeted therapy: current applications and future directions

Targeted anticancer drugs block cancer cell growth by interfering with specific signaling pathways vital to carcinogenesis and tumor growth rather than harming all rapidly dividing cells as in cytotoxic chemotherapy. The Response Evaluation Criteria in Solid Tumor (RECIST) system has been used to assess tumor response to therapy via changes in the size of target lesions as measured by calipers, conventional anatomically based imaging modalities such as computed tomography (CT), and magnetic resonance imaging (MRI), and other imaging methods. However, RECIST is sometimes inaccurate in assessing the efficacy of targeted therapy drugs because of the poor correlation between tumor size and treatment-induced tumor necrosis or shrinkage. This approach might also result in delayed identification of response when the therapy does confer a reduction in tumor size. Innovative molecular imaging techniques have rapidly gained importance in the dawning era of targeted therapy as they can visualize, characterize, and quantify biological processes at the cellular, subcellular, or even molecular level rather than at the anatomical level. This review summarizes different targeted cell signaling pathways, various molecular imaging techniques, and developed probes. Moreover, the application of molecular imaging for evaluating treatment response and related clinical outcome is also systematically outlined. In the future, more attention should be paid to promoting the clinical translation of molecular imaging in evaluating the sensitivity to targeted therapy with biocompatible probes. In particular, multimodal imaging technologies incorporating advanced artificial intelligence should be developed to comprehensively and accurately assess cancer-targeted therapy, in addition to RECIST-based methods.

(1)H-MR imaging of the lungs at 3.0 T

BACKGROUND

One disadvantage of magnetic resonance imaging (MRI) is the inability to adequately image the lungs. Recent advances in hyperpolarized gas technology [e.g., helium-3 ((3)He) and xenon-129 ((129)Xe)] have changed this. However, the required technology is expensive and often needing extra physics or engineering staff. Hence there is considerable interest in developing (1)H (proton)-based MRI approaches that can be readily implemented on standard clinical systems. Thus, the purpose of this work was to compare a newly developed free breathing proton-based MR lung imaging method to that of a standard gadolinium (Gd) based perfusion approach.

METHODS

Healthy volunteers [10] were scanned using a 3-T MRI with 8 parallel receivers, and a cardiac gated fast spin echo (FSE) sequence. Acquisition was cardiac triggered, with different time delays incremented to cover the entire cardiac cycle. Image k-space was filled rectilinearly. But to reduce motion artefacts k-space was retrospectively sorted using the minimal variance algorithm (MVA), based on physiologic data recorded from both the respiratory bellows and electrocardiogram (ECG). Resorted and reconstructed FSE images were compared to contrast enhanced lung images, obtained following intravenous injection of Gd-DTPA-BMA.

RESULTS

Biphasic variation in FSE lung signal intensity was observed across the cardiac cycle with a maximal signal change following rapid cardiac ejection (between S and T waves), and following rapid isovolumetric relaxation. A difference image between systolic and diastolic states in the cardiac cycle resulted in images with improved lung contrast to noise ratio (CNR). FSE image intensity was uniform over lung parenchyma while Gd-based enhancement of spoiled gradient recalled echo (SPGR) images showed gravitational dependence.

CONCLUSIONS

Here we show how 1H-MR images of lung can be obtained during free breathing. The image contrast obtained during this approach is likely the result of flow and oxygen modulation during the cardiac cycle. This free breathing method provides lung images comparable to those obtained using Gd-enhancement. Besides having the advantage of free breathing, this approach doesn't require any Gd-contrast or suffer from methodological problems associated with perfusion (e.g., poor bolus timing). However, as gravitational differences typically observed in lung perfusion are not visible with this method it is not providing exclusive microvascular perfusion information.

Inflow-weighted pulmonary perfusion: comparison between dynamic contrast-enhanced MRI versus perfusion scintigraphy in complex pulmonary circulation

BACKGROUND

Due to the different properties of the contrast agents, the lung perfusion maps as measured by 99mTc-labeled macroaggregated albumin perfusion scintigraphy (PS) are not uncommonly discrepant from those measured by dynamic contrast-enhanced MRI (DCE-MRI) using indicator-dilution analysis in complex pulmonary circulation. Since PS offers the pre-capillary perfusion of the first-pass transit, we hypothesized that an inflow-weighted perfusion model of DCE-MRI could simulate the result by PS.

METHODS

22 patients underwent DCE-MRI at 1.5T and also PS. Relative perfusion contributed by the left lung was calculated by PS (PS(L%)), by DCE-MRI using conventional indicator dilution theory for pulmonary blood volume (PBV(L%)) and pulmonary blood flow (PBFL%) and using our proposed inflow-weighted pulmonary blood volume (PBV(iw)(L%)). For PBViw(L%), the optimal upper bound of the inflow-weighted integration range was determined by correlation coefficient analysis.

RESULTS

The time-to-peak of the normal lung parenchyma was the optimal upper bound in the inflow-weighted perfusion model. Using PSL% as a reference, PBV(L%) showed error of 49.24% to -40.37% (intraclass correlation coefficient R(I) = 0.55) and PBF(L%) had error of 34.87% to -27.76% (R(I) = 0.80). With the inflow-weighted model, PBV(iw)(L%) had much less error of 12.28% to -11.20% (R(I) = 0.98) from PS(L%).

CONCLUSIONS

The inflow-weighted DCE-MRI provides relative perfusion maps similar to that by PS. The discrepancy between conventional indicator-dilution and inflow-weighted analysis represents a mixed-flow component in which pathological flow such as shunting or collaterals might have participated.

Pulmonary arterial hypertension: an imaging review comparing MR pulmonary angiography and perfusion with multidetector CT angiography

Pulmonary hypertension (PH) is a progressive disease that leads to substantial morbidity and eventual death. Pulmonary multidetector CT angiography (MDCTA), pulmonary MR angiography (MRA) and MR-derived pulmonary perfusion (MRPP) imaging are non-invasive imaging techniques for the differential diagnosis of PH. MDCTA is considered the gold standard for the diagnosis of pulmonary embolism, one of the most common causes of PH. MRA and MRPP are promising techniques that do not require the use of ionising radiation or iodinated contrast material, and can be useful for patients for whom such material cannot be used. This review compares the imaging aspects of pulmonary MRA and 64-row MDCTA in patients with chronic thromboembolic or idiopathic PH.

Magnetic resonance imaging to assess the effect of exercise training on pulmonary perfusion and blood flow in patients with pulmonary hypertension

OBJECTIVES

To evaluate whether careful exercise training improves pulmonary perfusion and blood flow in patients with pulmonary hypertension (PH), as assessed by magnetic resonance imaging (MR).

METHODS

Twenty patients with pulmonary arterial hypertension or inoperable chronic thromboembolic PH on stable medication were randomly assigned to control (n = 10) or training groups (n = 10). Training group patients received in-hospital exercise training; patients of the sedentary control group received conventional rehabilitation. Medication remained unchanged during the study period. Changes of 6-min walking distance (6MWD), MR pulmonary flow (peak velocity) and MR perfusion (pulmonary blood volume) were assessed from baseline to week 3.

RESULTS

After 3 weeks of training, increases in mean 6MWD (P = 0.004) and mean MR flow peak velocity (P = 0.012) were significantly greater in the training group. Training group patients had significantly improved 6MWD (P = 0.008), MR flow (peak velocity -9.7 ± 8.6 cm/s, P = 0.007) and MR perfusion (pulmonary blood volume +2.2 ± 2.7 mL/100 mL, P = 0.017), whereas the control group showed no significant changes.

CONCLUSION

The study indicates that respiratory and physical exercise may improve pulmonary perfusion in patients with PH. Measurement of MR parameters of pulmonary perfusion might be an interesting new method to assess therapy effects in PH. The results of this initial study should be confirmed in a larger study group.

The role and potential of imaging in COPD

Chronic obstructive pulmonary disease is a heterogeneous condition of the lungs and body. Techniques in chest imaging and quantitative image analysis provide novel in vivo insight into the disease and potentially examine divergent responses to therapy. This article reviews the strengths and limitations of the leading imaging techniques: computed tomography, magnetic resonance imaging, positron emission tomography, and optical coherence tomography. Following an explanation of the technique, each section details some of the useful information obtained with these examinations. Future clinical care and investigation will likely include some combination of these imaging modalities and more standard assessments of disease severity.

Fast dynamic contrast-enhanced lung MR imaging using k-t BLAST: a spatiotemporal perspective

Dynamic contrast-enhanced MR imaging has long been an attractive alternative to measure pulmonary perfusion as it offers simultaneous acquisition of high-resolution anatomical images and various functional information without exposing to ionizing radiation. As higher temporal resolution in addition to simultaneous acquisition of more slices from different positions favors more precise diagnosis, rapid acquisition of multiple images during bolus contrast administration remains essential to pulmonary perfusion imaging. Nevertheless, the branching morphology together with asynchronization of contrast-enhanced pulmonary perfusion scattered among distinct blood vessels imposes difficulties to faster imaging. This work demonstrates that k-t broad-use linear acquisition speed-up technique (k-t BLAST), having substantial performance on accelerating cardiac cine imaging, can be applied to accelerate dynamic contrast-enhanced lung imaging up to a factor of 5 with errors less than 6% on five healthy subjects and less than 10% on 13 patients, respectively, in the overall signal intensity. Perfusion parameter estimates show somewhat less errors than those in overall signal intensity. Results from healthy subjects and two groups of patients with various diseases show high consistency between fully sampled datasets and their accelerated counterparts. These suggest feasibility of accelerated contrast-enhanced lung images in clinical examinations and potential of extending k-t BLAST into related applications.

Assessment of pulmonary hypertension what CT and MRI can provide

RATIONALES AND OBJECTIVES

Pulmonary hypertension (PH) is a life-threatening condition, characterized by elevated pulmonary arterial pressure, which is confirmed based on invasive right heart catheterization (RHC). Noninvasive examinations may support diagnosis of PH before proceeding to RHC and play an important role in management and treatment of the disease. Although echocardiography is considered a standard tool in diagnosis, recent advances have made computed tomography (CT) and magnetic resonance (MR) imaging promising tools, which may provide morphologic and functional information. In this article, we review image-based assessment of PH with a focus on CT and MR imaging.

CONCLUSIONS

CT may provide useful morphologic information for depicting PH and seeking for underlying diseases. With the accumulated technological advancement, CT and MRI may provide practical tools for not only morphologic but also functional assessment of patients with PH.

Pulmonary MR angiography techniques and applications

This article discusses the role of magnetic resonance angiography (MRA) in evaluating the pulmonary arterial system. For depiction of pulmonary arterial anatomy and morphology, MRA techniques are compared with CT angiography and digital subtraction x-ray angiography. Perfusion, flow, and function are emphasized, as the integrated MR examination offers a comprehensive assessment of vascular morphology and function. Advances in MR technology that improve spatial and temporal resolution and compensate for potential artifacts are reviewed as they pertain to pulmonary MRA. Current and emerging gadolinium contrast-enhanced and non-contrast-enhanced MRA techniques are discussed. The role of pulmonary MRA, clinical protocols, imaging findings, and interpretation pitfalls are reviewed for clinical indications.

Methods of Prospective Investigation of Pulmonary Embolism Diagnosis III (PIOPED III)

In this work, the methods of the Prospective Investigation of Pulmonary Embolism Diagnosis III (PIOPED III) are described in detail. PIOPED III is a multicenter collaborative investigation sponsored by the National Heart, Lung and Blood Institute. The purpose is to determine the accuracy of gadolinium-enhanced magnetic resonance angiography in combination with venous phase magnetic resonance venography for the diagnosis of acute pulmonary embolism (PE). A composite reference standard based on usual diagnostic methods for PE is used. All images will be read by 2 blinded and study-certified central readers. Patients with no PE according to the composite reference test will be randomized to undergo gadolinium-enhanced magnetic resonance angiography in combination with venous phase magnetic resonance venography. This procedure will reduce the proportion of patients with negative tests at no loss in evaluation of sensitivity and specificity.

Detectability of regional lung ventilation with flat-panel detector-based dynamic radiography

This study was performed to investigate the ability of breathing chest radiography using flat-panel detector (FPD) to quantify relative local ventilation. Dynamic chest radiographs during respiration were obtained using a modified FPD system. Imaging was performed in three different positions, ie, standing and right and left decubitus positions, to change the distribution of local ventilation. We measured the average pixel value in the local lung area. Subsequently, the interframe differences, as well as difference values between maximum inspiratory and expiratory phases, were calculated. The results were visualized as images in the form of a color display to show more or less x-ray translucency. Temporal changes and spatial distribution of the results were then compared to lung physiology. In the results, the average pixel value in each lung was associated with respiratory phase. In all positions, respiratory changes of pixel value in the lower area were greater than those in the upper area (P < 0.01), which was the same tendency as the regional differences in ventilation determined by respiratory physiology. In addition, in the decubitus position, it was observed that areas with large respiratory changes in pixel value moved up in the vertical direction during expiration, which was considered to be airway closure. In conclusion, breathing chest radiography using FPD was shown to be capable of quantifying relative ventilation in local lung area and detecting regional differences in ventilation and timing of airway closure. This method is expected to be useful as a new diagnostic imaging modality for evaluating relative local ventilation.

MR imaging of the chest: A practical approach at 1.5T

Magnetic resonance imaging (MRI) is capable of imaging infiltrative lung diseases as well as solid lung pathologies with high sensitivity. The broad use of lung MRI was limited by the long study time as well as its sensitivity to motion and susceptibility artifacts. These disadvantages were overcome by the utilisation of new techniques such as parallel imaging. This article aims to propose a standard MR imaging protocol at 1.5T and presents a spectrum of indications. The standard protocol comprises non-contrast-enhanced sequences. Following a GRE localizer (2D-FLASH), a coronal T2w single-shot half-Fourier TSE (HASTE) sequence with a high sensitivity for infiltrates and a transversal T1w 3D-GRE (VIBE) sequence with a high sensitivity for small lesions are acquired in a single breath hold. Afterwards, a coronal steady-state free precession sequence (TrueFISP) in free breathing is obtained. This sequence has a high sensitivity for central pulmonary embolism. Distinct cardiac dysfunctions as well as an impairment of the breathing mechanism are visible. The last step of the basic protocol is a transversal T2w-STIR (T2-TIRM) in a multi-breath holds technique to visualize enlarged lymph nodes as well as skeletal lesions. The in-room time is approximately 15min. The extended protocol comprises contrast-enhanced sequences (3D-GRE sequence (VIBE) after contrast media; about five additional minutes). Indications are tumorous lesions, unclear (malignant) pleural effusions and inflammatory diseases (vaskulitis). A perfusion analysis can be achieved using a 3D-GRE in shared echo-technique (TREAT) with a high temporal resolution. This protocol can be completed using a MR-angiography (3D-FLASH) with high spatial resolution. The in-room time for the complete protocol is approximately 30min.

[MRI of pulmonary perfusion]

Lung perfusion is a crucial prerequisite for effective gas exchange. Quantification of pulmonary perfusion is important for diagnostic considerations and treatment planning in various diseases of the lungs. Besides disorders of pulmonary vessels such as acute pulmonary embolism and pulmonary hypertension, these also include diseases of the respiratory tract and lung tissue as well as pulmonary tumors. This contribution presents the possibilities and technical requirements of MRI for diagnostic work-up of pulmonary perfusion.

Evaluation of pulmonary function using breathing chest radiography with a dynamic flat panel detector: primary results in pulmonary diseases

OBJECTIVES

Dynamic flat panel detectors (FPD) permit acquisition of distortion-free radiographs with a large field of view and high image quality. The present study was performed to evaluate pulmonary function using breathing chest radiography with a dynamic FPD. We report primary results of a clinical study and computer algorithm for quantifying and visualizing relative local pulmonary airflow.

MATERIALS AND METHODS

Dynamic chest radiographs of 18 subjects (1 emphysema, 2 asthma, 4 interstitial pneumonia, 1 pulmonary nodule, and 10 normal controls) were obtained during respiration using an FPD system. We measured respiratory changes in distance from the lung apex to the diaphragm (DLD) and pixel values in each lung area. Subsequently, the interframe differences (D-frame) and difference values between maximum inspiratory and expiratory phases (D-max) were calculated. D-max in each lung represents relative vital capacity (VC) and regional D-frames represent pulmonary airflow in each local area. D-frames were superimposed on dynamic chest radiographs in the form of color display (fusion images). The results obtained using our methods were compared with findings on computed tomography (CT) images and pulmonary functional test (PFT), which were examined before inclusion in the study.

RESULTS

In normal subjects, the D-frames were distributed symmetrically in both lungs throughout all respiratory phases. However, subjects with pulmonary diseases showed D-frame distribution patterns that differed from the normal pattern. In subjects with air trapping, there were some areas with D-frames near zero indicated as colorless areas on fusion images. These areas also corresponded to the areas showing air trapping on computed tomography images. In asthma, obstructive abnormality was indicated by areas continuously showing D-frame near zero in the upper lung. Patients with interstitial pneumonia commonly showed fusion images with an uneven color distribution accompanied by increased D-frames in the area identified as normal on computed tomography images. Furthermore, measurement of DLD was very effective for evaluating diaphragmatic kinetics.

CONCLUSIONS

This is a rapid and simple method for evaluation of respiratory kinetics for pulmonary diseases, which can reveal abnormalities in diaphragmatic kinetics and regional lung ventilation. Furthermore, quantification and visualization of respiratory kinetics is useful as an aid in interpreting dynamic chest radiographs.

Quantitative 3D pulmonary MR-perfusion in patients with pulmonary arterial hypertension: correlation with invasive pressure measurements

PURPOSE

Pathological changes of the peripheral pulmonary arteries induce pulmonary arterial hypertension (PAH). Aim of this study was to quantitatively assess the effect of PAH on pulmonary perfusion by 3D-MR-perfusion techniques and to compare findings to healthy controls. Furthermore, quantitative perfusion data were correlated with invasive pressure measurements.

MATERIAL AND METHODS

Five volunteers and 20 PAH patients (WHO class II or III) were examined using a 1.5T MR scanner. Measurement of pulmonary perfusion was done in an inspiratory breathhold (FLASH3D; 3.5 mm x 1.9 mm x 4mm; TA per 3D dataset 1.5s). Injection of contrast media (0.1 mmol Gd-DTPA/kg BW) and image acquisition were started simultaneously. Evaluation of 3D perfusion was done using singular value decomposition. Lung borders were outlined manually. Each lung volume was divided into three regions (anterior, middle, posterior), and the following parameters were assessed: Time-to-Peak (TTP), blood flow (PBF), blood volume (PBV), and mean transit time (MTT). In 10 patients invasive pulmonary artery pressure measurements were available and correlated to the perfusion measurements.

RESULTS

In both, controls and patients, an anterior-to-posterior gradient with higher PBF and PBV posterior was observed. In the posterior lung region, a significant difference (p<0.05) was found for TTP (12s versus 16s) and MTT (4s versus 6s) between volunteers and patients. PBF and PBV were lower in patients than in volunteers (i.e. dorsal regions: 124 versus 180 ml/100 ml/min and 10 versus 12 ml/100 ml), but the difference failed to be significant. The ratio of PBF and PBV between the posterior and the middle or ventral regions showed no difference between both groups. A moderate linear correlation between mean pulmonary arterial pressure (mPAP) and PBV (r=0.51) and MTT (r=0.56) was found.

CONCLUSION

The only measurable effect of PAH on pulmonary perfusion is a prolonging of the MTT. There is only a moderate linear correlation of invasive mPAP with PBV and MTT.

Experience in 207 Combined MRI Examinations for Acute Pulmonary Embolism and Deep Vein Thrombosis

OBJECTIVE

The purpose of this study was to prospectively assess the feasibility and quality of combined MRI examinations consisting of thoracic MRI for suspected pulmonary embolism (PE) and MR venography for deep vein thrombosis (DVT), to assess the diagnostic yield of a combined examination for detecting thromboembolism compared with each component alone, and to retrospectively assess the concordance of duplex sonography and MR venography.

SUBJECTS AND METHODS

Two hundred twenty-one consecutive patients (119 men, 102 women; mean age, 51 years; range, 31-86 years) with suspected PE were examined using a multitechnique thoracic MRI protocol (real-time MRI using true fast imaging with steady-state precession [FISP], perfusion MRI, and MR angiography) followed by stepping-table MR venography.

RESULTS

Two hundred twenty-one thoracic MRI examinations were performed. Two hundred eighteen MR venography examinations were scheduled, of which five (2.3%) were not performed for clinical or technical reasons and six were not performed after negative thoracic MRI. Among 207 combined examinations, PE was diagnosed in 76 and DVT in 78 examinations. Thirteen patients without PE showed DVT; thus, MR venography detected 17% additional cases of thromboembolism. Agreement with duplex sonography was good at the upper leg (kappa = 0.87-0.89) but moderate at the pelvis (kappa = 0.59-0.65).

CONCLUSION

A combined "one-stop-shopping" MRI approach for PE and DVT was routinely feasible and detected 17% more cases of thromboembolism compared with separate examinations. MRI may be considered a second-line technique to avoid contraindications to CT but also a primary comprehensive technique for diagnosing thromboembolism.

Accuracy and feasibility of dynamic contrast-enhanced 3D MR imaging in the assessment of lung perfusion: comparison with Tc-99 MAA perfusion scintigraphy

AIM

The aim of this study was to correlate findings of perfusion magnetic resonance imaging (MRI) and perfusion scintigraphy in cases where there was a suspicion of abnormal pulmonary vasculature, and to evaluate the usefulness of MRI in the detection of perfusion deficits of the lung.

METHODS

In all, 17 patients with suspected abnormality of the pulmonary vasculature underwent dynamic contrast-enhanced MRI. T1-weighted 3D fast-field echo pulse sequences were obtained (TR/TE 3.3/1.58 ms; flip angle 30 degrees; slice thickness 12 to 15 mm). The dynamic study was acquired in the coronal plane following administration of 0.1 mmol/kg gadopentetate dimeglumine. A total of 8 to 10 sections repeated 20 to 25 times at intervals of 1s were performed. Perfusion lung scintigraphy was carried out a maximum of 48 h before the MR examination in all cases. Two radiologists, who were blinded to the clinical data and results of other imaging methods, reviewed all coronal sections. MR perfusion images were independently assessed in terms of segmental or lobar perfusion defects in the 85 lobes of the 17 individuals, and the findings were compared with the results of scintigraphy.

RESULTS

Of the 17 patients, 8 were found to have pulmonary emboli, 2 chronic obstructive pulmonary disease with emphysema, 2 bullous emphysema, 2 Takayasu arteritis and 1 had a hypoplastic pulmonary artery. Pulmonary perfusion was completely normal in 2 cases. In 35 lobes, perfusion defects were detected using both methods, in 4 with MR alone and in 9 only with scintigraphy. There was good agreement between MRI and scintigraphy findings (kappa=0.695).

CONCLUSION

Pulmonary perfusion MRI is a new alternative to scintigraphy in the evaluation of pulmonary perfusion for various lung disorders. In addition, this technique allows measurement and quantification of pulmonary perfusion abnormalities.

Pulmonary Arterial Hypertension: Diagnosis with Fast Perfusion MR Imaging and High-Spatial-Resolution MR Angiography—Preliminary Experience

PURPOSE

To determine prospectively the accuracy of a magnetic resonance (MR) perfusion imaging and MR angiography protocol for differentiation of chronic thromboembolic pulmonary arterial hypertension (CTEPH) and primary pulmonary hypertension (PPH) by using parallel acquisition techniques.

MATERIALS AND METHODS

The study was approved by the institution's internal review board, and all patients gave written consent prior to participation. A total of 29 patients (16 women; mean age, 54 years +/- 17 [+/- standard deviation]; 13 men; mean age, 57 years +/- 15) with known pulmonary hypertension were examined with a 1.5-T MR imager. MR perfusion imaging (temporal resolution, 1.1 seconds per phase) and MR angiography (matrix, 512; voxel size, 1.0 x 0.7 x 1.6 mm) were performed with parallel acquisition techniques. Dynamic perfusion images and reformatted three-dimensional MR angiograms were analyzed for occlusive and nonocclusive changes of the pulmonary arteries, including perfusion defects, caliber irregularities, and intravascular thrombi. MR perfusion imaging results were compared with those of radionuclide perfusion scintigraphy, and MR angiography results were compared with those of digital subtraction angiography (DSA) and/or contrast material-enhanced multi-detector row computed tomography (CT). Sensitivity, specificity, and diagnostic accuracy of MR perfusion imaging and MR angiography were calculated. Receiver operator characteristic analyses were performed to compare the diagnostic value of MR angiography, MR perfusion imaging, and both modalities combined. For MR angiography and MR perfusion imaging, kappa values were used to assess interobserver agreement.

RESULTS

A correct diagnosis was made in 26 (90%) of 29 patients by using this comprehensive MR imaging protocol. Results of MR perfusion imaging demonstrated 79% agreement (ie, identical diagnosis on a per-patient basis) with those of perfusion scintigraphy, and results of MR angiography demonstrated 86% agreement with those of DSA and/or CT angiography. Interobserver agreement was good for both MR perfusion imaging and MR angiography (kappa = 0.63 and 0.70, respectively).

CONCLUSION

The combination of fast MR perfusion imaging and high-spatial-resolution MR angiography with parallel acquisition techniques enables the differentiation of PPH from CTEPH with high accuracy.

Feasibility of combining MR perfusion, angiography, and 3He ventilation imaging for evaluation of lung function in a porcine model

RATIONALE AND OBJECTIVE

To assess the feasibility of combining magnetic resonance (MR) perfusion, angiography, and 3He ventilation imaging for the evaluation of lung function in a porcine model.

MATERIALS AND METHODS

Fourteen consecutive porcine models with externally delivered pulmonary emboli and/or airway occlusions were examined with MR perfusion, angiography, and 3He ventilation imaging. Ultrafast gradient-echo sequences were used for 3D perfusion and angiographic imaging, in conjunction with the use of contrast-agent injections. 2D multiple-section 3He imaging was performed subsequently via the inhalation of hyperpolarized 3He gas. The diagnostic accuracy of MR angiography for detecting pulmonary emboli was determined by two reviewers. The diagnostic confidence for different combinations of MR techniques was rated on the basis of a 5-point grading scale (5 = definite).

RESULTS

The sensitivity, specificity, and accuracy of MR angiography for detecting pulmonary emboli were approximately 85.7%, 90.5%, and 88.1%, respectively. The interobserver agreement was very strong (k = 0.82). There was a clear tendency for confidence to increase when first perfusion and then ventilation imaging were added to the angiographic image (Wilcoxon signed ranks test, P = 0.03).

CONCLUSION

The combination of the three methods of MR perfusion, angiography, and 3H ventilation imaging may provide complementary information on abnormal lung anatomy and function.

Quantification of Pulmonary Blood Flow and Volume in Healthy Volunteers by Dynamic Contrast-Enhanced Magnetic Resonance Imaging Using a Parallel Imaging Technique

RATIONALE AND OBJECTIVES

We sought to optimize the dosage of a paramagnetic contrast medium (CM) for the quantification of pulmonary blood flow and volume by contrast-enhanced dynamic magnetic resonance imaging (MRI) using a parallel imaging technique and to prove the feasibility of the approach in healthy volunteers.

METHODS

In a phantom study, the dependency of signal increase on different concentrations of the CM gadodiamide was evaluated by means of an ultra-fast MRI sequence with a generalized autocalibrating partially parallel acquisition technique (acceleration factor = 2). Using the same sequence, measurements were performed in a healthy volunteer after administration of different CM dosages for contrast dosage optimization in vivo. Finally, perfusion measurements were performed in 16 healthy volunteers after the administration of the optimal CM dose. Signal-time curves were evaluated from the pulmonary artery and from predefined regions of the lung. Pulmonary regional blood volume (RBV) and flow (RBF) were estimated using an open 1-compartment model.

RESULTS

Phantom studies yielded a linear signal increase up to a concentration of 5.0 mmol/L gadodiamide. Results of contrast dosage optimization in vivo showed that the maximum CM dose providing a linear relationship between signal increase and CM concentration in the pulmonary artery of a healthy volunteer was approximately 0.05 mmol/kg-bw. Quantification of pulmonary blood volume and flow was reproducible in healthy volunteers, yielding mean values for the upper lung zones of 7.1 +/- 2.3 mL/100 mL for RBV and 197 +/- 97 mL/min/100 mL for RBF and for lower lung zones, 12.5 +/- 3.9 mL/100 mL for RBV and 382 +/- 111 mL/min/100 mL for RBF.

CONCLUSIONS

If an adequate amount of gadodiamide and fast MR sequences are used, quantification of pulmonary blood flow and volume is feasible.

Contrast-enhanced three-dimensional pulmonary perfusion magnetic resonance imaging: intraindividual comparison of 1.0 M gadobutrol and 0.5 M Gd-DTPA at three dose levels

RATIONALE AND OBJECTIVES

To compare 1.0 M gadobutrol and 0.5 M Gd-DTPA for contrast-enhanced three-dimensional pulmonary perfusion magnetic resonance imaging (3D MRI).

MATERIALS AND METHODS

Ten healthy volunteers (3 females; 7 males; median age, 27 years; age range, 18-31 years) were examined with contrast-enhanced dynamic 3D MRI with parallel acquisition technique (FLASH 3D; reconstruction algorithm: generalized autocalibrating partially parallel acquisitions; acceleration factor: 2; TE/TR/alpha: 0.8/1.9 milliseconds/40 degrees; FOV: 500 x 375 mm; matrix: 256 x 86; slab thickness: 180 mm; 36 partitions; voxel size: 4.4 x 2 x 5 mm; TA: 1.48 seconds). Twenty-five consecutive data sets were acquired after intravenous injection of 0.025, 0.05, and 0.1 mmol/kg body weight of gadobutrol and Gd-DTPA. Quantitative measurements of peak signal-to-noise ratios (SNR) of both lungs were performed independently by 3 readers. Bolus transit times through the lungs were assessed from signal intensity time curves.

RESULTS

The peak SNR in the lungs was comparable between gadobutrol and Gd-DTPA at all dose levels (15.7 vs. 15.5 at 0.1 mmol/kg bw; 12.9 vs. 12.5 at 0.05 mmol/kg bw; 7.6 vs. 8.9 at 0.025 mmol/kg bw). A dose of 0.1 mmol/kg achieved the highest peak SNR compared with all other dose levels (P < 0.05). A higher peak SNR was observed in gravity dependent lung (P < 0.05). Despite different injection volumes, transit times of the contrast bolus did not differ between both agents.

CONCLUSION

Higher concentrated gadolinium chelates offer no advantage over standard 0.5 M Gd-DTPA for contrast-enhanced 3D MRI of lung perfusion.

3D pulmonary perfusion MRI and MR angiography of pulmonary embolism in pigs after a single injection of a blood pool MR contrast agent

The purpose of this study was to assess the feasibility of contrast-enhanced 3D perfusion MRI and MR angiography (MRA) of pulmonary embolism (PE) in pigs using a single injection of the blood pool contrast Gadomer. PE was induced in five domestic pigs by injection of autologous blood thrombi. Contrast-enhanced first-pass 3D perfusion MRI (TE/TR/FA: 1.0 ms/2.2 ms/40 degrees; voxel size: 1.3 x 2.5 x 4.0 mm3; TA: 1.8 s per data set) and high-resolution 3D MRA (TE/TR/FA: 1.4 ms/3.4 ms/40 degrees; voxel size: 0.8 x 1.0 x 1.6 mm3) was performed during and after a single injection of 0.1 mmol/kg body weight of Gadomer. Image data were compared to pre-embolism Gd-DTPA-enhanced MRI and post-embolism thin-section multislice CT (n = 2). SNR measurements were performed in the pulmonary arteries and lung. One animal died after induction of PE. In all other animals, perfusion MRI and MRA could be acquired after a single injection of Gadomer. At perfusion MRI, PE could be detected by typical wedge-shaped perfusion defects. While the visualization of central PE at MRA correlated well with the CT, peripheral PE were only visualized by CT. Gadomer achieved a higher peak SNR of the lungs compared to Gd-DTPA (21 +/- 8 vs. 13 +/- 3). Contrast-enhanced 3D perfusion MRI and MRA of PE can be combined using a single injection of the blood pool contrast agent Gadomer.

Gadolinium-enhanced magnetic resonance angiography for detection of acute pulmonary embolism: an in-depth review

STUDY OBJECTIVE

To review the published experience with gadolinium-enhanced magnetic resonance angiography (MRA) for the detection of acute pulmonary embolism (PE) in order to test the hypothesis that gadolinium-enhanced MRA may be potentially sensitive and specific enough to include it among diagnostic alternatives in the evaluation of patients with suspected PE.

METHODS

Studies were identified by searching MEDLINE for trials that used gadolinium-enhanced MRA to diagnose acute PE based on the visualization of an intraluminal filling defect or a cutoff vessel, using pulmonary angiography as a reference standard.

RESULTS

Twenty-eight investigations were identified in which MRA was used to diagnose PE. Only three studies, however, met the criteria for inclusion in the analysis. In these three case series, the sensitivity of gadolinium-enhanced MRA ranged from 77 to 100%, and the specificity ranged from 95 to 98%.

CONCLUSION

Gadolinium-enhanced MRA may be a useful diagnostic alternative in some patients with suspected acute PE, particularly if they have an elevated creatinine level, have an allergy to radiographic contrast material, or should, if possible, avoid exposure to ionizing radiation.

Comparison of arterial spin labeling and first-pass dynamic contrast-enhanced MR imaging in the assessment of pulmonary perfusion in humans: The inflow spin-tracer saturation effect

The flow-sensitive alternating inversion recovery (FAIR) and the first-pass dynamic contrast-enhanced MR imaging (CE-MRI) techniques have both been shown to be effective in the assessment of human pulmonary perfusion. However, no comprehensive comparison of the measurements by these two methods has been reported. In this study, healthy adults were recruited, with FAIR and CE-MRI performed for an estimation of the relative pulmonary blood flow (rPBF). Regions of interest were encircled from the right and left lungs, with right-to-left rPBF ratios calculated. Results indicated that, on posterior coronal slices, the rPBF ratios obtained with the FAIR technique agreed well with CE-MRI measurements (mean difference = -0.02, intraclass correlation coefficient RI = 0.78, 95% confidence interval = [0.67, 0.86]). On middle coronal slices, however, FAIR showed a substantially lower rPBF by up to 43% in the right lung compared with CE-MRI (mean difference = -0.38, RI = 0.34, 95% confidence interval = [-0.09, 0.68]). The location-dependent discrepancy between measurements by FAIR and CE-MRI methods is attributed to tracer saturation effects of arterial inflow when the middle coronal slice contains the in-plane-oriented right pulmonary artery, whereas the left lung rPBF is less affected due to oblique orientation of the left pulmonary artery. Intrasequence comparison on additional subjects using FAIR at different slice orientations supported the above hypothesis. It is concluded that FAIR imaging for pulmonary perfusion in the coronal plane provides equivalent rPBF information with CE-MRI only in the absence of tracer saturation effects; hence, FAIR should be carefully exercised to avoid misleading interpretations.

Assessment of lung perfusion impairment in patients with pulmonary artery-occlusive and chronic obstructive pulmonary diseases with noncontrast electrocardiogram-gated fast-spin-echo perfusion MR imaging

PURPOSE

To evaluate the ability of noncontrast electrocardiogram (ECG)-gated fast-spin-echo (FSE) perfusion MR images for defining regional lung perfusion impairment, as compared with technetium (Tc)-99m macroaggregated albumin (MAA) single-photon emission computed tomography (SPECT) images.

MATERIALS AND METHODS

After acquisition of ECG-gated multiphase FSE MR images during cardiac cycles at selected lung levels in nine healthy volunteers, 11 patients with pulmonary artery-occlusive diseases, and 15 patients with chronic obstructive pulmonary diseases (COPD), the subtracted perfusion-weighted (PW) MR images were obtained from the two-phase images of the minimum lung signal intensity (SI) during systole and the maximum SI during diastole, and were compared with SPECT images.

RESULTS

ECG-gated PW images showed uniform but posture-dependent perfusion gradient in normal lungs and visualized the various sizes of perfusion defects in affected lungs. These defect sites were nearly consistent with those on SPECT images, with a significant correlation for the affected-to-unaffected perfusion contrast (r = 0.753; P < 0.0001). These MR images revealed that the pulmonary arterial blood flow in the affected areas of COPD was relatively preserved as compared with pulmonary artery-occlusive diseases, and also showed significant decrease in blood flow, even in the areas with homogeneous perfusion on SPECT images in patients with focal pulmonary emphysema.

CONCLUSION

This noninvasive MR technique allows qualitative and quantitative assessment of lung perfusion, and may better characterize regional perfusion impairment in pulmonary artery-occlusive diseases and COPD.

Comparison of contrast-enhanced ct angiography and gadolinium-enhanced MR angiography in the detection of subsegmental-sized pulmonary embolism. An experimental study in a pig model

PURPOSE

To compare contrast-enhanced CT angiography (CTA) and gadolinium-enhanced MR angiography (MRA) for the detection of subsegmental-sized pulmonary emboli in a pig model.

MATERIAL AND METHODS

In 5 anesthetized pigs, 3-mm diameter embolic materials made of Konjac, a semisolid food, were introduced through the internal jugular vein into pulmonary arteries. After embolization, CTA and MRA images were obtained. Respiration was suspended during CTA and MRA image acquisition. Two readers reviewed the CTA and MRA images to detect emboli. The pigs were sacrificed, and sliced specimens of inflated lung served as the gold standard.

RESULTS

Thirty-six emboli were detected within peripheral arteries. The sensitivity (and 95% confidence intervals) of CTA for the two readers were 57% (39-74%) and 66% (48-81%), and 88% (69-98%) and 92% (74-94%) for MRA. The specificity of CTA was 95% (91-97%) and 98% (96-99%), and that of MRA was 85% (74-93%) and 90% (80-96%). Interobserver agreement was higher for MRA (kappa 0.898) than CTA (kappa 0.574).

CONCLUSION

For the detection of subsegmental pulmonary emboli, MRA was superior to CTA, with a higher sensitivity and interobserver agreement by demonstrating perfusion deficits.

Recent advances in magnetic resonance perfusion imaging of the lung

Magnetic resonance imaging has been relatively underused for clinical application in the lung; however, developments in magnetic resonance perfusion imaging using contrast agents and spin labeling techniques have shown significant potential for clinical application in lung perfusion. This article reviews the recent publications on magnetic resonance pulmonary perfusion.

Assessment of pulmonary perfusion with ultrafast projection magnetic resonance angiography in comparison with lung perfusion scintigraphy in patients with malignant stenosis

RATIONALE AND OBJECTIVE

The aim of this study was to demonstrate and measure perfusion deficits caused by central bronchogenic carcinoma and to compare magnetic resonance angiography (MRA) perfusion data with data of perfusion scintigraphy. The diagnostic value of 2D MRA in detection of malignant pulmonary artery stenosis in comparison with conventional DSA was investigated.

MATERIALS AND METHODS

Eighteen patients were included in the study. MRA, conventional pulmonary angiograms, and pulmonary perfusion scintigrams were performed. MRA and DSA were compared and MR pulmonary perfusion data were assessed and compared with scintigraphical data.

RESULTS

Perfusion defect could be demonstrated and localized in all patients. A quantitative perfusion deficit and a side dependent perfusion ratio could be evaluated. There was statistically significant correlation between MR perfusion and scintigraphically acquired data. 2D MRA showed a high correlation for detection and grading of stenosis compared with angiograms.

CONCLUSIONS

Pulmonary perfusion could be demonstrated by using an ultrafast 2D projection MR DSA sequence. This technique allows measurement and quantification of pulmonary perfusion abnormalities in patients with malignant stenosis with statistically significant correlation to perfusion scintigraphy. The diagnostic potency in the evaluation of malignant pulmonary artery stenosis compared with conventional DSA could be shown.

Potential of noncontrast electrocardiogram-gated half-fourier fast-spin-echo magnetic resonance imaging to monitor dynamically altered perfusion in regional lung

RATIONALE AND OBJECTIVES

The potential of a noncontrast, electrocardiography (ECG)-gated fast-spin-echo (FSE) MR imaging (MRI) to monitor dynamically altered regional lung perfusion was assessed in acute and temporal pulmonary embolic and airway obstruction dog models.

MATERIALS AND METHODS

After acquisition of ECG-gated multiphase FSE MR images during one cardiac cycle, the two phase images of the minimal lung signal intensity (SI) during systole and the maximal SI during diastole were acquired in the lower lung levels in six normal dogs, in 13 dogs before and for 35 minutes after temporal microvascular embolization in regional lungs with gradually degradable starch microspheres of spherex, and in 12 dogs before and for 45 minutes after bronchial occlusion with a balloon catheter. In three of the 13 embolic models, the opposite lung areas, however, were permanently embolized with enbucrilate. Subtraction between the diastolic and systolic images yielded a perfusion-weighted image. The results were compared with a gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA)-enhanced dynamic perfusion MRI, which was subsequently performed after the ECG-gated MRI in each animal.

RESULTS

The multiphase FSE images provided cardiac-dependent pulsatile lung SI changes, and the subtracted perfusion-weighted images provided a uniform perfusion map in normal lungs. In all the embolic models, the subtracted perfusion-weighted images showed gradual disappearance of the spherex-induced perfusion deficits, while the enbucrilate-induced perfusion deficits persistently remained in the three animals. In all airway obstruction models, these images showed gradually decreased perfusion in the hypoventilated areas. These results were consistent with the matched Gd-DTPA-enhanced pulmonary arterial perfusion phase images in each animal.

CONCLUSION

This noncontrast perfusion MRI may have excellent potential for continuously monitoring dynamically changed regional lung perfusion within a short time on its high spatial resolution cross-sectional images.

Cardiovascular MR imaging: technique optimization and detection of disease in clinical practice

Magnetic resonance (MR) imaging has emerged as an important and growing means of cardiovascular imaging, with many advantages over other radiologic modalities, including excellent spatial and temporal resolution, lack of ionizing radiation, and noninvasiveness. In this article, the utility of MR imaging in cardiovascular imaging and in the diagnosis of cardiovascular disease will be discussed. MR techniques for evaluating the heart and vasculature will be described, and troubleshooting techniques will be presented. Imaging findings in congenital anomalies such as septal defects, patent ductus arteriosus, transposition of the great arteries, and tetralogy of Fallot will be identified. Valvular lesions and methods for evaluating valvular function will be discussed. MR imaging findings in acquired disorders such as aneurysms and pericardial disease will be described.

Quantification of regional pulmonary flow with 9mTc-MAA SPECT and cine phase contrast MR imaging

The purpose of this study was to evaluate the relationship between left and right pulmonary arterial flow measured by cine phase contrast magnetic resonance imaging (cine PCMRI) and the distribution of perfusion on 99mTc-MAA SPECT and to determine whether the regional pulmonary flow quantification was feasible with the combined use of these techniques. Twenty patients with different pulmonary diseases were evaluated. Left and right lung counts on 99mTc-MAA SPECT images were separately summed and the left-to-total count ratio was calculated. The left-to-total pulmonary flow ratio was calculated from the left and right main pulmonary flows measured with cine PCMRI. We evaluated the correlation and agreement between the ratio determined with 99mTc-MAA SPECT and cine PCMRI by linear regression analysis and Bland-Altman analysis. The left-to-total ratios obtained by 99mTc-MAA and cine PCMRI were 52.0 +/- 22.1% and 52.2 +/- 20.8%, respectively, and showed a strong correlation (r = 0.99, p < 0.001). The mean difference between the two methods in the ratio was 0.25 +/- 2.3% with a 95% confidence interval from -0.84 to 1.34. The results showed that the regional pulmonary flow was calculated with both the left and right pulmonary flow measured with cine PCMRI and the ratio of regional distribution on 99Tc-MAA SPECT images.

CT and MR in pulmonary embolism: A changing role for nuclear medicine in diagnostic strategy

The goal of this article is to summarize current data on computed tomography (CT) and magnetic resonance (MR) in the diagnosis of acute pulmonary embolism (PE) in relation to the radionuclide ventilation perfusion scan. It is important for the nuclear medicine, CT, and MR communities to develop a shared approach to this disorder. Triage using chest radiographs appears to be a practical method for enhancing both nuclear medicine and CT/MR performance. The realization that there is no clinically available gold standard for the diagnosis of PE suggests that the imaging community should replace impractical and idealistic discussions with more realistic outcome-oriented approaches. A simplified one-step evaluation of the pulmonary arteries and the lower extremity veins for deep venous thrombus can provide a comprehensive examination for PE. CT is currently a more practical diagnostic tool, whereas MR offers a scientific probe for pulmonary physiology including the regional mapping of ventilation-perfusion relationships. Nuclear medicine, CT, and MR thus form an imaging triad for the diagnosis of acute PE.

Prediction of postoperative pulmonary function using perfusion magnetic resonance imaging of the lung

PURPOSE

To assess semiquantitatively the regional distribution of lung perfusion using magnetic resonance (MR) perfusion imaging.

MATERIALS AND METHODS

Subjects were 20 consecutive patients with bronchogenic carcinoma, who underwent MR imaging (MRI) and radionuclide (RN) perfusion scans for preoperative evaluation. Three-dimensional (3D) images of whole lungs were obtained before and 7 seconds after bolus injection of contrast material (5 ml of Gd-DTPA). Subtraction images were constructed from these dynamic images. Lung areas enhanced with the contrast material were measured and multiplied by changes in signal intensity, summed for the whole lung, and the right-to-left lung ratios were calculated. The predicted postoperative forced expiratory volume in 1 second (FEV1) was estimated using MR and RN perfusion ratios.

RESULTS

The correlation between perfusion ratios derived from the MR and RN studies was excellent (r = 0.92). Sixteen of 20 patients underwent surgery, and 12 patients had postoperative pulmonary function tests. The predicted FEV1 derived from the MR perfusion ratio correlated well with the postoperative FEV1 in the 12 patients (r = 0.68).

CONCLUSION

Perfusion MRI is suitable for semiquantitative evaluation of regional pulmonary perfusion.

Lung perfusion impairments in pulmonary embolic and airway obstruction with noncontrast MR imaging

A noncontrast electrocardiography (ECG)-gated, fast-spin-echo magnetic resonance imaging was applied to noninvasively define perfusion impairments in pulmonary embolic and airway obstruction dog models. Two-phase ECG-gated lung images of the minimal lung signal intensity during systole and maximal signal intensity during diastole were acquired by using optimized R-wave triggering delay times in seven dogs anesthetized with pentobarbital sodium before, soon after, and 2 mo after embolization with enbucrilate and in another eight dogs before and after bronchial occlusion with balloon catheters, in combination with a gadolinium diethylenetriaminepentaacetic acid-enhanced dynamic study. An ECG-gated subtraction image between the two-phase lung images provided a uniform but gravity-dependent perfusion map in normal lungs. Furthermore, it defined all 13 variable-size perfusion deficits associated with pulmonary embolism and the dynamically decreased perfusion with time after bronchial occlusion in all the airway obstruction models. These results were consistent with contrast-enhanced pulmonary arterial perfusion phase images. This noncontrast imaging could be equivalent to a contrast-enhanced dynamic study in the definition of regionally impaired pulmonary arterial perfusion in pulmonary embolism and airway obstruction.

Perfusion abnormalities in pulmonary embolism studied with perfusion MRI and ventilation-perfusion scintigraphy: an intra-modality and inter-modality agreement study

PURPOSE

To compare perfusion magnetic resonance imaging (MRI) and ventilation-perfusion scintigraphy (V-P scan) in the study of perfusion abnormalities in pulmonary embolism (PE) and to compare the PE results to the findings previously reported for pneumonia and chronic obstructive pulmonary disease (COPD), in terms of perfusion abnormalities.

MATERIALS AND METHODS

Dynamic contrast-enhanced MR images and V-P scans of 20 patients with PE, 11 patients with acute pneumonia, and 13 patients with exacerbation of COPD were studied. Five categories of perfusion abnormalities within each imaging modality were defined. Intra- and inter-modality agreement (kappa values) in the evaluation of perfusion abnormalities were calculated, based on the two observers of each imaging modality (all blinded to each other and true diagnosis). Finally, three categories of perfusion MRI diagnosis (PE, pneumonia, and COPD) were also defined and the inter-observer agreement (kappa value) was calculated.

RESULTS

For PE, the intra-modality agreement (kappa value) in the evaluation of perfusion abnormalities was 0.77 for MRI and 0.65 for V-P scan. The inter-modality agreement varied from 0.52 to 0.57, respectively, and was observer-dependent. For the pooled group of PE, pneumonia, and COPD, the intra-modality agreement of perfusion abnormalities was 0.76 for MRI and 0.65 for V-P scan, and the inter-modality agreement varied from 0.51 to 0.56. The kappa value for inter-observer agreement for MRI diagnosis was 0.92.

CONCLUSION

Evaluation of perfusion abnormalities in PE, pneumonia, and COPD using perfusion MRI and V-P scan showed a high intra-modality agreement that was higher than the inter-modality agreement. Further studies are now needed in patients presenting with possible PE to evaluate the sensitivity and specificity of the method.

Combined MR proton lung perfusion/angiography and helium ventilation: potential for detecting pulmonary emboli and ventilation defects

Three-dimensional (3D) perfusion imaging allows the assessment of pulmonary blood flow in parenchyma and main pulmonary arteries simultaneously. MRI using laser-polarized (3)He gas clearly shows the ventilation distribution with high signal-to-noise ratio (SNR). In this report, the feasibility of combined lung MR angiography, perfusion, and ventilation imaging is demonstrated in a porcine model. Ultrafast gradient-echo sequences have been used for 3D perfusion and angiographic imaging, in conjunction with the use of contrast agent injections. 2D multiple-section (3)He imaging was performed subsequently by inhalation of 450 ml of hyperpolarized (3)He gas. The MR techniques were examined in a series of porcine models with externally delivered pulmonary emboli and/or airway occlusions. With emboli, perfusion deficits without ventilation defects were observed; airway occlusion resulted in matched deficits in perfusion and ventilation. High-resolution MR angiography can unambiguously reveal the location and size of the blood emboli. The combination of the three imaging methods may provide complementary information on abnormal lung anatomy and function.

Pulmonary diffusing capacity: assessment with oxygen-enhanced lung MR imaging preliminary findings

PURPOSE

To determine differences in the signal intensity (SI) time courses at oxygen-enhanced magnetic resonance (MR) lung imaging in healthy volunteers and patients with pulmonary diseases and to correlate these differences with pulmonary diffusing capacity.

MATERIALS AND METHODS

Seventeen patients with pulmonary diseases and 11 healthy volunteers underwent oxygen-enhanced MR imaging while they breathed room air and 100% oxygen. A turbo spin-echo sequence with global or section-selective inversion pulses was used. For postprocessing, SI slope maps during the breathing of 100% oxygen were calculated. Mean SI slope and SI change values were compared with the diffusing capacity of the lung for carbon monoxide (DLCO).

RESULTS

The SI slopes were significantly different for patients and volunteers (P < or = .05, Mann-Whitney U test). Linear correlations were detected between the DLCO and SI slopes for the section-selective inversion pulse (r(2) = 0.81) and the global inversion pulse (r(2) = 0.74). A lower correlation was associated with the SI change for the section-selective pulse (r(2) = 0.04; global pulse, r(2) = 0.81). Regional differences were seen in the SI slope and SI change maps. These differences correlated with findings on radiographs and computed tomographic scans.

CONCLUSION

The SI slope during the breathing of 100% oxygen allows spatially resolved assessment of the pulmonary diffusion capacity.

Effect of the rate of gadolinium injection on magnetic resonance pulmonary perfusion imaging

PURPOSE

To determine whether the injection rate of contrast agent affects the dynamics of enhancement of the pulmonary parenchyma on magnetic resonance (MR) pulmonary perfusion imaging.

MATERIALS AND METHODS

Fifteen healthy volunteers underwent enhanced MR pulmonary perfusion imaging to evaluate the effects of different injection rates. Injection rates were 1, 3, or 5 mL/second. Regions of interest (ROIs) were chosen in the lung and aorta to analyze the change in signal intensity over time.

RESULTS

As the injection rate increased, the peak enhancement occurred significantly earlier (P = 0.0012), but the peak enhancement signal-to-noise ratio (SNR) value was not affected (P = 0.25). With the 3- and 5-mL/second injection rates, images of both the pulmonary circulation and systemic circulation were obtained separately. However, with 1 mL/second, higher enhancement of the aorta was overlapped with peak enhancement of the lung tissue.

CONCLUSION

The injection rate affects the enhancement profiles of the pulmonary parenchyma.

Newer diagnostic modalities for pulmonary embolism. Pulmonary angiography using CT and MR imaging compared with conventional angiography

CTPA is a highly sensitive and excellent primary method for evaluating patients with symptoms of PE. Ongoing studies will demonstrate the good clinical outcome of patients with negative CTPA results. The ability to visualize the lung parenchyma in addition to the pulmonary vasculature, and the smaller number of nondiagnostic scans, make CT more cost effective than V/Q scans, and CT therefore should be used as a first-line evaluation. MR imaging is a continually developing modality with more imaging options that could make it an invaluable or adjunctive test in the near future.

Detectability of pulmonary perfusion defect and influence of breath holding on contrast-enhanced thick-slice 2D and on 3D MR pulmonary perfusion images

The present study assesses the detectability of perfusion defect and the influence of breathhold on pulmonary magnetic resonance (MR) perfusion imaging using contrast-enhanced thick-slice two-dimensional (2D) fast gradient-echo sequence compared with three-dimensional (3D) fast spoiled gradient-recalled sequence. Dynamic studies were performed in 16 patients. MR perfusion images were interpreted by two independent observers using perfusion scintigraphy as the reference standard. The patients were divided into two groups according to the duration of holding the breath measured during MR imaging. The sensitivity and specificity of 2D MR perfusion imaging in detecting perfusion defects were 93% and 94%, respectively, while those of 3D MR perfusion imaging were 89% and 85%, respectively. The diagnostic accuracy of 2D MR perfusion imaging was significantly higher than that of 3D MR perfusion imaging (P < 0.05) among those who could not hold their breath. Therefore, 2D MR perfusion imaging offers promise for evaluating pulmonary perfusion even among patients who cannot hold their breath.

Potential of Gd-DTPA-mannan liposome particles as a pulmonary perfusion MRI contrast agent: an initial animal study

Suga K, Mikawa M, Ogasawara N, et al. Potential of Gd-DTPA-mannan liposome particles as a pulmonary perfusion MRI contrast agent: An initial animal study. Invest Radiol 2001;36:136-145.

RATIONALE AND OBJECTIVES

A paramagnetic, particle-type MR contrast agent, (Gd-diethylenetriamine pentaacetic acid [DTPA]-mannan-cholesterol)-coated liposomes, was designed to localize in the lung by the mechanism of capillary blockade, and the potential of this agent for pulmonary perfusion MRI was experimentally investigated.

METHODS

Before and up to 60 minutes after slow injection of this contrast agent, MR images were sequentially acquired at 10-second intervals along the same transaxial plane of the lung by using a gradient-echo pulse sequence with a short echo time of 1.2 ms on a 1.5-T MR scanner. After the minimal dose for obtaining a sufficient lung enhancement effect was determined in five rabbits, the time course of the enhancement effect was evaluated in six dogs by arterial blood gas analysis. The efficacy of MRI for detecting perfusion defects was evaluated in seven other dogs with pulmonary embolism.

RESULTS

Normal lungs were dose-dependently enhanced by this agent, and with a 2.0 mL/kg dose, dependent lungs were enhanced by more than 201%, with an average half-life of the enhancement effect of 35.7 +/- 5.3 minutes. With less than this dose (1.0-1.5 mL/kg), all of the embolized lung portions were clearly identified as perfusion defects. The prolonged enhancement effect allowed the acquisition of subsequent multisectional lung images, thus facilitating the assessment of anatomic location and extent of the perfusion defects. The reduction of PaO2 in room air after injection was within 5 mm Hg in both normal and embolized animals.

CONCLUSIONS

These initial, experimental results show that paramagnetically labeled liposome particles may be a successful MR contrast agent for pulmonary perfusion imaging.

Three-dimensional MR imaging of pulmonary vessels and parenchyma with NC100150 injection (Clariscan)

The influence of increasing doses of NC100150 Injection (Clariscantrade mark) and echo times on visualization of pulmonary vessels and parenchyma was evaluated. The effects of 0.5, 1, 2, 4, and 8 mg Fe/kg NC100150 Injection and echo times (TE) of 1.1, 1.8, 2. 2, and 4.3 msec were determined in six dogs using breath-hold three-dimensional (3D) spoiled gradient-echo magnetic resonance (MR) sequence. At 2 mg Fe/kg and TE of 1.1 msec, the signal-to-noise ratio of the central pulmonary arteries and parenchyma was significantly increased (5.3 +/- 2.2 to 50.3 +/- 2.4) and (2.2 +/- 0. 9 to 6.4 +/- 1.1), respectively. Using the TE of 1.1 msec, signal intensity in the main arteries continued to increase with increasing dose. Moreover, the enhancement of pulmonary parenchyma and microvasculature had a positive dose response. 3D MR imaging with ultrashort echo time and 2 mg Fe/kg NC100150 Injection produces angiograms with strong vascular contrast and allows qualitative assessment of pulmonary parenchyma and microvasculature.

Contrast-enhanced MRI of the lung

The lung has long been neglected by MR imaging. This is due to unique intrinsic difficulties: (1) signal loss due to cardiac pulsation and respiration; (2) susceptibility artifacts caused by multiple air-tissue interfaces; (3) low proton density. There are many MR strategies to overcome these problems. They consist of breath-hold imaging, respiratory and cardiac gating procedures, use of short repetition and echo times, increase of the relaxivity of existing spins by administration of intravenous contrast agents, and enrichment of spin density by hyperpolarized noble gases or oxygen. Improvements in scanner performance and frequent use of contrast media have increased the interest in MR imaging and MR angiography of the lung. They can be used on a routine basis for the following indications: characterization of pulmonary nodules, staging of bronchogenic carcinoma, in particular assessment of chest wall invasion; evaluation of inflammatory activity in interstitial lung disease; acute pulmonary embolism, chronic thromboembolic pulmonary hypertension, vascular involvement in malignant disease; vascular abnormalities. Future perspectives include perfusion imaging using extracellular or intravascular (blood pool) contrast agents and ventilation imaging using inhalation of hyperpolarized noble gases, of paramagnetic oxygen or of aerosolized contrast agents. These techniques represent new approaches to functional lung imaging. The combination of visualization of morphology and functional assessment of ventilation and perfusion is unequalled by any other technique.

Diagnosis of pulmonary embolism with spiral computed tomography and magnetic resonance angiography

Radiologic imaging techniques such as contrast-enhanced spiral computed tomography (CT) and magnetic resonance (MR) angiography provide noninvasive means of diagnosing pulmonary thromboembolic disease. In addition, both techniques permit direct visualization of the embolus. Although imperfect, both CT and MR angiography in various circumstances fit diagnostic pathways for pulmonary embolism detection. Recent advances in both CT (multidetector ring spiral units and electron beam) and MR technology allow not only depiction of the pulmonary arteries, but also are capable of providing information about the lower extremity deep venous system in a single examination.