Evaluation of upper airway collapsibility using real-time MRI

Simultaneous multi-slice cardiac real-time MRI at 0.55T

PURPOSE

To determine the feasibility of simultaneous multi-slice (SMS) real-time MRI (RT-MRI) at 0.55T for the evaluation of cardiac function.

METHODS

Cardiac CINE MRI is routinely used to evaluate left-ventricular (LV) function. The standard is sequential multi-slice balanced SSFP (bSSFP) over a stack of short-axis slices using electrocardiogram (ECG) gating and breath-holds. SMS has been used in CINE imaging to reduce the number of breath-holds by a factor of 2-4 at 1.5T, 3T, and recently at 0.55T. This work aims to determine if SMS is similarly effective in the RT-MRI evaluation of cardiac function. We used an SMS bSSFP pulse sequence with golden-angle spirals at 0.55T with an SMS factor of three. We cover the LV with three acquisitions for SMS, and nine for single-band (SB). Imaging was performed on 9 healthy volunteers and 1 patient with myocardial fibrosis and sternal wires. A spatio-temporal constrained reconstruction is used, with regularization parameters selected by a board-certified cardiologist. Images were quantitatively analyzed with a normalized contrast and an Edge Sharpness (ES) score.

RESULTS

There was a statistically significant 2-fold difference in contrast between SMS and SB and no significant difference in ES score. The contrast for SMS and SB were 13.38/29.05 at mid-diastole and 10.79/22.26 at end-systole; the ES scores for SMS and SB were 1.77/1.83 at mid-diastole and 1.50/1.72 at end-systole.

CONCLUSIONS

SMS cardiac RT-MRI at 0.55T is feasible and provides sufficient blood-myocardium contrast to evaluate LV function in three slices simultaneously without any gating or periodic motion assumptions.

New clinical opportunities of low-field MRI: heart, lung, body, and musculoskeletal

Contemporary whole-body low-field MRI scanners (< 1 T) present new and exciting opportunities for improved body imaging. The fundamental reason is that the reduced off-resonance and reduced SAR provide substantially increased flexibility in the design of MRI pulse sequences. Promising body applications include lung parenchyma imaging, imaging adjacent to metallic implants, cardiac imaging, and dynamic imaging in general. The lower cost of such systems may make MRI favorable for screening high-risk populations and population health research, and the more open configurations allowed may prove favorable for obese subjects and for pregnant women. This article summarizes promising body applications for contemporary whole-body low-field MRI systems, with a focus on new platforms developed within the past 5 years. This is an active area of research, and one can expect many improvements as MRI physicists fully explore the landscape of pulse sequences that are feasible, and as clinicians apply these to patient populations.

Dynamic sleep MRI in obstructive sleep apnea: a systematic review and meta-analysis

PURPOSE

The objective of this study is to systematically review the international literature for dynamic sleep magnetic resonance imaging (MRI) as a diagnostic tool in obstructive sleep apnea (OSA), to perform meta-analysis on the quantitative data from the review, and to discuss its implications in future research and potential clinical applications.

STUDY DESIGN

A comprehensive review of the literature was performed, followed by a detailed analysis of the relevant data that has been published on the topic.

METHODS

Clinical key, Uptodate, Ovid, Ebscohost, Pubmed/MEDLINE, Scopus, Dynamed, Web of Science and The Cochrane Library were systematically searched. Once the search was completed, dynamic sleep MRI data were analyzed.

RESULTS

Nineteen articles reported on 410 OSA patients and 79 controls that underwent dynamic sleep MRI and were included in this review. For meta-analysis of dynamic sleep MRI data, eight articles presented relevant data on 160 OSA patients. Obstruction was reported as follows: retropalatal (RP) 98%, retroglossal (RG) 41% and hypopharyngeal (HP) in 5%. Lateral pharyngeal wall (LPW) collapse was found in 35/73 (48%) patients. The combinations of RP + RG were observed in 24% and RP + RG + LPW in 16%. If sedation was used, 98% of study participants fell asleep compared to 66% of unsedated participants.

CONCLUSIONS

Dynamic sleep MRI has demonstrated that nearly all patients have retropalatal obstruction, retroglossal obstruction is common and hypopharyngeal obstruction is rare. Nearly all patients (98%) who are sedated are able to fall asleep during the MRI. There is significant heterogeneity in the literature and standardization is needed.

Real-Time Magnetic Resonance Imaging

Real-time magnetic resonance imaging (RT-MRI) allows for imaging dynamic processes as they occur, without relying on any repetition or synchronization. This is made possible by modern MRI technology such as fast-switching gradients and parallel imaging. It is compatible with many (but not all) MRI sequences, including spoiled gradient echo, balanced steady-state free precession, and single-shot rapid acquisition with relaxation enhancement. RT-MRI has earned an important role in both diagnostic imaging and image guidance of invasive procedures. Its unique diagnostic value is prominent in areas of the body that undergo substantial and often irregular motion, such as the heart, gastrointestinal system, upper airway vocal tract, and joints. Its value in interventional procedure guidance is prominent for procedures that require multiple forms of soft-tissue contrast, as well as flow information. In this review, we discuss the history of RT-MRI, fundamental tradeoffs, enabling technology, established applications, and current trends. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 1.

Acoustic characterization of upper airway variations from wakefulness to sleep with respect to obstructive sleep apnea

The upper airway (UA) is in general thicker and narrower in obstructive sleep apnea (OSA) population than in normal. Additionally, the UA changes during sleep are much more in the OSA population. The UA changes can alter the tracheal breathing sound (TBS) characteristics. Therefore, we hypothesize the TBS changes from wakefulness to sleep are significantly correlated to the OSA severity; thus, they may represent the physiological characteristics of the UA. To investigate our hypothesis, we recorded TBS of 18 mild-OSA (AHI < 15) and 22 moderate/severe-OSA (AHI > 15) during daytime (wakefulness) and then during sleep. The power spectral density (PSD) of the TBS was calculated and compared within the two OSA groups and between wakefulness and sleep. The average PSD of the mild-OSA group in the low-frequency range (< 280 Hz) was found to be decreased significantly from wakefulness to sleep (p-value < 10^-4). On the other hand, the average PSD of the moderate/severe-OSA group in the high-frequency range (> 900 Hz) increased marginally significantly from wakefulness to sleep (p-value < 9 × 10^-3). Our findings show that the changes in spectral characteristics of TBS from wakefulness to sleep correlate with the severity of OSA and can represent physiological variations of UA. Therefore, TBS analysis has the potentials to assist with diagnosis and clinical management decisions in OSA patients based on their OSA severity stratification; thus, obviating the need for more expensive and time-consuming sleep studies. Graphical abstract Tracheal breathing sound (TBS) changes from wakefulness to sleep and their correlation with Obstructive sleep apnea (OSA) were investigated in individuals with different levels of OSA severity. We also assessed the classification power of the spectral characteristics of these TBS for screening purposes. Consequently, we analyzed and compared spectral characteristics of TBS recorded during wakefulness (a combination of mouth and nasal TBS) to those during sleep for mild and moderate/severe OSA groups.

Regularized logistic regression for obstructive sleep apnea screening during wakefulness using daytime tracheal breathing sounds and anthropometric information

Obstructive sleep apnea (OSA) is a prevalent health problem. Developing a technology for quick OSA screening is momentous. In this study, we used regularized logistic regression to predict the OSA severity level of 199 individuals (116 males) with apnea/hypopnea index (AHI) ≥ 15 (moderate/severe OSA) and AHI < 5 (non-OSA) using their tracheal breathing sounds (TBS) recorded during daytime, while they were awake. The participants were guided to breathe through their nose, and then through their mouth at their deep breathing rate. The least absolute shrinkage and selection operator (LASSO) feature selection approach was used to select the discriminative features from the power spectra of the TBS and the anthropometric information. Using a five-fold cross-validation procedure, five different training sets and their corresponding blind-testing sets were formed. The average blind-testing classification accuracy over the five different folds was found to be 79.3% ± 6.1 with the sensitivity (specificity) of 82.2% ± 7.2% (75.8% ± 9.9%). The accuracy for the entire dataset was found to be 81.1% with sensitivity (specificity) of 84.4% (77.0%). The feature selection and classification procedures were intelligible and fast. The selected features were physiologically meaningful. Overall, the results show that TBS analysis can be used as a quick and reliable prediction of the presence and severity of OSA during wakefulness without a sleep study. Graphical abstract Wakefulness screening of obstructive sleep apnea using tracheal breathing sounds and anthropometric information by means of regularized logistic regression with the least absolute shrinkage and selection operator approach for feature selection and classification.

A novel method to generate dynamic boundary conditions for airway CFD by mapping upper airway movement with non-rigid registration of dynamic and static MRI

Computational fluid dynamics (CFD) simulations of airflow in the human airways have the potential to provide a great deal of information that can aid clinicians in case management and surgical decision making, such as airway resistance, energy expenditure, airflow distribution, heat and moisture transfer, and particle deposition, as well as the change in each of these due to surgical interventions. However, the clinical relevance of CFD simulations has been limited to date, as previous models either did not incorporate neuromuscular motion or any motion at all. Many common airway pathologies, such as obstructive sleep apnea (OSA) and tracheomalacia, involve large movements of the structures surrounding the airway, such as the tongue and soft palate. Airway wall motion may be due to many factors including neuromuscular motion, internal aerodynamic forces, and external forces such as gravity. Therefore, to realistically model these airway diseases, a method is required to derive the airway wall motion, whatever the cause, and apply it as a boundary condition to CFD simulations. This paper presents and validates a novel method of capturing in vivo motion of airway walls from magnetic resonance images with high spatiotemporal resolution, through a novel combination of non-rigid image, surface, and surface-normal-vector registration. Coupled with image-synchronous pneumotachography, this technique provides the necessary boundary conditions for dynamic CFD simulations of breathing, allowing the effect of the airway's complex motion to be calculated for the first time, in both normal subjects and those with conditions such as OSA.

Recent advances in parallel imaging for MRI

Magnetic Resonance Imaging (MRI) is an essential technology in modern medicine. However, one of its main drawbacks is the long scan time needed to localize the MR signal in space to generate an image. This review article summarizes some basic principles and recent developments in parallel imaging, a class of image reconstruction techniques for shortening scan time. First, the fundamentals of MRI data acquisition are covered, including the concepts of k-space, undersampling, and aliasing. It is demonstrated that scan time can be reduced by sampling a smaller number of phase encoding lines in k-space; however, without further processing, the resulting images will be degraded by aliasing artifacts. Nearly all modern clinical scanners acquire data from multiple independent receiver coil arrays. Parallel imaging methods exploit properties of these coil arrays to separate aliased pixels in the image domain or to estimate missing k-space data using knowledge of nearby acquired k-space points. Three parallel imaging methods-SENSE, GRAPPA, and SPIRiT-are described in detail, since they are employed clinically and form the foundation for more advanced methods. These techniques can be extended to non-Cartesian sampling patterns, where the collected k-space points do not fall on a rectangular grid. Non-Cartesian acquisitions have several beneficial properties, the most important being the appearance of incoherent aliasing artifacts. Recent advances in simultaneous multi-slice imaging are presented next, which use parallel imaging to disentangle images of several slices that have been acquired at once. Parallel imaging can also be employed to accelerate 3D MRI, in which a contiguous volume is scanned rather than sequential slices. Another class of phase-constrained parallel imaging methods takes advantage of both image magnitude and phase to achieve better reconstruction performance. Finally, some applications are presented of parallel imaging being used to accelerate MR Spectroscopic Imaging.

Test-retest repeatability of human speech biomarkers from static and real-time dynamic magnetic resonance imaging

Static anatomical and real-time dynamic magnetic resonance imaging (RT-MRI) of the upper airway is a valuable method for studying speech production in research and clinical settings. The test-retest repeatability of quantitative imaging biomarkers is an important parameter, since it limits the effect sizes and intragroup differences that can be studied. Therefore, this study aims to present a framework for determining the test-retest repeatability of quantitative speech biomarkers from static MRI and RT-MRI, and apply the framework to healthy volunteers. Subjects (n = 8, 4 females, 4 males) are imaged in two scans on the same day, including static images and dynamic RT-MRI of speech tasks. The inter-study agreement is quantified using intraclass correlation coefficient (ICC) and mean within-subject standard deviation (σ_e). Inter-study agreement is strong to very strong for static measures (ICC: min/median/max 0.71/0.89/0.98, σ_e: 0.90/2.20/6.72 mm), poor to strong for dynamic RT-MRI measures of articulator motion range (ICC: 0.26/0.75/0.90, σ_e: 1.6/2.5/3.6 mm), and poor to very strong for velocities (ICC: 0.21/0.56/0.93, σ_e: 2.2/4.4/16.7 cm/s). In conclusion, this study characterizes repeatability of static and dynamic MRI-derived speech biomarkers using state-of-the-art imaging. The introduced framework can be used to guide future development of speech biomarkers. Test-retest MRI data are provided free for research use.

Real-time multislice MRI during continuous positive airway pressure reveals upper airway response to pressure change

PURPOSE

To determine if a real-time magnetic resonance imaging (RT-MRI) method during continuous positive airway pressure (CPAP) can be used to measure neuromuscular reflex and/or passive collapsibility of the upper airway in individual obstructive sleep apnea (OSA) subjects.

MATERIALS AND METHODS

We conducted experiments on four adolescents with OSA and three healthy controls, during natural sleep and during wakefulness. Data were acquired on a clinical 3T scanner using simultaneous multislice (SMS) RT-MRI during CPAP. CPAP pressure level was alternated between therapeutic and subtherapeutic levels. Segmented airway area changes in response to rapid CPAP pressure drop and restoration were used to estimate 1) upper airway loop gain (UALG), and 2) anatomical risk factors, including fluctuation of airway area (FAA).

RESULTS

FAA significantly differed between OSA patients (2-4× larger) and healthy controls (Student's t-test, P < 0.05). UALG and FAA measurements indicate that neuromuscular reflex and passive collapsibility varied among the OSA patients, suggesting the presence of different OSA phenotypes. Measurements had high intrasubject reproducibility (intraclass correlation coefficient r > 0.7).

CONCLUSION

SMS RT-MRI during CPAP can reproducibly identify physiological traits and anatomical risk factors that are valuable in the assessment of OSA. This technique can potentially locate the most collapsible airway sites. Both UALG and FAA possess large variation among OSA patients.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2017;46:1400-1408.

Feasibility of through-time spiral generalized autocalibrating partial parallel acquisition for low latency accelerated real-time MRI of speech

PURPOSE

To evaluate the feasibility of through-time spiral generalized autocalibrating partial parallel acquisition (GRAPPA) for low-latency accelerated real-time MRI of speech.

METHODS

Through-time spiral GRAPPA (spiral GRAPPA), a fast linear reconstruction method, is applied to spiral (k-t) data acquired from an eight-channel custom upper-airway coil. Fully sampled data were retrospectively down-sampled to evaluate spiral GRAPPA at undersampling factors R = 2 to 6. Pseudo-golden-angle spiral acquisitions were used for prospective studies. Three subjects were imaged while performing a range of speech tasks that involved rapid articulator movements, including fluent speech and beat-boxing. Spiral GRAPPA was compared with view sharing, and a parallel imaging and compressed sensing (PI-CS) method.

RESULTS

Spiral GRAPPA captured spatiotemporal dynamics of vocal tract articulators at undersampling factors ≤4. Spiral GRAPPA at 18 ms/frame and 2.4 mm² /pixel outperformed view sharing in depicting rapidly moving articulators. Spiral GRAPPA and PI-CS provided equivalent temporal fidelity. Reconstruction latency per frame was 14 ms for view sharing and 116 ms for spiral GRAPPA, using a single processor. Spiral GRAPPA kept up with the MRI data rate of 18ms/frame with eight processors. PI-CS required 17 minutes to reconstruct 5 seconds of dynamic data.

CONCLUSION

Spiral GRAPPA enabled 4-fold accelerated real-time MRI of speech with a low reconstruction latency. This approach is applicable to wide range of speech RT-MRI experiments that benefit from real-time feedback while visualizing rapid articulator movement. Magn Reson Med 78:2275-2282, 2017. © 2017 International Society for Magnetic Resonance in Medicine.

Anatomically correct visualization of the human upper airway using a high-speed long range optical coherence tomography system with an integrated positioning sensor

The upper airway is a complex tissue structure that is prone to collapse. Current methods for studying airway obstruction are inadequate in safety, cost, or availability, such as CT or MRI, or only provide localized qualitative information such as flexible endoscopy. Long range optical coherence tomography (OCT) has been used to visualize the human airway in vivo, however the limited imaging range has prevented full delineation of the various shapes and sizes of the lumen. We present a new long range OCT system that integrates high speed imaging with a real-time position tracker to allow for the acquisition of an accurate 3D anatomical structure in vivo. The new system can achieve an imaging range of 30 mm at a frame rate of 200 Hz. The system is capable of generating a rapid and complete visualization and quantification of the airway, which can then be used in computational simulations to determine obstruction sites.

Minimum Field Strength Simulator for Proton Density Weighted MRI

OBJECTIVE

To develop and evaluate a framework for simulating low-field proton-density weighted MRI acquisitions based on high-field acquisitions, which could be used to predict the minimum B0 field strength requirements for MRI techniques. This framework would be particularly useful in the evaluation of de-noising and constrained reconstruction techniques.

MATERIALS AND METHODS

Given MRI raw data, lower field MRI acquisitions can be simulated based on the signal and noise scaling with field strength. Certain assumptions are imposed for the simulation and their validity is discussed. A validation experiment was performed using a standard resolution phantom imaged at 0.35 T, 1.5 T, 3 T, and 7 T. This framework was then applied to two sample proton-density weighted MRI applications that demonstrated estimation of minimum field strength requirements: real-time upper airway imaging and liver proton-density fat fraction measurement.

RESULTS

The phantom experiment showed good agreement between simulated and measured images. The SNR difference between simulated and measured was ≤ 8% for the 1.5T, 3T, and 7T cases which utilized scanners with the same geometry and from the same vendor. The measured SNR at 0.35T was 1.8- to 2.5-fold less than predicted likely due to unaccounted differences in the RF receive chain. The predicted minimum field strength requirements for the two sample applications were 0.2 T and 0.3 T, respectively.

CONCLUSIONS

Under certain assumptions, low-field MRI acquisitions can be simulated from high-field MRI data. This enables prediction of the minimum field strength requirements for a broad range of MRI techniques.