On the nature and reduction of plaque-mimicking flow artifacts in black blood MRI of the carotid bifurcation

[Carotid artery wall imaging using 7.0T magnetic resonance imaging with threedimensional DANTE-prepared FLASH in ApoE-/- mice]

OBJECTIVE

To explore the feasibility of three-dimensional (3D) vessel wall imaging of carotid atherosclerotic plaques in ApoE-/- mice using 7.0T magnetic resonance imaging (MRI) with delays alternating with nutations for tailored excitation (DANTE)-prepared fast low-angle shot (DANTE-FLASH) technique.

OBJECTIVE

Numerical simulations were performed for optimizing imaging parameters to maximize the wall-lumen contrast. Six ApoE-/- and three wild-type mice were scanned using a 7.0T MRI scanner with DANTE-FLASH and multi-slice 2D RARE coupled with inflow outflow saturation bands (2D-IOSBRARE). The wall signal-to-noise ratio (SNRwall), lumen SNR (SNRlumen), wall-lumen contrast-to-noise ratio (CNR), lumen area (LA), and wall area (WA) were compared between DANTE- FLASH and 2D-IOSB-RARE sequences. Linear regression analysis was performed to assess the correlation between the MRI measurements and histopathological measurements of LA and WA.

OBJECTIVE

Based on the simulation results, a flip angle of 15° and a train length of 150 were implemented in the live imaging study. Compared with 2D-IOSB-RARE, DANTE-FLASH provided a slightly reduced CNR (P < 0.001) but much improved slice resolution. The LA and WA measurements from the DANTE-FLASH and 2D-IOSB- RARE showed excellent agreement based on ICC analysis (LA: ICC=0.94, P < 0.001; WA: ICC=0.93, P < 0.001) and Bland-Altman plots. Strong correlations were observed between the MRI and histopathological measurements for both LA (P < 0.0001) and WA (P < 0.0001).

OBJECTIVE

As a 3D black-blood MR sequence, DANTE-FLASH provides isotropic high spatial resolution to allow reliable visualization and quantitative evaluation of the arteriosclerotic lesions within the carotid artery of ApoE-/- mice using a 7.0T MRI scanner.

Quantitative comparisons between relaxation enhanced compressed sensing 3D MERGE and conventional 3D MERGE for vessel wall imaging in equal scan time: preliminary studies

In this study, we quantitatively compared relaxation enhanced compressed sensing (RECS-3D MERGE) with conventional 3D MERGE techniques on blood suppression efficiency, wall-lumen contrast and plaque burden measurement for carotid atherosclerotic imaging in equal scan time. Twelve patients were recruited in the study. RECS-3D MERGE and conventional 3D MERGE were implemented. 2D DIR-FSE was carried out as a reference standard. The lumen signal-to-tissue ratio (STR) was used as the quantitative measure of blood suppression efficiency. The contrast-to-tissue ratio (CTR) was used as the quantitative measure of wall-lumen contrast. Vessel lumen area (LA) and wall area (WA) were measured for morphological comparisons. The lumen STR of RECS-3D MERGE was significantly lower than that of 3D MERGE while the wall-lumen CTR of RECS-3D MERGE was significantly higher. There were no significant differences in plaque burden measurements between RECS-3D MERGE and 2D DIR-FSE. For comparison between conventional 3D MERGE and 2D DIR-FSE, there were no significant differences in LA measurement. However, the WA of 3D MERGE was significantly larger. The RECS-3D MERGE sequence achieved more sufficient blood suppression and higher image contrast without prolonging the scan time. These improvements lead to more accurate morphological measurements of carotid atherosclerotic imaging.

Technical Note: Measurement of common carotid artery lumen dynamics using black-blood MR cine imaging

PURPOSE

To demonstrate the feasibility of measuring the common carotid artery (CCA) lumen dynamics using a black-blood cine (BB-cine) imaging method.

METHODS

Motion-sensitized driven-equilibrium (MSDE) prepared spoiled gradient sequence was used for the BB-cine imaging. CCAs of eleven healthy volunteers were studied using this method. Lumen dynamics, including lumen area evolution waveforms and distension values, were measured and evaluated by comparing this method with bright-blood cine (BrB-cine) imaging.

RESULTS

Compared with the BrB-cine images, flow artifacts were effectively suppressed in the BB-cine images. BrB-cine images generally show larger lumen areas than BB-cine images. The lumen area waveforms and distension measurements from BB-cine imaging showed smaller variances among different subjects than BrB-cine imaging.

CONCLUSIONS

The proposed BB-cine imaging technique can suppress the flow artifacts effectively and reduce the partial volume effects from the vessel wall. This might allow more accurate lumen dynamics measurements than traditional BrB-cine imaging, which may further be valuable for investigating biomechanical and functional properties of the cardiovascular system.

Flow artifact removal in carotid wall imaging based on black and gray-blood dual-contrast images subtraction

PURPOSE

To develop and validate a dual-contrast image subtraction (DCIS) strategy for eliminating the flow artifacts in black-blood carotid MRI.

METHODS

Twelve patients with carotid stenosis and eight healthy volunteers were imaged using the black and gray-blood dual-contrast imaging based on the relaxation-enhanced compressed sensing three-dimensional motion-sensitizing driven equilibrium prepared rapid-gradient-echo (RECS-3D MERGE) sequence. Subtraction of black-blood images (BBIs) and gray-blood images (GBIs), together with a preweighting procedure, was performed to eliminate the residual blood signal in BBIs. A wavelet denoising procedure was applied to offset the noise amplification. In addition to the lumen signal-to-noise ratio (SNR) and wall-lumen contrast-to-noise ratio (CNR), the signal variance ratio (SVR) and contrast variance ratio (CVR) were also used to evaluate the blood suppression efficiency.

RESULTS

By choosing the weighting factor of one, the lumen SNR of DCIS images was approximately 1% of that of the original BBIs, and the CNR showed a 91.4% improvement as compared with the BBIs. The median of the lumen SVR decreased to zero, and the CVR increased to 123% of that of the BBIs.

CONCLUSIONS

DCIS is demonstrated to be an effective strategy for sufficiently removing the residual flow signal from black-blood carotid MRI. Magn Reson Med 77:1612-1618, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Comparison of Gated and Ungated Black-Blood Fast Spin-echo MRI of Carotid Vessel Wall at 3T

PURPOSE

Multi-slice ungated double inversion recovery has been proposed as an alternative time-efficient and effective sequence for black-blood carotid imaging. The purpose of this study is to evaluate the comparative repeatability of this multi-contrast sequence with respect to a single slice double inversion recovery prepared gated sequence.

MATERIALS AND METHODS

Ten healthy volunteers and three patients with Doppler ultrasound defined carotid artery stenosis >30% were recruited. T1-weighted (T1W) and T2W fast spin-echo (FSE) images were acquired centered at the carotid bifurcation with and without cardiac gating. Repeat imaging was performed without patient repositioning to determine the variations in vessel wall measurement and signal intensity due to gating, while negating variations as a result of slice misalignment and anatomical displacement relative to the receiver coil. The distributions and the repeatability of lumen area, vessel wall area, signal and contrast-to-noise ratio (SNR/CNR) of the vessel wall and adjacent muscle were reported.

RESULTS

The T1W ungated sequence generally had comparable wall SNR/CNR with respect to the gated sequence, however the muscle SNR was lower (P = 0.013). The T2W ungated multi-slice sequence had lower SNR/CNR than the gated single slice sequence (P < 0.001), but with equivalent effective wall CNR (P = 0.735). Vessel area measurements using the gated/ungated sequences were equivalent. Ungated sequences had better repeatability in SNR/CNR than the gated sequences with borderline and statistically significant differences. The repeatability of T2W wall area measurement was better using the ungated sequences (P = 0.02), and the repeatability of the remaining vessel area measurements were equivalent.

CONCLUSIONS

Ungated sequences can achieve comparable SNR/CNR and equivalent carotid vessel area measurements than gated sequences with improved repeatability of SNR/CNR. Ungated sequences are good alternatives of gated sequences for vessel area measurement and plaque composition quantification.

Advanced MRI for carotid plaque imaging

Atherosclerosis is the ubiquitous underling pathological process that manifests in heart attack and stroke, cumulating in the death of one in three North American adults. High-resolution magnetic resonance imaging (MRI) is able to delineate atherosclerotic plaque components and total plaque burden within the carotid arteries. Using dedicated hardware, high resolution images can be obtained. Combining pre- and post-contrast T1, T2, proton-density, and magnetization-prepared rapid acquisition gradient echo weighted fat-saturation imaging, plaque components can be defined. Post-processing software allows for semi- and fully automated quantitative analysis. Imaging correlation with surgical specimens suggests that this technique accurately differentiates plaque features. Total plaque burden and specific plaque components such as a thin fibrous cap, large fatty or necrotic core and intraplaque hemorrhage are accepted markers of neuroischemic events. Given the systemic nature of atherosclerosis, emerging science suggests that the presence of carotid plaque is also an indicator of coronary artery plaque burden, although the preliminary data primarily involves patients with stable coronary disease. While the availability and cost-effectiveness of MRI will ultimately be important determinants of whether carotid MRI is adopted clinically in cardiovascular risk assessment, the high accuracy and reliability of this technique suggests that it has potential as an imaging biomarker of future risk.

Cerebrovascular MRI: a review of state-of-the-art approaches, methods and techniques

Cerebrovascular imaging is of great interest in the understanding of neurological disease. MRI is a non-invasive technology that can visualize and provide information on: (i) the structure of major blood vessels; (ii) the blood flow velocity in these vessels; and (iii) the microcirculation, including the assessment of brain perfusion. Although other medical imaging modalities can also interrogate the cerebrovascular system, MR provides a comprehensive assessment, as it can acquire many different structural and functional image contrasts whilst maintaining a high level of patient comfort and acceptance. The extent of examination is limited only by the practicalities of patient tolerance or clinical scheduling limitations. Currently, MRI methods can provide a range of metrics related to the cerebral vasculature, including: (i) major vessel anatomy via time-of-flight and contrast-enhanced imaging; (ii) blood flow velocity via phase contrast imaging; (iii) major vessel anatomy and tissue perfusion via arterial spin labeling and dynamic bolus passage approaches; and (iv) venography via susceptibility-based imaging. When designing an MRI protocol for patients with suspected cerebral vascular abnormalities, it is appropriate to have a complete understanding of when to use each of the available techniques in the 'MR angiography toolkit'. In this review article, we: (i) overview the relevant anatomy, common pathologies and alternative imaging modalities; (ii) describe the physical principles and implementations of the above listed methods; (iii) provide guidance on the selection of acquisition parameters; and (iv) describe the existing and potential applications of MRI to the cerebral vasculature and diseases. The focus of this review is on obtaining an understanding through the application of advanced MRI methodology of both normal and abnormal blood flow in the cerebrovascular arteries, capillaries and veins.

Assessment of carotid artery atherosclerotic disease by using three-dimensional fast black-blood MR imaging: comparison with DSA

PURPOSE

To assess fast three-dimensional (3D) black-blood (BB) magnetic resonance (MR) imaging as a noninvasive alternative to intraarterial digital subtraction angiography (DSA) at quantifying moderate to severe carotid artery atherosclerotic disease.

MATERIALS AND METHODS

Local ethics committee approval and written informed patient consent were obtained for this study. Sixty-five carotid arteries from 52 patients with at least 50% stenosis underwent 3D BB MR imaging and DSA. Quantitative measurements, including stenosis, lesion length, and the presence or absence of plaque ulceration, obtained with the two modalities were independently determined. Sensitivity and specificity, the intraclass correlation coefficient (ICC), Cohen κ, and Bland-Altman analysis were used to assess the agreement.

RESULTS

Excellent agreement in measuring luminal stenosis was found between 3D BB MR imaging and DSA (ICC, 0.96; 95% confidence interval [CI]: 0.93, 0.97). Three-dimensional BB MR imaging was also found to have high sensitivity (91.7%), specificity (96.2%), and agreement (Cohen κ, 0.85; 95% CI: 0.66, 0.99) with DSA for detection of ulcers. Good agreement was found between lesion length measured by using 3D BB MR imaging and DSA (ICC, 0.75; 95% CI: 0.51, 0.84). However, lesion length measurements by using 3D BB MR imaging were, on average, 4.0 mm longer than those measured by using DSA (P < .001).

CONCLUSION

Three-dimensional BB MR imaging is a noninvasive and accurate way to quantify moderate to severe carotid artery atherosclerotic disease. With fast acquisition and large coverage, 3D BB MR imaging has the potential to become an alternative imaging approach in evaluating the severity of atherosclerosis.

Optimization of improved motion-sensitized driven-equilibrium (iMSDE) blood suppression for carotid artery wall imaging

BACKGROUND

Improved motion-sensitized driven-equilibrium (iMSDE) preparations have been successfully used in carotid artery wall imaging to achieve blood suppression, but it causes notable signal loss, mostly due to inherent T2 decay, eddy current effects and B1 + inhomogeneity. In this study, we investigate the signal to noise ratio (SNR) and blood suppression performance of iMSDE using composite RF pulses and sinusoidal gradients. Optimized first moment (m1) values for iMSDE prepared T1- and T2- weighted (T1- and T2-w) imaging are presented.

METHODS

Twelve healthy volunteers and six patients with carotid artery disease underwent iMSDE and double inversion recovery (DIR) prepared T1- and T2-w fast spin echo (FSE) MRI of the carotid arteries. Modified iMSDE module using composite RF pulses and sinusoidal gradients were evaluated with a range of m1. SNR of adjacent muscle, vessel wall and the lumen were reported. The optimized iMSDE module was also tested in a 3D variable flip angle FSE (CUBE) acquisition.

RESULTS

The SNR of muscle was highest using sinusoidal gradients, and the relative improvement over the trapezoidal gradient increased with higher m1 (p<0.001). Optimal SNR was observed using an iMSDE preparation scheme containing two 180° composite pulses and standard 90° and -90° pulses (p=0.151). iMSDE produced better blood suppression relative to DIR preparations even with a small m1 of 487 mT*ms2/m (p<0.001). In T1-w iMSDE, there was a SNR decrease and an increased T2 weighting with increasing m1. In T2-w iMSDE, by matching the effective echo time (TE), the SNR was equivalent when m1 was <= 1518 mT*ms2/m, however, higher m1 values (2278 - 3108 mT*ms2/m) reduced the SNR. In the patient study, iMSDE improved blood suppression but reduced vessel wall CNR efficiency in both T1-w and T2-w imaging. iMSDE also effectively suppressed residual flow artifacts in the CUBE acquisition.

CONCLUSIONS

iMSDE preparation achieved better blood suppression than DIR preparation with reduced vessel wall CNR efficiency in T1-w and T2-w images. The optimized m1s are 487 mT*ms2/m for T1-w imaging and 1518 mT*ms2/m for T2-w imaging. Composite 180° refocusing pulses and sinusoidal gradients improve SNR performance. iMSDE further improves the inherent blood suppression of CUBE.

Lagrangian postprocessing of computational hemodynamics

Recent advances in imaging, modeling, and computing have rapidly expanded our capabilities to model hemodynamics in the large vessels (heart, arteries, and veins). This data encodes a wealth of information that is often under-utilized. Modeling (and measuring) blood flow in the large vessels typically amounts to solving for the time-varying velocity field in a region of interest. Flow in the heart and larger arteries is often complex, and velocity field data provides a starting point for investigating the hemodynamics. This data can be used to perform Lagrangian particle tracking, and other Lagrangian-based postprocessing. As described herein, Lagrangian methods are necessary to understand inherently transient hemodynamic conditions from the fluid mechanics perspective, and to properly understand the biomechanical factors that lead to acute and gradual changes of vascular function and health. The goal of the present paper is to review Lagrangian methods that have been used in post-processing velocity data of cardiovascular flows.

Reduced blood flow artifact in intraplaque hemorrhage imaging using CineMPRAGE

Magnetization prepared rapid acquisition gradient echo (3D MPRAGE) has been shown to be a sensitive method to image carotid intraplaque hemorrhage. As the MPRAGE sequence used to identify potential intraplaque hemorrhage does not utilize cardiac gating, it is difficult to optimize the inversion times due to the dynamic nature of flowing blood. As a result, a best fit inversion time is often determined experimentally and then used for in vivo clinical examination. This results in compromised blood suppression and occasional hemorrhage mimicking flow artifacts. We demonstrate that a retrospective cardiac correlated reconstruction can be applied to the conventional MPRAGE sequence (CineMPRAGE) to more accurately identify blood signal. This CineMPRAGE reconstruction uses the data from a standard nongated MPRAGE sequence to generate a full sequence of cardiac correlated images throughout the cardiac cycle and, therefore, provides a dynamic view of the carotid artery and a better ability to discern blood signal from potential intraplaque hemorrhage. In our preliminary study of 35 patients, signal from potential hemorrhage was constant over the cardiac cycle, whereas any signal from blood flow artifact was observed as an oscillating signal over the cardiac cycle.

Carotid artery disease and stroke: assessing risk with vessel wall MRI

Although MRI is widely used to diagnose stenotic carotid arteries, it also detects characteristics of the atherosclerotic plaque itself, including its size, composition, and activity. These features are emerging as additional risk factors for stroke that can be feasibly acquired clinically. This paper summarizes the state of evidence for a clinical role for MRI of carotid atherosclerosis.

Accelerated 3D MERGE carotid imaging using compressed sensing with a hidden Markov tree model

PURPOSE

To determine the potential for accelerated 3D carotid magnetic resonance imaging (MRI) using wavelet based compressed sensing (CS) with a hidden Markov tree (HMT) model.

MATERIALS AND METHODS

We retrospectively applied HMT model-based CS and conventional CS to 3D carotid MRI data with 0.7 mm isotropic resolution from six subjects with known carotid stenosis (12 carotids). We applied a wavelet-tree model learned from a training database of carotid images to improve CS reconstruction. Quantitative endpoints such as lumen area, wall area, mean and maximum wall thickness, plaque calcification, and necrotic core area were measured and compared using Bland-Altman analysis along with image quality.

RESULTS

Rate-4.5 acceleration with HMT model-based CS provided image quality comparable to that of rate-3 acceleration with conventional CS and fully sampled reference reconstructions. Morphological measurements made on rate-4.5 HMT model-based CS reconstructions were in good agreement with measurements made on fully sampled reference images. There was no significant bias or correlation between mean and difference of measurements when comparing rate 4.5 HMT model-based CS with fully sampled reference images.

CONCLUSION

HMT model-based CS can potentially be used to accelerate clinical carotid MRI by a factor of 4.5 without impacting diagnostic quality or quantitative endpoints.

Peripheral arterial wall imaging using contrast-enhanced, susceptibility-weighted phase imaging

PURPOSE

To demonstrate improved delineation of peripheral arterial wall in susceptibility-weighted imaging (SWI) phase images by using gadolinium contrast agent.

MATERIALS AND METHODS

Superficial femoral arteries were imaged using high-resolution SWI in 11 healthy volunteers before and after injection of gadopentetate dimeglumine. Two postcontrast scans started 1 minute and 11 minutes after injection, respectively. Eight of the 11 volunteers also underwent double-inversion recovery turbo-spin-echo (TSE) scans. The same resolution and matrix size were used between SWI and TSE studies, and TSE locations were matched to SWI images. Arterial lumen-wall phase difference and phase contrast-to-noise ratio were measured and compared between precontrast and postcontrast SWI measurements. The lumen and wall areas measured on both TSE and matching SWI images were analyzed for agreement. Two other volunteers participated in a double-echo gradient-echo study. Results were compared to SWI.

RESULTS

By injecting gadolinium contrast agent, phase difference changed by 54.5% and -1.6%, and phase contrast-to-noise ratio changed by 85.7% and 27.0% for the first and second postcontrast scans, respectively. Morphological measurements showed insignificant difference between TSE and SWIs based on paired t tests; good agreements in Bland-Altman plots were achieved. The double-echo gradient-echo study had similar phase measurements as SWI.

CONCLUSION

Contrast-enhanced phase imaging improves arterial wall delineation in SWI of peripheral arterial wall. Contrast-enhanced SWI is a promising vessel wall imaging technique.

CINE turbo spin echo imaging

High-resolution turbo spin echo (TSE) images have demonstrated important details of carotid artery morphology; however, it is evident that pulsatile blood and wall motion related to the cardiac cycle are still significant sources of image degradation. Although ECG gating can reduce artifacts due to cardiac-induced pulsations, gating is rarely used because it lengthens the acquisition time and can cause image degradation due to nonconstant repetition time. This work introduces a relatively simple method of converting a conventional TSE acquisition into a retrospectively ECG-correlated cineTSE sequence. The cineTSE sequence generates a full sequence of ECG-correlated images at each slice location throughout the cardiac cycle in the same scan time that is conventionally used by standard TSE sequences to produce a single image at each slice location. The cineTSE images exhibit reduced pulsatile artifacts associated with a gated sequence but without the increased scan time or associated nonconstant repetition time effects.

Nonenhanced methods for lower-extremity MRA: a phantom study examining the effects of stenosis and pathologic flow waveforms at 1.5T

PURPOSE

To evaluate the signal properties of 2D time of flight (TOF), quiescent-interval single-shot (QISS), ECG-gated 3D fast spin-echo (FBI), and ungated 3D fast spin-echo ghost (Ghost) magnetic resonance angiography (MRA) over a range of flow velocities in a pulsatile flow phantom with a 50% diameter stenosis at 1.5T.

MATERIALS AND METHODS

Blood-mimicking fluid was pumped at eight peak flow velocities through a stenotic region in triphasic and monophasic waveforms. Vascular signal proximal, within, and distal to the stenosis was measured from the source images of the four MRA methods. Coronal maximum intensity projection images were used to compare image quality.

RESULTS

TOF and QISS signal trends were similar, but QISS exhibited the most consistent signal across velocities. At high velocities (≥ 42.4 cm/s), TOF showed poststenotic signal loss that was not observed with QISS. FBI and Ghost signals peaked at low velocities (3.9-9.7 cm/s) without flow compensation and at high velocities (≥ 64.6 cm/s) with flow compensation.

CONCLUSION

FBI and Ghost demonstrated dependence on blood flow velocity and flow compensation. TOF was sensitive to flow artifacts at high velocities. QISS proved most robust for accurately depicting the normal lumen and stenosis under a wide range of flow conditions. Monophasic and triphasic flow did not appreciably affect the signal performance of any method.

A comparative analysis of double inversion recovery TFE and TSE sequences on carotid artery wall imaging

OBJECTIVE

To analyze the characteristics of double inversion recovery (DIR) turbo field echo (TFE) and turbo spin echo (TSE) sequences and explore the value of double inversion recovery TFE sequence on carotid artery wall imaging.

PATIENTS AND METHODS

56 patients (32 males and 24 females, aged 31-76 years with a mean age of 53 years) were performed with DIR TFE and DIR TSE T1 weighted imaging (T1WI) sequences on carotid artery bifurcations. Image quality acquired by different techniques were evaluated and scored by two physicians. Whether there is significant difference is determined by SPSS 11.0 software. Paired-samples t test was used for statistics.

RESULTS

There was no significant difference in the image quality scores between two sequences (t = 0.880, P = 0.383 > 0.05).

CONCLUSIONS

DIR TFE sequence has short scanning time and high spatial resolution. DIR TFE sequence can be used as the preferred sequence for screening carotid atherosclerotic plaque compared with DIR TSE sequence.

Enhanced image quality in black-blood MRI using the improved motion-sensitized driven-equilibrium (iMSDE) sequence

PURPOSE

To propose an improved motion-sensitized driven-equilibrium (iMSDE) pulse sequence to enhance the tissue signal-to-noise ratio (SNR) while maintaining the same flow suppression capability in black-blood carotid artery magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Compared to the traditional MSDE sequence, the iMSDE sequence uses an extra refocusing pulse and two extra gradients to achieve SNR improvement. Computer simulation and phantom studies were used to evaluate both eddy currents and local B(1) inhomogeneity effects on SNR behaviors on both MSDE and iMSDE images. To further assess the SNR improvements brought by iMSDE in vivo, five healthy volunteers were also scanned with both sequences. The paired t-test was used for statistical comparison.

RESULTS

Both simulations and phantom studies demonstrated that eddy currents and local B(1) inhomogeneity will cause image SNR reduction in the MSDE sequence, and that these factors can be partially compensated for with the iMSDE sequence. In vivo comparison showed that the iMSDE sequence significantly improved the tissue-lumen contrast-to-noise ratio (CNR) and static tissue SNR (P < 0.001 for both), while maintaining low lumen SNR in carotid MRI.

CONCLUSION

Compared to the traditional MSDE sequence, the iMSDE sequence can achieve improved soft-tissue SNR and CNR in carotid artery MRI without sacrificing flow suppression capability and time efficiency.

3D flow-independent peripheral vessel wall imaging using T(2)-prepared phase-sensitive inversion-recovery steady-state free precession

PURPOSE

To develop a 3D flow-independent peripheral vessel wall imaging method using T(2)-prepared phase-sensitive inversion-recovery (T(2)PSIR) steady-state free precession (SSFP).

MATERIALS AND METHODS

A 3D T(2)-prepared and nonselective inversion-recovery SSFP sequence was designed to achieve flow-independent blood suppression for vessel wall imaging based on T(1) and T(2) properties of the vessel wall and blood. To maximize image contrast and reduce its dependence on the inversion time (TI), phase-sensitive reconstruction was used to restore the true signal difference between vessel wall and blood. The feasibility of this technique for peripheral artery wall imaging was tested in 13 healthy subjects. Image signal-to-noise ratio (SNR), wall/lumen contrast-to-noise ratio (CNR), and scan efficiency were compared between this technique and conventional 2D double inversion recovery - turbo spin echo (DIR-TSE) in eight subjects.

RESULTS

3D T(2)PSIR SSFP provided more efficient data acquisition (32 slices and 64 mm in 4 minutes, 7.5 seconds per slice) than 2D DIR-TSE (2-3 minutes per slice). SNR of the vessel wall and CNR between vessel wall and lumen were significantly increased as compared to those of DIR-TSE (P < 0.001). Vessel wall and lumen areas of the two techniques are strongly correlated (intraclass correlation coefficients: 0.975 and 0.937, respectively; P < 0.001 for both). The lumen area of T(2)PSIR SSFP is slightly larger than that of DIR-TSE (P = 0.008). The difference in vessel wall area between the two techniques is not statistically significant.

CONCLUSION

T(2)PSIR SSFP is a promising technique for peripheral vessel wall imaging. It provides excellent blood signal suppression and vessel wall/lumen contrast. It can cover a 3D volume efficiently and is flow- and TI-independent.

Carotid arterial wall MRI at 3T using 3D variable-flip-angle turbo spin-echo (TSE) with flow-sensitive dephasing (FSD)

PURPOSE

To evaluate the effectiveness of flow-sensitive dephasing (FSD) magnetization preparation in improving blood signal suppression of three-dimensional (3D) turbo spin-echo (TSE) sequence (SPACE) for isotropic high-spatial-resolution carotid arterial wall imaging at 3T.

MATERIALS AND METHODS

The FSD-prepared SPACE sequence (FSD-SPACE) was implemented by adding two identical FSD gradient pulses right before and after the first refocusing 180 degrees -pulse of the SPACE sequence in all three orthogonal directions. Nine healthy volunteers were imaged at 3T with SPACE, FSD-SPACE, and multislice T2-weighted 2D TSE coupled with saturation band (SB-TSE). Apparent carotid wall-lumen contrast-to-noise ratio (aCNR(w-l)) and apparent lumen area (aLA) at the locations with residual-blood (rb) signal shown on SPACE images were compared between SPACE and FSD-SPACE. Carotid aCNR(w-l) and lumen (LA) and wall area (WA) measured from FSD-SPACE were compared to those measured from SB-TSE.

RESULTS

Plaque-mimicking flow artifacts identified in seven carotids on SPACE images were eliminated on FSD-SPACE images. The FSD preparation resulted in slightly reduced aCNR(w-l) (P = 0.025), but significantly improved aCNR between the wall and rb regions (P < 0.001) and larger aLA (P < 0.001). Compared to SB-TSE, FSD-SPACE offered comparable aCNR(w-l) with much higher spatial resolution, shorter imaging time, and larger artery coverage. The LA and WA measurements from the two techniques were in good agreement based on intraclasss correlation coefficient (0.988 and 0.949, respectively; P < 0.001) and Bland-Altman analyses.

CONCLUSION

FSD-SPACE is a time-efficient 3D imaging technique for carotid arterial wall with superior spatial resolution and blood signal suppression.

Effect of blood flow on double inversion recovery vessel wall MRI of the peripheral arteries: quantitation with T2 mapping and comparison with flow-insensitive T2-prepared inversion recovery imaging

Blood suppression in the lower extremities using flow-reliant methods such as double inversion recovery may be problematic due to slow blood flow. T(2) mapping using fast spin echo (FSE) acquisition was utilized to quantitate the effectiveness of double inversion recovery blood suppression in 13 subjects and showed that 25 +/- 12% of perceived vessel wall pixels in the popliteal arteries contained artifactual blood signal. To overcome this problem, a flow-insensitive T(2)-prepared inversion recovery sequence was implemented and optimal timing parameters were calculated for FSE acquisition. Black blood vessel wall imaging of the popliteal and femoral arteries was performed using two-dimensional T(2)-prepared inversion recovery-FSE in the same 13 subjects. Comparison with two-dimensional double inversion recovery-FSE showed that T(2)-prepared inversion recovery-FSE reduced wall-mimicking blood artifacts that inflated double inversion recovery-FSE vessel wall area measurements in the popliteal artery.

MR plaque imaging of the carotid artery

Atherosclerotic carotid plaque represents a major cause of cerebral ischemia. The detection of vulnerable plaque is important for preventing future cardiovascular events. The key factors in advanced plaque that are most likely to lead to patient complications are the condition of the fibrous cap, the size of the necrotic core and hemorrhage, and the extent of inflammatory activity within the plaque. Magnetic resonance (MR) imaging has excellent soft tissue contrast and can allow for a more accurate and objective estimation of carotid wall morphology and plaque composition. Recent advances in MR imaging techniques have permitted serial monitoring of atherosclerotic disease evolution and the identification of intraplaque risk factors for accelerated progression. The purpose of this review article is to review the current state of techniques of carotid wall MR imaging and the characterization of plaque components and surface morphology with MR imaging, and to describe the clinical practice of carotid wall MR imaging for the determination of treatment plan.

Improved blood suppression in three-dimensional (3D) fast spin-echo (FSE) vessel wall imaging using a combination of double inversion-recovery (DIR) and diffusion sensitizing gradient (DSG) preparations

PURPOSE

To provide improved blood suppression in three-dimensional inner-volume fast spin-echo (3D IV-FSE) carotid vessel wall imaging by using a hybrid preparation consisting of double inversion-recovery (DIR) and diffusion sensitizing gradients (DSG).

MATERIALS AND METHODS

Multicontrast black-blood MRI is widely used for vessel wall imaging and characterization of atherosclerotic plaque composition. Blood suppression is difficult when using 3D volumetric imaging techniques. DIR approaches do not provide robust blood suppression due to incomplete replacement of blood spins, and DSG approaches compromise vessel wall signal, reducing the lumen-wall contrast-to-noise ratio efficiency (CNR(eff)). In this work a hybrid DIR+DSG preparation is developed and optimized for blood suppression, vessel wall signal preservation, and vessel-wall contrast in 3D IV-FSE imaging. Cardiac gated T(1)-weighted carotid vessel wall images were acquired in five volunteers with 0.5 x 0.5 x 2.5 mm(3) spatial resolution in 80 seconds.

RESULTS

Data from healthy volunteers indicate that the proposed method yields a statistically significant (P < 0.01) improvement in blood suppression and lumen-wall CNR(eff) compared to standard DIR and standard DSG methods alone.

CONCLUSION

A combination of DIR and DSG preparations can provide improved blood suppression and lumen-wall CNR(eff) for 3D IV-FSE vessel wall imaging.

The added value of longitudinal black-blood cardiovascular magnetic resonance angiography in the cross sectional identification of carotid atherosclerotic ulceration

BACKGROUND

Carotid atherosclerotic ulceration is a significant source of stroke. This study evaluates the efficacy of adding longitudinal black-blood (BB) cardiovascular magnetic resonance (CMR) angiography to cross-sectional CMR images in the identification of carotid atherosclerotic ulceration.

METHODS

Thirty-two subjects (30 males and two females with ages between 48 and 83 years) scheduled for carotid endarterectomy were imaged on a 1.5T GE Signa scanner using multisequence [3D time-of-flight, T1, proton density, T2, contrast enhanced T1], cross-sectional CMR images and longitudinal BB CMR angiography (0.625 x 0.625 mm/pixel). Two rounds of review (round 1: cross-sectional CMR images alone and round 2: cross-sectional CMR images plus longitudinal BB CMR angiography) were conducted for the presence and volume measurements of ulceration. Ulceration was defined as a distinct depression into the plaque containing blood flow signal on cross-sectional CMR and longitudinal BB CMR angiography.

RESULTS

Of the 32 plaques examined by histology, 17 contained 21 ulcers. Using the longitudinal BB CMR angiography sequence in addition to the cross-sectional CMR images in round 2, the sensitivity improved to 80% for ulcers of at least 6 mm3 in volume by histology and 52.4% for all ulcers, compared to 30% and 23.8% in round 1, respectively. There was a slight decline in specificity from 88.2% to 82.3%, though both the positive and negative predictive values increased modestly from 71.4% to 78.6% and from 48.4% to 58.3%, respectively.

CONCLUSION

The addition of longitudinal BB CMR angiography to multisequence cross-sectional CMR images increases accuracy in the identification of carotid atherosclerotic ulceration.

Imaging the vessel wall in major peripheral arteries using susceptibility-weighted imaging

PURPOSE

To demonstrate a novel contrast mechanism for imaging the vessel wall and vessel wall calcification using susceptibility-weighted imaging (SWI).

MATERIALS AND METHODS

Eighteen subjects were imaged with multidetector computed tomography (MDCT) and high-resolution SWI at 3T. The SWI imaging parameters were optimized to allow for the best visualization of the femoral artery lumen and the arterial wall in magnitude and phase images, respectively. SWI-filtered phase data were used to evaluate the diamagnetic susceptibility of vessel wall and of putative vessel wall calcification. Imaging was performed using TE = 15.6 msec (in-phase for fat); TR = 25 msec, flip angle (FA) = 10 degrees , bandwidth (BW) = 80 Hz/pixel, resolution = 0.5 x 0.5 mm in-plane and 1.0 mm through-plane, an acquisition matrix of 512 x 384 x 64 (for read, phase, and slice-select directions), and a total scan time of 8 minutes.

RESULTS

Nineteen calcifications were identified in CT and SWI and they correlated well in both size and position. The contrast-to-noise ratio between the blood signal in the lumen of the artery and arterial wall was 11.7:1 and 7.4:1 in magnitude and in phase images, respectively.

CONCLUSION

SWI provides a novel means to visualize vessel wall and recognize the presence of calcification.

Nonrigid registration of three-dimensional ultrasound and magnetic resonance images of the carotid arteries

Atherosclerosis at the carotid bifurcation can result in cerebral emboli, which in turn can block the blood supply to the brain causing ischemic strokes. Noninvasive imaging tools that better characterize arterial wall, and atherosclerotic plaque structure and composition may help to determine the factors which lead to the development of unstable lesions, and identify patients at risk of plaque disruption and stroke. Carotid magnetic resonance (MR) imaging allows for the characterization of carotid vessel wall and plaque composition, the characterization of normal and pathological arterial wall, the quantification of plaque size, and the detection of plaque integrity. On the other hand, various ultrasound (US) measurements have also been used to quantify atherosclerosis, carotid stenosis, intima-media thickness, total plaque volume, total plaque area, and vessel wall volume. Combining the complementary information provided by 3D MR and US carotid images may lead to a better understanding of the underlying compositional and textural factors that define plaque and wall vulnerability, which may lead to better and more effective stroke prevention strategies and patient management. Combining these images requires nonrigid registration to correct the nonlinear misalignments caused by relative twisting and bending in the neck due to different head positions during the two image acquisition sessions. The high degree of freedom and large number of parameters associated with existing nonrigid image registration methods causes several problems including unnatural plaque morphology alteration, high computational complexity, and low reliability. Thus, a "twisting and bending" model was used with only six parameters to model the normal movement of the neck for nonrigid registration. The registration technique was evaluated using 3D US and MR carotid images at two field strengths, 1.5 and 3.0 T, of the same subject acquired on the same day. The mean registration error between the segmented carotid artery wall boundaries in the target US image and the registered MR images was calculated using a distance-based error metric after applying a "twisting and bending" model based nonrigid registration algorithm. An average registration error of 1.4 +/- 0.3 mm was obtained for 1.5 T MR and 1.5 +/- 0.4 mm for 3.0 T MR, when registered with 3D US images using the nonrigid registration technique presented in this paper. Visual inspection of segmented vessel surfaces also showed a substantial improvement of alignment with this nonrigid registration technique compared to rigid registration.

On the overestimation of early wall thickening at the carotid bulb by black blood MRI, with implications for coronary and vulnerable plaque imaging

Black blood MRI is an attractive tool for monitoring normal and pathological wall thickening; however, limited spatial resolutions can conspire with complex vascular geometries to distort the appearance of the wall in ways hitherto unclear. To elucidate this, a thin-walled cylinder model was developed to predict the composite effects of obliqueness, in-plane resolution and voxel anisotropy on the accuracy of MRI-derived wall thickness measurements. These predictions were validated by means of imaging of a thin-walled carotid bifurcation phantom. Typical thick-slice axial acquisitions were found to result in artifactual wall thickening at the carotid bulb, owing to its obliqueness to the nominal imaging plane. Obliqueness was less problematic for near-isotropic resolutions; however, the obligatory reduction of in-plane resolution served to inflate wall thicknesses uniformly by up to 50%. Moreover, the nonlinear relationship between wall thickness and its overestimation served to mask genuine differences in wall thickness, an effect predicted to be worse for thinner coronary artery walls and plaque caps. Therefore, care must be taken when interpreting black blood MRI wall thickness measurements in the presence-or absence-of observed differences within or between individuals.

Effective motion-sensitizing magnetization preparation for black blood magnetic resonance imaging of the heart

PURPOSE

To investigate the effectiveness of flow signal suppression of a motion-sensitizing magnetization preparation (MSPREP) sequence and to optimize a 2D MSPREP steady-state free precession (SSFP) sequence for black blood imaging of the heart.

MATERIALS AND METHODS

Using a flow phantom, the effect of varying field of speed (FOS), b-value, voxel size, and flow pattern on the flow suppression was investigated. In seven healthy volunteers, black blood images of the heart were obtained at 1.5T with MSPREP-SSFP and double inversion recovery fast spin echo (DIR-FSE) techniques. Myocardium and blood signal-to-noise ratio (SNR) and myocardium-to-blood contrast-to-noise ratio (CNR) were measured. The optimal FOS that maximized the CNR for MSPREP-SSFP was determined.

RESULTS

Phantom data demonstrated that the flow suppression was induced primarily by the velocity encoding effect. In humans, FOS=10-20 cm/s was found to maximize the CNR for short-axis (SA) and four-chamber (4C) views. Compared to DIR-FSE, MSPREP-SSFP provided similar blood SNR efficiency in the SA basal and mid-views and significantly lower blood SNR efficiency in the SA apical (P=0.02) and 4C (P=0.01) views, indicating similar or better blood suppression.

CONCLUSION

Velocity encoding is the primary flow suppression mechanism of the MSPREP sequence and 2D MSPREP-SSFP black blood imaging of the heart is feasible in healthy subjects.

Evaluation of carotid artery atherosclerotic plaque distribution by using long-axis high-resolution black-blood magnetic resonance imaging

Object

The goal of this study was to evaluate the usefulness of long-axis black-blood MR (BB–MR) imaging for assessing plaque morphology and distribution in patients with atherosclerotic carotid artery (CA) stenosis.

Methods

Sixty-eight carotid arteries in 67 patients who were scheduled to undergo CA endarterectomy or CA stent placement due to atherosclerotic stenosis were included in this study. The patients had undergone CA BB–MR imaging and digital subtraction (DS) angiography within 3 weeks of revascularization. The DS angiography studies were performed using the transfemoral artery approach with selective common CA catheterization. The BB–MR images were acquired using a 1.5-T whole-body MR imaging unit, and T1-weighted images parallel to the long axis of the artery at 1-mm intervals were obtained. Plaque distribution was evaluated by measuring the distance between the CA bifurcation and the point that appeared to be the distal extent of the plaque on BB–MR imaging (D–MR imaging) and DS angiography images (D–DS angiography).

Results

Plaque distribution was clearly shown in 88.2% of the cases using long-axis BB–MR images, except for 8 arteries with poor image quality. In 4 arteries, D–DS angiography could not be obtained because the distal plaque end could not be confirmed. In 56 vessels, both the D–DS angiography and D–MR imaging could be measured; the mean D–MR imaging (19.75 ± 6.85 mm [standard deviation]) was significantly longer than the average D–DS angiography (16.32 ± 7.07 mm).

Conclusions

Long-axis BB–MR imaging can provide a noninvasive and accurate way to show CA plaque distribution; it is of great use not only for stroke risk assessment in patients with CA atherosclerosis but also for preoperative evaluation in patients requiring CA endarterectomy or CA stent placement.

Improved suppression of plaque-mimicking artifacts in black-blood carotid atherosclerosis imaging using a multislice motion-sensitized driven-equilibrium (MSDE) turbo spin-echo (TSE) sequence

In this study, a turbo spin-echo (TSE) based motion-sensitized driven-equilibrium (MSDE) sequence was used as an alternative black-blood (BB) carotid MRI imaging scheme. The MSDE sequence was first optimized for more efficient residual blood signal suppression in the carotid bulb of healthy volunteers. Effective contrast-to-noise ratio (CNR(eff)) and residual signal-to-noise ratio (SNR) in the lumen measured from MSDE images were then compared to those measured from inflow saturation (IS) and double inversion-recovery (DIR) images. Statistically significant higher CNR(eff) and lower lumen SNR were obtained from MSDE images. To assess MSDE sequence in a clinical carotid protocol, 42 locations from six subjects with 50% to 79% carotid stenosis by duplex ultrasound were scanned with both MSDE and multislice DIR. The comparison showed that MSDE images present significantly higher CNR and lower lumen SNR compared to corresponding multislice DIR images. The vessel wall area and mean wall thickness measurements in MSDE images were slightly but significantly lower than those obtained with other blood suppression techniques. In conclusion, in vivo comparisons demonstrated that MSDE sequence can achieve better blood suppression and provide a more accurate depiction of the lumen boundaries by eliminating plaque mimicking artifacts in carotid artery (CA) imaging.

The integration of medical imaging and computational fluid dynamics for measuring wall shear stress in carotid arteries

The link between atherosclerosis and wall shear stress (WSS) has lead to considerable interest in the in vivo estimation of WSS. Both magnetic resonance imaging (MRI) and three-dimensional ultrasound (3DUS) are capable of providing the anatomical and flow data required for subject-specific computational fluid dynamics (CFD) simulations. This study compares, for the first time, predicted 3D flow patterns based on black blood MRI and 3DUS. Velocity fields in the carotid arteries of nine subjects have been reconstructed, and the haemodynamic wall parameters WSS, oscillatory shear index (OSI), WSS gradients (WSSG) and angle gradients (WSSAG) were computed and compared. There was a good qualitative agreement between results derived from MRI and 3DUS, embodied by a strong linear correlation between the patched representations of the haemodynamic wall parameters. The root-mean-square error between haemodynamic wall parameters was comparable to the range of the expected variability of each imaging technique (WSS: 0.411 N/m; OSI: 0.048; temporal WSSG: 2.29 N/(s.m/sup 2/); spatial WSSG: 150 N/m/sup 3/; WSSAG: 87.6 rad/m). In conclusion, MRI and 3DUS are comparable techniques for combining with CFD in the carotid artery. The relatively high cost of MRI favour 3DUS to MRI for future haemodynamic studies of superficial arteries.

Diffusion-prepared segmented steady-state free precession: Application to 3D black-blood cardiovascular magnetic resonance of the thoracic aorta and carotid artery walls

This work developed a three-dimensional (3D) diffusion-prepared segmented steady-steady free precession (DP-SSFP) cardiovascular magnetic resonance (CMR) sequence for black-blood (BB) thoracic aortic and carotid wall visualization. In 14 healthy volunteers, BB CMR of the thoracic aorta (n = 7) and carotid arteries (n = 7) was performed over 12 cm and 3 cm of transversal coverage, respectively, with a single 3D DP-SSFP acquisition and multiple two-dimensional (2D) slices using a T2-weighted (T2W) double inversion-recovery fast spin-echo (DIR-FSE) sequence. Arterial wall area (WA), lumen area (LA), and wall-lumen contrast-to-noise ratio (CNR) measured from the 3D DP-SSFP images were compared to those measured from the 2D T2W DIR-FSE images. Strong agreement in WA and LA between the two techniques was observed in the thoracic aorta (WA: intraclass correlation coefficient (ICC) = 0.866, LA: ICC = 0.993; p < 0.001 for both) and carotid arteries (WA: ICC = 0.939, LA: ICC = 0.991; p < 0.001 for both). Adjusted for slice thickness and number of slices, higher effective CNR per unit time (i.e., CNR efficiency) was attained with 3D DP-SSFP than 2D T2W DIR-FSE during thoracic aortic wall imaging (11.6 +/- 1.4 vs. 2.9 +/- 0.5; p < 0.001) and carotid artery wall imaging (10.1 +/- 1.9 vs. 3.1 +/- 0.5; p < 0.001). Diffusion-prepared segmented SSFP is a promising vessel wall CMR sequence that allows for 3D acquisition of thin and contiguous slices with BB image contrast.

Three-dimensional Black-Blood MR Imaging of Carotid Arteries with Segmented Steady-State Free Precession: Initial Experience

This HIPAA-compliant study had institutional review board approval. Informed consent was obtained. The purpose was to prospectively evaluate a segmented three-dimensional (3D) double inversion recovery (DIR)-prepared steady-state free precession (SSFP) magnetic resonance (MR) imaging sequence for fast high-spatial-resolution black-blood carotid arterial wall imaging. Carotid wall-lumen contrast-to-noise ratio (CNR) obtained with this sequence was compared with those obtained with two-dimensional (2D) single- and multisection black-blood fast spin-echo (SE) sequences. MR imaging of both carotid artery bifurcations over 3 cm of transverse coverage was performed in eight volunteers (seven men, one woman; age range, 26-56 years) with no known history of carotid artery disease. Adjusted for section thickness and imaging time per section, higher effective mean CNR was achieved with segmented 3D DIR-prepared SSFP than with single-section 2D DIR-prepared fast SE or multisection 2D saturation-band fast SE (P < .05). Segmented 3D DIR-prepared SSFP enables black-blood carotid arterial wall MR imaging with contiguous thin-section coverage and greater imaging speed and effective CNR than conventional 2D fast SE techniques.

Submillimeter isotropic resolution carotid wall MRI with swallowing compensation: Imaging results and semiautomated wall morphometry

PURPOSE

To assess a swallowing-compensated, three-dimensional (3D) diffusion-prepared segmented steady-state free precession (3D Nav-D-SSFP) technique for carotid wall MRI with 0.6-mm isotropic spatial resolution, and its utility for semiautomated carotid wall morphometry.

MATERIALS AND METHODS

The carotid arteries of seven healthy volunteers (N=14) were imaged with 3D Nav-D-SSFP and black-blood T2-weighted (T2w) two-dimensional (2D) fast spin-echo (FSE). Carotid wall-lumen contrast-to-noise ratio (CNR) was measured with both sequences. Measurement of carotid wall area (WA) and lumen area (LA) made in a semiautomated manner off of the 3D Nav-D-SSFP images were compared to those made manually.

RESULTS

Adjusted for voxel volume and number of slices, a near six-fold improvement in CNR per unit time was achieved with 3D Nav-D-SSFP relative to 2D T2w FSE (P<0.001). Manual and semiautomated measurements of carotid WA and LA on the 3D Nav-D-SSFP images were highly correlated (intraclass correlation coefficient (ICC)=0.961 and 0.996, respectively; P<0.001).

CONCLUSION

3D Nav-D-SSFP is a time-efficient, swallowing-compensated, black-blood technique that lends itself for semiautomated measurements of carotid WA and LA that are in good agreement with manual measurements.

MRI of atherosclerosis in clinical trials

Magnetic resonance imaging (MRI) of the arterial wall has emerged as a viable technology for characterizing atherosclerotic lesions in vivo, especially within carotid arteries and other large vessels. This capability has facilitated the use of carotid MRI in clinical trials to evaluate therapeutic effects on atherosclerotic lesions themselves. MRI is specifically able to characterize three important aspects of the lesion: size, composition and biological activity. Lesion size, expressed as a total wall volume, may be more sensitive than maximal vessel narrowing (stenosis) as a measure of therapeutic effects, as it reflects changes along the entire length of the lesion and accounts for vessel remodeling. Lesion composition (e.g. lipid, fibrous and calcified content) may reflect therapeutic effects that do not alter lesion size or stenosis, but cause a transition from a vulnerable plaque composition to a more stable one. Biological activity, most notably inflammation, is an emerging target for imaging that is thought to destabilize plaque and which may be a systemic marker of vulnerability. The ability of MRI to characterize each of these features in carotid atherosclerotic lesions gives it the potential, under certain circumstances, to replace traditional trials involving large numbers of subjects and hard end-points--heart attacks and strokes--with smaller, shorter trials involving imaging end-points. In this review, the state of the art in MRI of atherosclerosis is presented in terms of hardware, image acquisition protocols and post-processing. Also, the results of validation studies for measuring lesion size, composition and inflammation will be summarized. Finally, the status of several clinical trials involving MRI of atherosclerosis will be reviewed.

Simultaneous outer volume and blood suppression by quadruple inversion-recovery

A new method has been developed for reduced field-of-view (FOV) imaging with simultaneous blood suppression. This method combines suppression of signals from the outer volume and inflowing blood by using a small-FOV quadruple inversion-recovery (SFQIR) preparative pulse sequence consisting of two double-inversion pulse pairs separated by appropriate delays. Within each pair, inversion pulses are successively applied to the imaged slice and the slab orthogonal to the imaging plane with the thickness equal to the FOV size in the phase-encoding direction. Each double inversion results in the reinversion of the magnetization in the central part of the FOV, while the outer areas of the FOV and inflowing blood remain inverted. The SFQIR module was implemented for single- and multislice acquisition with a fast spin-echo readout sequence. Based on a theoretical model of the signal, the timing parameters of the sequence corresponding to the maximal suppression efficiency can be found by minimizing the variation of the normalized signal over the entire range of T1's that occur in tissues. The method was tested for black-blood imaging of the aorta and carotid arteries, and the results demonstrated its ability to eliminate motion and flow artifacts, reduce scan time, and improve spatial resolution.

Multislice dark-blood carotid artery wall imaging: a 1.5 T and 3.0 T comparison

PURPOSE

To compare two multislice turbo spin-echo (TSE) carotid artery wall imaging techniques at 1.5 T and 3.0 T, and to investigate the feasibility of higher spatial resolution carotid artery wall imaging at 3.0 T.

MATERIALS AND METHODS

Multislice proton density-weighted (PDW), T2-weighted (T2W), and T1-weighted (T1W) inflow/outflow saturation band (IOSB) and rapid extended coverage double inversion-recovery (REX-DIR) TSE carotid artery wall imaging was performed on six healthy volunteers at 1.5 T and 3.0 T using time-, coverage-, and spatial resolution-matched (0.47 x 0.47 x 3 mm3) imaging protocols. To investigate whether improved signal-to-noise ratio (SNR) at 3.0 T could allow for improved spatial resolution, higher spatial resolution imaging (0.31 x 0.31 x 3 mm3) was performed at 3.0 T. Carotid artery wall SNR, carotid lumen SNR, and wall-lumen contrast-to-noise ratio (CNR) were measured.

RESULTS

Signal gain at 3.0 T relative to 1.5 T was observed for carotid artery wall SNR (223%) and wall-lumen CNR (255%) in all acquisitions (P < 0.025). IOSB and REX-DIR images were found to have different levels of SNR and CNR (P < 0.05) with IOSB values observed to be larger. Normalized to a common imaging time, the higher spatial resolution imaging at 3.0 T and the lower spatial resolution imaging at 1.5 T provided similar levels of wall-lumen CNR (P = NS).

CONCLUSION

Multislice carotid wall imaging at 3.0 T with IOSB and REX-DIR benefits from improved SNR and CNR relative to 1.5 T, and allows for higher spatial resolution carotid artery wall imaging.

Bright and black blood imaging of the carotid bifurcation at 3.0T

PURPOSE

The aim of this study was to evaluate our preliminary experience at 3.0 T with imaging of the carotid bifurcation in healthy and atherosclerotic subjects. Application at 3.0 T is motivated by the signal-to-noise gain for improving spatial resolution and reducing signal averaging requirements.

MATERIALS AND METHODS

We utilized a dual phased array coil and applied 2D, 3D time of flight (TOF) and turbo spin echo (TSE) sequences with comparison of two lumen signal suppression methods for black blood (BB) TSE imaging including double inversion preparation (DIR) and spatial presaturation pulses. The signal-to-noise ratios (SNR) of healthy carotid vessel walls were compared in 2D and 3D BB TSE acquisitions. The bright and black blood multi-contrast exam was demonstrated for a complex carotid plaque.

RESULTS

Contrast-to-noise (CNR) greater than 150 was achieved between the lumen and suppressed background for 3D TOF. For BB, both methods provided sufficient lumen signal suppression but slight residual flow artifacts remained at the bifurcation level. As expected 3D TSE images had higher SNR compared to 2D, but increased motion sensitivity is a significant issue for 3D at high field. For multi-contrast imaging of atherosclerotic plaque, fibrous, calcified and lipid components were resolved. The CNR ratio of fibrous (bright on PDW, T2W) and calcified (dark in T1W, T2W, PDW) plaque components was maximal in the T2W images. The 3D TOF angiogram indicating a 40% stenosis was complemented by 3D multi-planar reformat of BB images that displayed plaque extent. Detection of intimal thickening, the earliest change associated with atherosclerotic progression was observed in BB PDW images at 3.0 T.

CONCLUSIONS

High SNR and CNR images have been demonstrated for the healthy and diseased carotid. Improvements in RF coils along with pulse sequence optimization, and evaluation of endogenous and exogenous contrast mechanisms will further enhance carotid imaging at 3.0T.

Comparison of gated and non-gated fast multislice black-blood carotid imaging using rapid extended coverage and inflow/outflow saturation techniques

PURPOSE

To comparatively analyze two fast in vivo multislice black-blood carotid artery vessel wall imaging techniques with and without cardiac gating.

MATERIALS AND METHODS

Eight subjects with carotid artery atherosclerosis, and four healthy subjects were studied using two black-blood multislice techniques: rapid extended coverage double inversion recovery (REX-DIR), and inflow/outflow saturation band (IOSB) rapid acquisition with relaxation enhancement (RARE) multislice acquisitions. Quantitative, qualitative, and morphometric analyses were performed on images.

RESULTS

Gating produced significantly lower values for the REX-DIR sequence with respect to signal intensity in muscle and the carotid artery wall, whereas it had no effect on flow suppression compared to non-gated images. For the IOSB sequences, gating had no significant effect on signal intensity of muscle and the carotid artery wall, but worsened flow suppression. REX-DIR and IOSB sequences were statistically different with respect to signal intensity of muscle (with REX-DIR sequences having lower values), while no statistical significance was observed for flow suppression and wall delineation. A morphologic analysis of the vessel wall and lumen comparing REX-DIR gated, IOSB gated, REX-DIR non-gated, and IOSB non-gated sequences revealed no significant differences between the acquisition techniques tested.

CONCLUSION

Non-gated sequences may be used instead of gated sequences in atherosclerotic vessel wall imaging without compromising image quality. This may shorten examination time and improve patient comfort.

Real-time gating system for mouse cardiovascular MR imaging

Mouse cardiac MR gating using ECG is affected by the hostile MR environment. It requires appropriate signal processing and correct QRS detection, but gating software methods are currently limited. In this study we sought to demonstrate the feasibility of digital real-time automatically updated gating methods, based on optimizing a signal-processing technique for different mouse strains. High-resolution MR images of mouse hearts and aortic arches were acquired using a chain consisting of ECG signal detection, digital signal processing, and gating signal generation modeled using Simulink (The MathWorks, Inc., Natick, MA, USA). The signal-processing algorithms used were respectively low-pass filtering, nonlinear passband, and wavelet decomposition. Both updated and nonupdated gating signal generation methods were tested. Noise reduction was assessed by comparison of the ECG signal-to-noise ratio (SNR) before and after each processing step. Gating performance was assessed by measuring QRS detection accuracy before and after online trigger-level adjustments. Low-pass filtering with trigger-level adjustment gave the best performance for mouse cardiovascular imaging using gradient-echo (GE), spin-echo (SE), and fast SE (FSE) sequences with minimum induced delay and maximum gating efficiency (99% sensitivity and R-peak detection). This simple digital gating interface will allow various gating strategies to be optimized for cardiovascular MR explorations in mice.

Resolution and SNR effects on carotid plaque classification

Multicontrast-weighted MRI, which is increasingly being used in combination with automatic classification algorithms, has the potential to become a powerful tool for assessing plaque composition. The current literature, however, does not address the relationship between imaging conditions and segmentation viability well. In this study 13 carotid endarterectomy samples were imaged with a 156-microm in-plane resolution and high signal-to-noise ratio (SNR) using proton density (PD), T1, T2, and diffusion weightings. The maximum likelihood (ML) algorithm was used to classify plaque components, with sets of three contrast weighting intensities used as features. The resolution and SNR of the images were then degraded. Classification accuracy was found to be independent of in-plane resolution between 156 microm and 1250 microm, but dependent on SNR. Accuracy decreased less than 10% for degradation in SNR down to 25% of original values, and decreased sharply thereafter. The robustness of automatic classifiers makes them applicable to a wide range of imaging conditions, including standard in vivo carotid imaging scenarios.

Magnetic resonance imaging of atherosclerosis

Abundant data now link composition of the vascular wall, rather than the degree of luminal narrowing, with the risk for acute ischemic syndromes in the coronary, central nervous system, and peripheral arterial beds. Over the past few years, magnetic resonance angiography has evolved as a well-established method to determine the location and severity of advanced, lumen-encroaching atherosclerotic lesions. In addition, more recent studies have shown that high spatial resolution, multisequence MRI is also a promising tool for noninvasive, serial imaging of the aortic and carotid vessel wall, which potentially can be applied in the clinical setting. Because of the limited spatial resolution of current MRI techniques, characterization of coronary vessel wall atherosclerosis, however, is not yet possible and remains the holy grail of plaque imaging. Recent technical developments in MRI technology such as dedicated surface coils, the introduction of 3.0-T high-field systems and parallel imaging, as well as developments in the field of molecular imaging such as contrast agents targeted to specific plaque constituents, are likely to lead to the necessary improvements in signal to noise ratio, imaging speed, and specificity. These improvements will ultimately lead to more widespread application of this technology in clinical practice. In the present review, the current status and future role of MRI for plaque detection and characterization are summarized.

Image-based carotid flow reconstruction: a comparison between MRI and ultrasound

Atherosclerosis is a major cause of morbidity and mortality. Its apparent link with wall shear stress (WSS) has led to considerable interest in the in vivo estimation of WSS. Determining WSS by combining medical images with computational fluid dynamics (CFD) simulations can be performed both with magnetic resonance imaging (MRI) and three-dimensional ultrasound (3DUS). This study compares predicted 3D flow patterns based on black blood MRI and 3DUS. Velocity fields in the carotid arteries of nine subjects have been reconstructed, and the haemodynamic wall parameters WSS, oscillatory shear index (OSI), WSS gradients (WSSG) and angle gradients (WSSAG) were compared between the two imaging techniques. There was a good qualitative agreement between results derived from MRI and 3DUS (average correlation strength above 0.60). The root mean square error between haemodynamic wall parameters was comparable to the range of the expected variability of each imaging technique (WSS: 0.411 N m(-2); OSI: 0.048; temporal WSSG: 150 N s(-1) m(-2); spatial WSSG: 2.29 N m(-3); WSSAG: 87.6 rad m(-1)). In conclusion, MRI and 3DUS are capable of providing haemodynamic parameters when combined with CFD, and the predictions are in most cases qualitatively and quantitatively similar. The relatively high cost of MRI and continuing improvement in ultrasound favour US to MRI for future haemodynamic studies of superficial arteries.

MRI of atherosclerosis

The emergence of high-resolution, rapid imaging methods has enabled MRI to noninvasively image the fine internal structure of atherosclerotic artery walls. This capability has, in turn, captured the interest of clinicians, who see it as an opportunity to assess disease severity based on the characteristics of atherosclerotic lesions themselves, rather than only their effects on the vessel lumen. MRI of atherosclerosis thus has the potential to be used in medical treatment decisions or to assess the effects of experimental treatment options. Given this potential, a number of research groups have been investigating MRI of atherosclerosis in an effort to establish the ability of MRI to determine atherosclerotic plaque burden, detect plaque composition, and ultimately identify vulnerable plaque before it leads to a clinical event. In this review, the current state of the art is summarized for the three primary vessel targets: the carotid artery, the aorta, and the coronary arteries.

Evaluation of carotid stenosis with axial high-resolution black-blood MR imaging

High-resolution axial black-blood MR imaging (BB MRI) has been shown to be able to characterise carotid plaque morphology. The aim of this study was to explore the accuracy of this technique in quantifying the severity of carotid stenosis. A prospective study of 54 patients with symptomatic carotid disease was conducted, comparing BB MRI to the gold standard, conventional digital subtraction X-ray angiography (DSA). The BB MRI sequence was a fast-spin echo acquisition (TE = 42 ms, ETL = 24, field of view = 100 x 100 mm, slice thickness = 3.0 mm) at 1.5 T using a custom-built phased-array coil. Linear measurements of luminal and outer carotid wall diameter were made directly from the axial BB MRI slices by three independent blinded readers and stenosis was calculated according to European Carotid Surgery Trial (ECST) criteria. There was good agreement between BB MRI and DSA (intraclass correlation = 0.83). Inter-observer agreement was good (average kappa = 0.77). BB MRI was accurate for detection of severe stenosis (> or = 80%) with sensitivity and specificity of 87 and 81%, respectively. Eight cases of "DSA-defined" moderate stenosis were overestimated as severe by BB MRI and this may be related to non-circular lumens. Axial imaging with BB MRI could potentially be used to provide useful information about severity of carotid stenosis.