Quantitative MRI for the assessment of bone structure and function

More accurate trabecular bone imaging using UTE MRI at the resonance frequency of fat

High-resolution magnetic resonance imaging (HR-MRI) has been increasingly used to assess the trabecular bone structure. High susceptibility at the marrow/bone interface may significantly reduce the marrow's apparent transverse relaxation time (T2*), overestimating trabecular bone thickness. Ultrashort echo time MRI (UTE-MRI) can minimize the signal loss caused by susceptibility-induced T2* shortening. However, UTE-MRI is sensitive to chemical shift artifacts, which manifest as spatial blurring and ringing artifacts partially due to non-Cartesian sampling. In this study, we proposed UTE-MRI at the resonance frequency of fat to minimize marrow-related chemical shift artifacts and the overestimation of trabecular thickness. Cubes of trabecular bone from six donors (75 ± 4 years old) were scanned using a 3 T clinical scanner at the resonance frequencies of fat and water, respectively, using 3D UTE sequences with five TEs (0.032, 1.1, 2.2, 3.3, and 4.4 ms) and a clinical 3D gradient echo (GRE) sequence at 0.2 × 0.2 × 0.4 mm3 voxel size. Trabecular bone thickness was measured in 30 regions of interest (ROIs) per sample. MRI results were compared with thicknesses obtained from micro-computed tomography (μCT) at 50 μm3 voxel size. Linear regression models were used to calculate the coefficient of determination between MRI- and μCT-based trabecular thickness. All MRI-based trabecular thicknesses showed significant correlations with μCT measurements. The correlations were higher (examined with paired Student's t-test, P < 0.01) for 3D UTE images performed at the fat frequency (R2 = 0.59-0.74, P < 0.01) than those at the water frequency (R2 = 0.18-0.52, P < 0.01) and clinical GRE images (R2 = 0.39-0.47, P < 0.01). Significantly reduced correlations were observed with longer TEs. This study highlighted the feasibility of UTE-MRI at the fat frequency for a more accurate assessment of trabecular bone thickness.

Bone Biomarkers Based on Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is increasingly used to evaluate the microstructural and compositional properties of bone. MRI-based biomarkers can characterize all major compartments of bone: organic, water, fat, and mineral components. However, with a short apparent spin-spin relaxation time (T2*), bone is invisible to conventional MRI sequences that use long echo times. To address this shortcoming, ultrashort echo time MRI sequences have been developed to provide direct imaging of bone and establish a set of MRI-based biomarkers sensitive to the structural and compositional changes of bone. This review article describes the MRI-based bone biomarkers representing total water, pore water, bound water, fat fraction, macromolecular fraction in the organic matrix, and surrogates for mineral density. MRI-based morphological bone imaging techniques are also briefly described.

Six-minute, in vivo MRI quantification of proximal femur trabecular bone 3D microstructure

BACKGROUND

Assessment of proximal femur trabecular bone microstructure in vivo by magnetic resonance imaging has recently been validated for acquiring information independent of bone mineral density in osteoporotic patients. However, the requisite signal-to-noise ratio (SNR) and resolution for interrogation of the trabecular microstructure at this anatomical location prolongs the scan duration and renders the imaging protocol clinically infeasible. Parallel imaging and compressed sensing (PICS) techniques can reduce the scan duration of the imaging protocol without substantially compromising image quality. The present work investigates the limits of acceleration for a commonly used PICS technique, ℓ1-ESPIRiT, for the purpose of quantifying measures of trabecular bone microarchitecture. Based on a desired error tolerance, a six-minute, prospectively accelerated variant of the imaging protocol was developed and assessed for intersession reproducibility and agreement with the longer reference scan.

PURPOSE

To investigate the limits of acceleration for MRI-based trabecular bone quantification by parallel imaging and compressed sensing reconstruction, and to develop a prototypical imaging protocol for assessing the proximal femur microstructure in a clinically practical scan time.

METHODS

Healthy participants (n = 11) were scanned by a 3D balanced steady-state free precession (bSSFP) sequence satisfying the Nyquist criterion with a scan duration of about 18 min. The raw data were retrospectively undersampled and reconstructed to mimic various acceleration factors ranging from 2 to 6. Trabecular volumes-of-interest in four major femoral regions (greater trochanter, intertrochanteric region, femoral neck, and femoral head) were analyzed and six relevant measures of trabecular bone microarchitecture (bone volume fraction, surface-to-curve ratio, erosion index, elastic modulus, trabecular thickness, plates-to-rods ratio) were obtained for images of all accelerations. To assess agreement, median percent error and intraclass correlation coefficients (ICCs) were computed using the fully-sampled data as reference. Based on this analysis, a prospectively 3-fold accelerated sequence with a duration of about 6 min was developed and the analysis was repeated.

RESULTS

A prospective acceleration factor of 3 demonstrated comparable performance in reproducibility and absolute agreement to the fully-sampled scan. The median CoV over all image-derived metrics was generally <6 % and ICCs >0.70. Also, measurements from prospectively 3-fold accelerated scans demonstrated in general median percent errors of <7 % and ICCs >0.70.

CONCLUSION

The present work proposes a method to make in vivo quantitative assessment of proximal femur trabecular microstructure with a clinically practical scan duration of about 6 min.

Correlation of R2* with fat fraction and bone mineral density and its role in quantitative assessment of osteoporosis

OBJECTIVES

To investigate the correlation of R2* with vertebral fat fraction (FF) and bone mineral density (BMD), and to explore its role in the quantitative assessment of osteoporosis (OP).

METHODS

A total of 83 patients with low back pain (59.77 ± 7.46 years, 30 males) were enrolled, which underwent lumbar MRI in IDEAL-IQ sequences and quantitative computed tomography (QCT) scanning within 48h. The FF, R2*, and BMD of all 415 lumbar vertebrae were respectively measured. According to BMD, all vertebrae were divided into BMD normal, osteopenia, and OP groups, and the difference of FF and R2* among groups was analyzed by one-way ANOVA. The correlation between R2*, FF, and BMD was analyzed by Pearson's test. Taking BMD as the gold standard, the efficacies for FF and R2* in diagnosis of OP and osteopenia were assessed by receiver operating characteristic curve, and their area under the curve (AUC) was compared with DeLong's test.

RESULTS

The FF and R2* were statistically different among groups (F values of 102.521 and 11.323, both p < 0.05), and R2* were significantly correlated with FF and BMD, respectively (r values of -0.219 and 0.290, both p < 0.05). In diagnosis of OP and osteopenia, the AUCs were 0.776 and 0.778 for FF and 0.638 and 0.560 for R2*, and the AUCs of R2* were lower than those of FF, with Z values of 4.030 and 4.087, both p < 0.001.

CONCLUSION

R2* is significantly correlated with FF and BMD and can be used as a complement to FF and BMD for quantitative assessment of OP.

KEY POINTS

• R2* based on IDEAL-IQ sequences has a definite but weak linear relationship with FF and BMD. • FF is significantly correlated with BMD and can effectively evaluate BMAT. • R2* can be used as a complement to FF and BMD for fine quantification of bone mineral loss and bone marrow fat conversion.

Ultrashort Echo Time (UTE) MRI porosity index (PI) and suppression ratio (SR) correlate with the cortical bone microstructural and mechanical properties: Ex vivo study

Ultrashort echo time (UTE) MRI can image and consequently enable quantitative assessment of cortical bone. UTE-MRI-based evaluation of bone is largely underutilized due to the high cost and time demands of MRI in general. The signal ratio in dual-echo UTE imaging, known as porosity index (PI), as well as the signal ratio between UTE and inversion recovery UTE (IR-UTE) imaging, known as the suppression ratio (SR), are two rapid UTE-based bone evaluation techniques (∼ 5 mins scan time each), which can potentially reduce the time demand and cost in future clinical studies. This study aimed to investigate the correlations of PI and SR measures with cortical bone microstructural and mechanical properties. Cortical bone strips (n = 135) from tibial and femoral midshafts of 37 donors (61 ± 24 years old) were scanned using a dual-echo 3D Cones UTE sequence and a 3D Cones IR-UTE sequence for PI and SR calculations, respectively. Average bone mineral density, porosity, and pore size were measured using microcomputed tomography (μCT). Bone mechanical properties were measured using 4-point bending tests. The μCT measures showed significant correlations with PI (moderate to strong, R = 0.68-0.71) and SR (moderate, R = 0.58-0.68). Young's modulus, yield stress, and ultimate stress demonstrated significant moderate correlations with PI and SR (R = 0.52-0.62) while significant strong correlations with μCT measures (R > 0.7). PI and SR can potentially serve as fast and noninvasive (non-ionizing radiation) biomarkers for evaluating cortical bone in various bone diseases.

Comprehensive assessment of osteoporosis in lumbar spine using compositional MR imaging of trabecular bone

OBJECTIVES

To comprehensively assess osteoporosis in the lumbar spine, a compositional MR imaging technique is proposed to quantify proton fractions for all the water components as well as fat in lumbar vertebrae measured by a combination of a 3D short repetition time adiabatic inversion recovery prepared ultrashort echo time (STAIR-UTE) MRI and IDEAL-IQ.

METHODS

A total of 182 participants underwent MRI, quantitative CT, and DXA. Lumbar collagen-bound water proton fraction (CBWPF), free water proton fraction (FWPF), total water proton fraction (TWPF), bone mineral density (BMD), and T-score were calculated in three vertebrae (L2-L4) for each subject. The correlations of the CBWPF, FWPF, and TWPF with BMD and T-score were investigated respectively. A comprehensive diagnostic model combining all the water components and clinical characteristics was established. The performances of all the water components and the comprehensive diagnostic model to discriminate between normal, osteopenia, and osteoporosis cohorts were also evaluated using receiver operator characteristic (ROC).

RESULTS

The CBWPF showed strong correlations with BMD (r = 0.85, p < 0.001) and T-score (r = 0.72, p < 0.001), while the FWPF and TWPF showed moderate correlations with BMD (r = 0.65 and 0.68, p < 0.001) and T-score (r = 0.47 and 0.49, p < 0.001). The high area under the curve values obtained from ROC analysis demonstrated that CBWPF, FWPF, and TWPF have the potential to differentiate the normal, osteopenia, and osteoporosis cohorts. At the same time, the comprehensive diagnostic model shows the best performance.

CONCLUSIONS

The compositional MRI technique, which quantifies CBWPF, FWPF, and TWPF in trabecular bone, is promising in the assessment of bone quality.

KEY POINTS

• Compositional MR imaging technique is able to quantify proton fractions for all the water components (i.e., collagen-bound water proton fraction (CBWPF), free water proton fraction (FWPF), and total water proton fraction (TWPF)) in the human lumbar spine. • The biomarkers derived from the compositional MR imaging technique showed moderate to high correlations with bone mineral density (BMD) and T-score and showed good performance in distinguishing people with different bone mass. • The comprehensive diagnostic model incorporating CBWPF, FWPF, TWPF, and clinical characteristics showed the highest clinical diagnostic capability for the assessment of osteoporosis.

Making the invisible visible-ultrashort echo time magnetic resonance imaging: Technical developments and applications

Magnetic resonance imaging (MRI) uses a large magnetic field and radio waves to generate images of tissues in the body. Conventional MRI techniques have been developed to image and quantify tissues and fluids with long transverse relaxation times (T2s), such as muscle, cartilage, liver, white matter, gray matter, spinal cord, and cerebrospinal fluid. However, the body also contains many tissues and tissue components such as the osteochondral junction, menisci, ligaments, tendons, bone, lung parenchyma, and myelin, which have short or ultrashort T2s. After radio frequency excitation, their transverse magnetizations typically decay to zero or near zero before the receiving mode is enabled for spatial encoding with conventional MR imaging. As a result, these tissues appear dark, and their MR properties are inaccessible. However, when ultrashort echo times (UTEs) are used, signals can be detected from these tissues before they decay to zero. This review summarizes recent technical developments in UTE MRI of tissues with short and ultrashort T2 relaxation times. A series of UTE MRI techniques for high-resolution morphological and quantitative imaging of these short-T2 tissues are discussed. Applications of UTE imaging in the musculoskeletal, nervous, respiratory, gastrointestinal, and cardiovascular systems of the body are included.

Clinical Anatomy and Medical Malpractice-A Narrative Review with Methodological Implications

Anatomical issues are intrinsically included in medico-legal methodology, however, higher awareness would be needed about the relevance of anatomy in addressing medico-legal questions in clinical/surgical contexts. Forensic Clinical Anatomy has been defined as "the practical application of Clinical Anatomy to the ascertainment and evaluation of medico-legal problems". The so-called individual anatomy (normal anatomy, anatomical variations, or anatomical modifications due to development, aging, para-physiological conditions, diseases, or surgery) may acquire specific relevance in medico-legal ascertainment and evaluation of cases of supposed medical malpractice. Here, we reviewed the literature on the relationships between anatomy, clinics/surgery, and legal medicine. Some methodological considerations were also proposed concerning the following issues: (1) relevant aspects of individual anatomy may arise from the application of methods of ascertainment, and they may be furtherly ascertained through specific anatomical methodology; (2) data about individual anatomy may help in the objective application of the criteria of evaluation (physio-pathological pathway, identification-evaluation of errors, causal value, damage estimation) and in final judgment about medical responsibility/liability. Awareness of the relevance of individual anatomy (risk of iatrogenic lesions, need for preoperative diagnostic procedures) should be one of the principles guiding the clinician; medico-legal analyses can also take advantage of its contribution in terms of ascertainment/evaluation.

Biomineralization of bone tissue: calcium phosphate-based inorganics in collagen fibrillar organic matrices

Background

Bone regeneration research is currently ongoing in the scientific community. Materials approved for clinical use, and applied to patients, have been developed and produced. However, rather than directly affecting bone regeneration, these materials support bone induction, which regenerates bone. Therefore, the research community is still researching bone tissue regeneration. In the papers published so far, it is hard to find an improvement in the theory of bone regeneration. This review discusses the relationship between the existing theories on hard tissue growth and regeneration and the biomaterials developed so far for this purpose and future research directions.

Mainbody

Highly complex nucleation and crystallization in hard tissue involves the coordinated action of ions and/or molecules that can produce different organic and inorganic composite biomaterials. In addition, the healing of bone defects is also affected by the dynamic conditions of ions and nutrients in the bone regeneration process. Inorganics in the human body, especially calcium- and/or phosphorus-based materials, play an important role in hard tissues. Inorganic crystal growth is important for treating or remodeling the bone matrix. Biomaterials used in bone tissue regeneration require expertise in various fields of the scientific community. Chemical knowledge is indispensable for interpreting the relationship between biological factors and their formation. In addition, sources of energy for the nucleation and crystallization processes of such chemical bonds and minerals that make up the bone tissue must be considered. However, the exact mechanism for this process has not yet been elucidated. Therefore, a convergence of broader scientific fields such as chemistry, materials, and biology is urgently needed to induce a distinct bone tissue regeneration mechanism.

Conclusion

This review provides an overview of calcium- and/or phosphorus-based inorganic properties and processes combined with organics that can be regarded as matrices of these minerals, namely collagen molecules and collagen fibrils. Furthermore, we discuss how this strategy can be applied to future bone tissue regenerative medicine in combination with other academic perspectives.

Mechanical Behavior of Human Cancellous Bone in Alveolar Bone under Uniaxial Compression and Creep Tests

In the process of orthodontic treatment, the remodeling of cancellous bone in alveolar bone (in this paper, cancellous bone in alveolar bone is abbreviated as CBAB) is key to promoting tooth movement. Studying the mechanical behavior of CBAB is helpful to predict the displacement of teeth and achieve the best effect of orthodontic treatment. Three CBAB samples were cut from alveolar bone around the root apex of human teeth. A uniaxial compression test was used to study the transient elastic properties of CBAB. A creep test was used to study the time-dependent viscoelastic properties of CBAB. Both tests were carried out at the loading rates of 0.02 mm/min, 0.1 mm/min and 0.5 mm/min. The results revealed that CBAB is a nonlinear viscoelastic and hyperelastic material. The stress−strain curve obtained from the uniaxial compression test could be divided into three stages: the collapse stage of the front section, the exponential stage of the middle section and the almost linear stage of the rear end. According to the strain−time curve obtained from the compression creep test, a trend of increasing strain over time was relatively obvious within the first 30 s. After 200 s, the curve gradually tended to plateau. Four hyperelastic models and three viscoelastic models were used to fit the test data. Finally, the fifth-order polynomial hyperelastic model (coefficient of determination “R2 > 0.999”) was used to describe the hyperelastic properties of CBAB, and the seven-parameter model of the generalized Kelvin modified model (“R2 > 0.98”) was used to describe the viscoelastic properties of CBAB.

On quantification errors of R 2 * $$ {R}_2^{\ast } $$ and proton density fat fraction mapping in trabecularized bone marrow in the static dephasing regime

PURPOSE

To study the effect of field inhomogeneity distributions in trabecularized bone regions on the gradient echo (GRE) signal with short TEs and to characterize quantification errors on R 2 * $$ {R}_2^{\ast } $$ and proton density fat fraction (PDFF) maps when using a water-fat model with an exponential R 2 * $$ {R}_2^{\ast } $$ decay model at short TEs.

METHODS

Field distortions were simulated based on a trabecular bone micro CT dataset. Simulations were performed for different bone volume fractions (BV/TV) and for different bone-fat composition values. A multi-TE UTE acquisition was developed to acquire multiple UTEs with random order to minimize eddy currents. The acquisition was validated in phantoms and applied in vivo in a volunteer's ankle and knee. Chemical shift encoded MRI (CSE-MRI) based on a Cartesian multi-TE GRE scan was acquired in the spine of patients with metastatic bone disease.

RESULTS

Simulations showed that signal deviations from the exponential signal decay at short TEs were more prominent for a higher BV/TV. UTE multi-TE measurements reproduced in vivo the simulation-based predicted behavior. In regions with high BV/TV, the presence of field inhomogeneities induced an R 2 * $$ {R}_2^{\ast } $$ underestimation in trabecularized bone marrow when using CSE-MRI at 3T with a short TE.

CONCLUSION

R 2 * $$ {R}_2^{\ast } $$ can be underestimated when using short TEs (<2 ms at 3 T) and a water-fat model with an exponential R 2 * $$ {R}_2^{\ast } $$ decay model in multi-echo GRE acquisitions of trabecularized bone marrow.

Multi-scanner and multi-modal lumbar vertebral body and intervertebral disc segmentation database

Magnetic resonance imaging (MRI) is widely utilized for diagnosing and monitoring of spinal disorders. For a number of applications, particularly those related to quantitative MRI, an essential step towards achieving reliable and objective measurements is the segmentation of the examined structures. Performed manually, such process is time-consuming and prone to errors, posing a bottleneck to its clinical applicability. A more efficient analysis would be achieved by automating a segmentation process. However, routine spine MRI acquisitions pose several challenges for achieving robust and accurate segmentations, due to varying MRI acquisition characteristics occurring in data acquired from different sites. Moreover, heterogeneous annotated datasets, collected from multiple scanners with different pulse sequence protocols, are limited. Thus, we present a manually segmented lumbar spine MRI database containing a wide range of data obtained from multiple scanners and pulse sequences, with segmentations of lumbar vertebral bodies and intervertebral discs. The database is intended for the use in developing and testing of automated lumbar spine segmentation algorithms in multi-domain scenarios.

Measurement(s)	Vertebral Body • Intervertebral Disc
Technology Type(s)	Magnetic Resonance Imaging

Quantitative assessment of lumbar spine bone marrow in patients with different severity of CKD by IDEAL-IQ magnetic resonance sequence

BACKGROUND

Chronic kidney disease (CKD) has a significant negative impact on bone health. Bone marrow is an essential component of bone, mainly composed of trabecular bone and fat. The IDEAL-IQ sequence of MRI allows indirect quantification of trabecular bone mass by R2* and direct quantification of bone marrow fat content by FF map, respectively.

OBJECTIVE

Our objective was to explore the association of CKD severity with bone marrow using IDEAL-IQ and whether mineral and bone metabolism markers alter this association.

METHOD

We recruited 68 CKD patients in this cross-sectional research (15 with CKD stages 3-4, 26 with stage 5, and 27 with stage 5d). All patients underwent lumbar spine IDEAL-IQ, BMD, and several bone metabolism markers (iPTH, 25-(OH)-VitD, calcium and phosphorus). Multiple linear regression analysis was used to examine the association of CKD severity with MRI measurements (R2* and FF).

RESULTS

More severe CKD was associated with a higher R2* value [CKD 5d versus 3-4: 30.077 s^-1 (95% CI: 12.937, 47.217), P for trend < 0.001], and this association was attenuated when iPTH was introduced [CKD 5d versus 3-4: 19.660 s^-1 (95% CI: 0.205, 39.114), P for trend = 0.042]. Furthermore, iPTH had an association with R2* value [iPTH (pg/mL): 0.033 s^-1 (95% CI: 0.001, 0.064), P = 0.041]. Besides, FF was mainly affected by age and BMI, but not CKD.

CONCLUSIONS

The bone marrow R2* value measured by IDEAL-IQ sequence is associated with CKD severity and iPTH. The R2* of IDEAL-IQ has the potential to reflect lumbar bone changes in patients with CKD.

Assessment of Osteoporosis in Lumbar Spine: In Vivo Quantitative MR Imaging of Collagen Bound Water in Trabecular Bone

AIM

Bone collagen matrix makes a crucial contribution to the mechanical properties of bone by imparting tensile strength and elasticity. The collagen content of bone is accessible via quantification of collagen bound water (CBW) indirectly. We prospectively study the performance of the CBW proton density (CBWPD) measured by a 3D short repetition time adiabatic inversion recovery prepared ultrashort echo time (STAIR-UTE) magnetic resonance imaging (MRI) sequence in the diagnosis of osteoporosis in human lumbar spine.

METHODS

A total of 189 participants with a mean age of 56 (ranged from 50 to 86) years old were underwent MRI, quantitative computed tomography (QCT), and dual-energy X-ray absorptiometry (DXA) in lumbar spine. Major fracture risk was also evaluated for all participants using Fracture Risk Assessment Tool (FRAX). Lumbar CBWPD, bone marrow fat fraction (BMFF), bone mineral density (BMD) and T score values were calculated in three vertebrae (L2-L4) for each subject. Both the CBWPD and BMFF were correlated with BMD, T score, and FRAX score for comparison. The abilities of the CBWPD and BMFF to discriminate between three different cohorts, which included normal subjects, patients with osteopenia, and patients with osteoporosis, were also evaluated and compared using receiver operator characteristic (ROC) analysis.

RESULTS

The CBWPD showed strong correlation with standard BMD (R² = 0.75, P < 0.001) and T score (R² = 0.59, P < 0.001), as well as a moderate correlation with FRAX score (R² = 0.48, P < 0.001). High area under the curve (AUC) values (≥ 0.84 using QCT as reference; ≥ 0.76 using DXA as reference) obtained from ROC analysis demonstrated that the CBWPD was capable of well differentiating between the three different subject cohorts. Moreover, the CBWPD had better correlations with BMD, T score, and FRAX score than BMFF, and also performed better in cohort discrimination.

CONCLUSION

The STAIR-UTE-measured CBWPD is a promising biomarker in the assessment of bone quality and fracture risk.

Zero echo time pediatric musculoskeletal magnetic resonance imaging: initial experience

BACKGROUND

Projection radiography (XR) is often supplemented by both CT (to evaluate osseous structures with ionizing radiation) and MRI (for marrow and soft-tissue assessment). Zero echo time (ZTE) MR imaging produces a "CT-like" osseous contrast that might obviate CT.

OBJECTIVE

This study investigated our institution's initial experience in implementing an isotropic ZTE MR imaging sequence for pediatric musculoskeletal examinations.

MATERIALS AND METHODS

Pediatric patients referred for extremity MRI at 3 tesla (T) underwent ZTE MR imaging to yield images with contrast similar to that of CT. A radiograph-like image was also created with ray-sum image processing. We assessed ZTE-CT/XR anatomical image quality (S_anat) from 0 (nondiagnostic) to 5 (outstanding). Further, we made image comparisons on a 5-point scale (S_comp) (range of -2 = conventional CT/XR greater anatomical delineation to +2 = ZTE-CT/XR greater anatomical delineation; 0=same) for three cohorts: (1) ZTE-XR to conventional radiography, (2) ZTE-CT to conventional CT and (3) pathological lesion assessment on ZTE-XR to conventional radiography. We measured cortical thickness of ZTE-XR and ZTE-CT and compared these with conventional imaging. We calculated confidence interval of proportions, Wilcoxon rank sum test and intraclass correlation coefficients for inter-reader agreement.

RESULTS

Cohorts 1, 2 and 3 consisted of 40, 20 and 35 cases, respectively (age range 0.6-23.0 years). ZTE-CT versus CT and ZTE-XR versus radiography of cortical thicknesses were not significantly different (P=0.55 and P=0.31, respectively). Cortical delineation was rated diagnostic or better (score of 3, 4 or 5) in all cases (confidence interval of proportions = 100%) for ZTE-CT/XR. Similarly, intramedullary cavity delineation was rated diagnostic or better in all cases for ZTE-CT, and ZTE-XR was at least diagnostic in 58-63% of cases. For cohort 2, cortex and intramedullary cavity S_comp for ZTE-CT was comparable to those of conventional CT, with confidence interval of proportion (sum of score of -1 to +2) of 93-100% and 95%, respectively. Pathology visualized on ZTE-CT/XR was comparable; S_comp confidence interval of proportions was 95%/97-100%, with improved delineation of non-displaced fractures on ZTE-XR. Readers had moderate to near-perfect intraclass correlation coefficient (range=0.60-0.93).

CONCLUSION

Implementation of a diagnostic-quality ZTE MRI sequence in the pediatric population is feasible and can be performed as a complementary pulse sequence to enhance musculoskeletal MRI studies. Compared to conventional CT, ZTE has comparable cortical delineation, intramedullary cavity and pathology visualization. While not intended as a replacement for conventional radiography, ZTE-XR provides similar visualization of pathology.

Simple parameters of synthetic MRI for assessment of bone density in patients with spinal degenerative disease

OBJECTIVE

Good bone quality is the key to avoiding osteoporotic fragility fractures and poor outcomes after lumbar instrumentation and fusion surgery. Although dual-energy x-ray absorptiometry (DEXA) screening is the current standard for evaluating osteoporosis, many patients lack DEXA measurements before undergoing lumbar spine surgery. The present study aimed to investigate the utility of using simple quantitative parameters generated with novel synthetic MRI to evaluate bone quality, as well as the correlations of these parameters with DEXA measurements.

METHODS

This prospective study enrolled patients with symptomatic lumbar degenerative disease who underwent DEXA and conventional and synthetic MRI. The quantitative parameters generated with synthetic MRI were T1 map, T2 map, T1 intensity, proton density (PD), and vertebral bone quality (VBQ) score, and these parameters were correlated with T-score of the lumbar spine.

RESULTS

There were 62 patients and 238 lumbar segments eligible for analysis. PD and VBQ score moderately correlated with T-score of the lumbar spine (r = -0.565 and -0.651, respectively; both p < 0.001). T1 intensity correlated fairly well with T-score (r = -0.411, p < 0.001). T1 and T2 correlated poorly with T-score. Receiver operating characteristic curve analysis demonstrated area under the curve values of 0.808 and 0.794 for detecting osteopenia/osteoporosis (T-score ≤ -1.0) and osteoporosis (T-score ≤ -2.5) with PD (both p < 0.001).

CONCLUSIONS

PD and T1 intensity values generated with synthetic MRI demonstrated significant correlation with T-score. PD has excellent ability for predicting osteoporosis and osteopenia.

Vertebral bone marrow T2* mapping using chemical shift encoding-based water-fat separation in the quantitative analysis of lumbar osteoporosis and osteoporotic fractures

BACKGROUND

Chemical shift encoding-based water-fat separation techniques have been used for fat quantification [proton density fat fraction (PDFF)], but they also enable the assessment of bone marrow T2*, which has previously been reported to be a potential biomarker for osteoporosis and may give insight into the cause of vertebral fractures (i.e., osteoporotic vs. traumatic) and the microstructure of the bone when applied to vertebral bone marrow.

METHODS

The 32 patients (78.1% with low-energy osteopenic/osteoporotic fractures, mean age 72.3±9.8 years, 76% women; 21.9% with high-energy traumatic fractures, 47.3±12.8 years, no women) were frequency-matched for age and sex to subjects without vertebral fractures (n=20). All study patients underwent 3T-MRI of the lumbar spine including sagittally acquired spoiled gradient echo sequences for chemical shift encoding-based water-fat separation, from which T2* values were obtained. Volumetric trabecular bone mineral density (BMD) and trabecular bone parameters describing the three-dimensional structural integrity of trabecular bone were derived from quantitative CT. Associations between T2* measurements, fracture status and trabecular bone parameters were assessed using multivariable linear regression models.

RESULTS

Mean T2* values of non fractured vertebrae in all patients showed a significant correlation with BMD (r=-0.65, P<0.001), trabecular number (TbN) (r=-0.56, P<0.001) and trabecular spacing (TbSp) (r=0.61, P<0.001); patients with low-energy osteoporotic vertebral fractures showed significantly higher mean T2* values than those with traumatic fractures (13.6±4.3 vs. 8.4±2.2 ms, P=0.01) as well as a significantly lower TbN (0.69±0.08 vs. 0.93±0.03 mm-1, P<0.01) and a significantly larger trabecular spacing (1.06±0.16 vs. 0.56±0.08 mm, P<0.01). Mean T2* values of osteoporotic patients with and without vertebral fracture showed no significant difference (13.5±3.4 vs. 15.6±3.5 ms, P=0.40). When comparing the mean T2* of the fractured vertebrae, no significant difference could be detected between low-energy osteoporotic fractures and high-energy traumatic fractures (12.6±5.4 vs. 8.1±2.4 ms, P=0.10).

CONCLUSIONS

T2* mapping of vertebral bone marrow using using chemical shift encoding-based water-fat separation allows for assessing osteoporosis as well as the trabecular microstructure and enables a radiation-free differentiation between patients with low-energy osteoporotic and high-energy traumatic vertebral fractures, suggesting its potential as a biomarker for bone fragility.

Characterization of Structural Bone Properties through Portable Single-Sided NMR Devices: State of the Art and Future Perspectives

Nuclear Magnetic Resonance (NMR) is a well-suited methodology to study bone composition and structural properties. This is because the NMR parameters, such as the T2 relaxation time, are sensitive to the chemical and physical environment of the 1H nuclei. Although magnetic resonance imaging (MRI) allows bone structure assessment in vivo, its cost limits the suitability of conventional MRI for routine bone screening. With difficulty accessing clinically suitable exams, the diagnosis of bone diseases, such as osteoporosis, and the associated fracture risk estimation is based on the assessment of bone mineral density (BMD), obtained by the dual-energy X-ray absorptiometry (DXA). However, integrating the information about the structure of the bone with the bone mineral density has been shown to improve fracture risk estimation related to osteoporosis. Portable NMR, based on low-field single-sided NMR devices, is a promising and appealing approach to assess NMR properties of biological tissues with the aim of medical applications. Since these scanners detect the signal from a sensitive volume external to the magnet, they can be used to perform NMR measurement without the need to fit a sample inside a bore of a magnet, allowing, in principle, in vivo application. Techniques based on NMR single-sided devices have the potential to provide a high impact on the clinical routine because of low purchasing and running costs and low maintenance of such scanners. In this review, the development of new methodologies to investigate structural properties of trabecular bone exploiting single-sided NMR devices is reviewed, and current limitations and future perspectives are discussed.

Cortical Bone Mechanical Assessment via Free Water Relaxometry at 3 T

BACKGROUND

Investigation of cortical bone using magnetic resonance imaging is a developing field, which uses short/ultrashort echo time (TE) pulse sequences to quantify bone water content and to obtain indirect information about bone microstructure.

PURPOSE

To improve the accuracy of the previously proposed technique of free water T₁ quantification and to seek the relationship between cortical bone free water T₁ and its mechanical competence.

STUDY TYPE

Prospective.

SUBJECTS

Twenty samples of bovine tibia bone.

FIELD STRENGTH/SEQUENCES

3.0 T; ultra-fast two-dimensional gradient echo, Radio frequency-spoiled three-dimensional gradient echo.

ASSESSMENT

Cortical bone free water T₁ was quantified via three different methods: inversion recovery (IR), variable flip angle (VFA), and variable repetition time (VTR). Signal-to-noise ratio was measured by dividing the signal of each segmented sample to background noise. Segmentation was done manually. The effect of noise on T₁ quantification was evaluated. Then, the samples were subjected to mechanical compression test to measure the toughness, yield stress, ultimate stress, and Young modulus.

STATISTICAL TESTS

All the statistical analysis (Shapiro-Wilk, way analysis of variance, paired t test, Pearson correlation, and Bland-Altman plot) were done using SPSS.

RESULTS

Significant difference was found between T₁ quantification groups (P < 0.05). Average T₁ of each quantification method differed significantly after adding noise (P < 0.05). VFA-T₁ values significantly correlated with toughness (r = -0.68, P < 0.05), ultimate stress (r = -0.71, P < 0.05), and yield stress (r = -0.62, P < 0.05). No significant correlation was found between VTR-T₁ values and toughness (P = 0.07), ultimate stress (P = 0.47), yield stress (P = 0.30), and Young modulus (P = 0.39).

DATA CONCLUSION

Pore water T₁ value is associated with bone mechanical competence, and VFA method employing short-TE pulse sequence seems a superior technique to VTR method for this quantification.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: 1.

Texture Analysis Using CT and Chemical Shift Encoding-Based Water-Fat MRI Can Improve Differentiation Between Patients With and Without Osteoporotic Vertebral Fractures

PURPOSE

Osteoporosis is a highly prevalent skeletal disease that frequently entails vertebral fractures. Areal bone mineral density (BMD) derived from dual-energy X-ray absorptiometry (DXA) is the reference standard, but has well-known limitations. Texture analysis can provide surrogate markers of tissue microstructure based on computed tomography (CT) or magnetic resonance imaging (MRI) data of the spine, thus potentially improving fracture risk estimation beyond areal BMD. However, it is largely unknown whether MRI-derived texture analysis can predict volumetric BMD (vBMD), or whether a model incorporating texture analysis based on CT and MRI may be capable of differentiating between patients with and without osteoporotic vertebral fractures.

MATERIALS AND METHODS

Twenty-six patients (15 females, median age: 73 years, 11 patients showing at least one osteoporotic vertebral fracture) who had CT and 3-Tesla chemical shift encoding-based water-fat MRI (CSE-MRI) available were analyzed. In total, 171 vertebral bodies of the thoracolumbar spine were segmented using an automatic convolutional neural network (CNN)-based framework, followed by extraction of integral and trabecular vBMD using CT data. For CSE-MRI, manual segmentation of vertebral bodies and consecutive extraction of the mean proton density fat fraction (PDFF) and T2* was performed. First-order, second-order, and higher-order texture features were derived from texture analysis using CT and CSE-MRI data. Stepwise multivariate linear regression models were computed using integral vBMD and fracture status as dependent variables.

RESULTS

Patients with osteoporotic vertebral fractures showed significantly lower integral and trabecular vBMD when compared to patients without fractures (p<0.001). For the model with integral vBMD as the dependent variable, T2* combined with three PDFF-based texture features explained 40% of the variance (adjusted R²[Ra2] = 0.40; p<0.001). Furthermore, regarding the differentiation between patients with and without osteoporotic vertebral fractures, a model including texture features from CT and CSE-MRI data showed better performance than a model based on integral vBMD and PDFF only ( Ra2 = 0.47 vs. Ra2  = 0.81; included texture features in the final model: integral vBMD, CT_Short-run_emphasis, CT_Varianceglobal, and PDFF_Variance).

CONCLUSION

Using texture analysis for spine CT and CSE-MRI can facilitate the differentiation between patients with and without osteoporotic vertebral fractures, implicating that future fracture prediction in osteoporosis may be improved.

Single-sided NMR to estimate morphological parameters of the trabecular bone structure

PURPOSE

Single-sided ¹ H-NMR is proposed for the estimation of morphological parameters of trabecular bone, and potentially the detection of pathophysiological alterations of bone structure. In this study, a new methodology was used to estimate such parameters without using an external reference signal, and to study intratrabecular and intertrabecular porosities, with a view to eventually scanning patients.

METHODS

Animal trabecular bone samples were analyzed by a single-sided device. The Carr-Purcell-Meiboom-Gill sequence of ¹ H nuclei of fluids, including marrow, confined inside the bone, was analyzed by quasi-continuous T₂ distributions and separated into two ¹ H pools: short and long T₂ components. The NMR parameters were estimated using models of trabecular bone structure, and compared with the corresponding micro-CT.

RESULTS

Without any further assumptions, the internal reference parameter (short T₂ signal intensity fraction) enabled prediction of the micro-CT parameters BV/TV (volume of the trabeculae/total sample volume) and BS/TV (external surface of the trabeculae/total sample volume) with linear correlation coefficient >0.80. The assignment of the two pools to intratrabecular and intertrabecular components yielded an estimate of average intratrabecular porosity (33 ± 5)%. Using the proposed models, the NMR-estimated BV/TV and BS/TV were found to be linearly related to the corresponding micro-CT values with high correlation (>0.90 for BV/TV; >0.80 for BS/TV) and agreement coefficients.

CONCLUSION

Low-field, low-cost portable devices that rely on intrinsic magnetic field gradients and do not use ionizing radiation are viable tools for in vitro preclinical studies of pathophysiological structural alterations of trabecular bone.

Quantitative Ultrashort Echo Time (UTE) Magnetic Resonance Imaging of Bone: An Update

Bone possesses a highly complex hierarchical structure comprised of mineral (~45% by volume), organic matrix (~35%) and water (~20%). Water exists in bone in two forms: as bound water (BW), which is bound to bone mineral and organic matrix, or as pore water (PW), which resides in Haversian canals as well as in lacunae and canaliculi. Magnetic resonance (MR) imaging has been increasingly used for assessment of cortical and trabecular bone. However, bone appears as a signal void on conventional MR sequences because of its short T2*. Ultrashort echo time (UTE) sequences with echo times (TEs) 100-1,000 times shorter than those of conventional sequences allow direct imaging of BW and PW in bone. A series of quantitative UTE MRI techniques has been developed for bone evaluation. UTE and adiabatic inversion recovery prepared UTE (IR-UTE) sequences have been developed to quantify BW and PW. UTE magnetization transfer (UTE-MT) sequences have been developed to quantify collagen backbone protons, and UTE quantitative susceptibility mapping (UTE-QSM) sequences have been developed to assess bone mineral.

Quantitative Magnetic Resonance Imaging of Cortical and Trabecular Bone

Bone is a composite material consisting of mineral, organic matrix, and water. Water in bone can be categorized as bound water (BW), which is bound to bone mineral and organic matrix, or as pore water (PW), which resides in Haversian canals as well as in lacunae and canaliculi. Bone is generally classified into two types: cortical bone and trabecular bone. Cortical bone is much denser than trabecular bone that is surrounded by marrow and fat. Magnetic resonance (MR) imaging has been increasingly used for noninvasive assessment of both cortical bone and trabecular bone. Bone typically appears as a signal void with conventional MR sequences because of its short T2*. Ultrashort echo time (UTE) sequences with echo times 100 to 1,000 times shorter than those of conventional sequences allow direct imaging of BW and PW in bone. This article summarizes several quantitative MR techniques recently developed for bone evaluation. Specifically, we discuss the use of UTE and adiabatic inversion recovery prepared UTE sequences to quantify BW and PW, UTE magnetization transfer sequences to quantify collagen backbone protons, UTE quantitative susceptibility mapping sequences to assess bone mineral, and conventional sequences for high-resolution imaging of PW as well as the evaluation of trabecular bone architecture.

MRI-Based Quantitative Osteoporosis Imaging at the Spine and Femur

Osteoporosis is a systemic skeletal disease with a high prevalence worldwide, characterized by low bone mass and microarchitectural deterioration, predisposing an individual to fragility fractures. Dual-energy X-ray absorptiometry (DXA) has been the clinical reference standard for diagnosing osteoporosis and for assessing fracture risk for decades. However, other imaging modalities are of increasing importance to investigate the etiology, treatment, and fracture risk. The purpose of this work is to review the available literature on quantitative magnetic resonance imaging (MRI) methods and related findings in osteoporosis at the spine and proximal femur as the clinically most important fracture sites. Trabecular bone microstructure analysis at the proximal femur based on high-resolution MRI allows for a better prediction of osteoporotic fracture risk than DXA-based bone mineral density (BMD) alone. In the 1990s, T₂ * mapping was shown to correlate with the density and orientation of the trabecular bone. Recently, quantitative susceptibility mapping (QSM), which overcomes some of the limitations of T₂ * mapping, has been applied for trabecular bone quantifications at the spine, whereas ultrashort echo time (UTE) imaging provides valuable surrogate markers of cortical bone quantity and quality. Magnetic resonance spectroscopy (MRS) and chemical shift encoding-based water-fat MRI (CSE-MRI) enable the quantitative assessment of the nonmineralized bone compartment through extraction of the bone marrow fat fraction (BMFF). Furthermore, CSE-MRI allows for the differentiation of osteoporotic vs. pathologic fractures, which is of high clinical relevance. Lastly, advanced postprocessing and image analysis tools, particularly considering statistical parametric mapping and region-specific BMFF distributions, have high potential to further improve MRI-based fracture risk assessments at the spine and hip. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 2.

Quantifying cortical bone free water using short echo time (STE-MRI) at 1.5 T

PURPOSE

The purpose of our study was to use Dual-TR STE-MR protocol as a clinical tool for cortical bone free water quantification at 1.5 T and validate it by comparing the obtained results (MR-derived results) with dehydration results.

METHODS

Human studies were compliant with HIPPA and were approved by the institutional review board. Short Echo Time (STE) MR imaging with different Repetition Times (TRs) was used for quantification of cortical bone free water T₁ (T₁free) and concentration (ρ_free). The proposed strategy was compared with the dehydration technique in seven bovine cortical bone samples. The agreement between the two methods was quantified by using Bland and Altman analysis. Then we applied the technique on a cross-sectional population of thirty healthy volunteers (18F/12M) and examined the association of the biomarkers with age.

RESULTS

The mean values of ρ_free for bovine cortical bone specimens were quantified as 4.37% and 5.34% by using STE-MR and dehydration techniques, respectively. The Bland and Altman analysis showed good agreement between the two methods along with the suggestion of 0.99% bias between them. Strong correlations were also reported between ρ_free (r² = 0.62) and T_1free and age (r² = 0.8). The reproducibility of the method, evaluated in eight subjects, yielded an intra-class correlation of 0.95.

CONCLUSION

STE-MR imaging with dual-TR strategy is a clinical solution for quantifying cortical bone ρ_free and T_1free.

Trabecular bone imaging using a 3D adiabatic inversion recovery prepared ultrashort TE Cones sequence at 3T

PURPOSE

To investigate direct imaging of trabecular bone using a 3D adiabatic inversion recovery prepared ultrashort TE cones (3D IR-UTE-Cones) sequence.

METHODS

The proposed 3D IR-UTE-Cones sequence used a broadband adiabatic inversion pulse together with a short TR/TI combination to suppress signals from long T2 tissues such as muscle and marrow fat, followed by multispoke UTE acquisition to detect signal from short T2 water components in trabecular bone. The feasibility of this technique for robust suppression of long T2 tissues was first demonstrated through numerical simulations. The proposed IR-UTE-Cones sequence was applied to a hip agarose bone phantom and to 6 healthy volunteers for morphologic and quantitative T 2 ∗ and proton density mapping of trabecular bone.

RESULTS

Numeric simulation suggests that the IR technique with a short TR/TI combination provides sufficient suppression of long T2 tissues with a wide range of T1 s. High contrast imaging of trabecular bone can be achieved ex vivo and in vivo, with fitted T 2 ∗ values of 0.3-0.45 ms and proton densities of 5-9 mol/L.

CONCLUSION

The 3D IR-UTE-Cones sequence with a short TR/TI combination provides robust suppression of long T2 tissues and allows both selective imaging and quantitative ( T 2 ∗ and proton density) assessment of short T2 water components in trabecular bone in vivo.

Diffusion MRI for Assessment of Bone Quality; A Review of Findings in Healthy Aging and Osteoporosis

Diffusion MRI (dMRI) is a growing imaging technique with the potential to provide biomarkers of tissue variation, such as cellular density, tissue anisotropy, and microvascular perfusion. However, the role of dMRI in characterizing different aspects of bone quality, especially in aging and osteoporosis, has not yet been fully established, particularly in clinical applications. The reason lies in the complications accompanied with implementation of dMRI in assessment of human bone structure, in terms of acquisition and quantification. Bone is a composite tissue comprising different elements, each contributing to the overall quality and functional competence of bone. As diffusion is a critical biophysical process in biological tissues, early changes of tissue microstructure and function can affect diffusive properties of the tissue. While there are multiple MRI methods to detect variations of individual properties of bone quality due to aging and osteoporosis, dMRI has potential to serve as a superior method for characterizing different aspects of bone quality within the same framework but with higher sensitivity to early alterations. This is mainly because several properties of the tissue including directionality and anisotropy of trabecular bone and cell density can be collected using only dMRI. In this review article, we first describe components of human bone that can be potentially detected by their diffusivity properties and contribute to variations in bone quality during aging and osteoporosis. Then we discuss considerations and challenges of dMRI in bone imaging, current status, and suggestions for development of dMRI in research studies and clinics to segregate different contributing components of bone quality in an integrated acquisition. Level of Evidence: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2020;51:975-992.

An Update in Qualitative Imaging of Bone Using Ultrashort Echo Time Magnetic Resonance

Bone is comprised of mineral, collagenous organic matrix, and water. X-ray-based techniques are the standard approach for bone evaluation in clinics, but they are unable to detect the organic matrix and water components in bone. Magnetic resonance imaging (MRI) is being used increasingly for bone evaluation. While MRI can non-invasively assess the proton pools in soft tissues, cortical bone typically appears as a signal void with clinical MR techniques because of its short T2*. New MRI techniques have been recently developed to image bone while avoiding the ionizing radiation present in x-ray-based methods. Qualitative bone imaging can be achieved using ultrashort echo time (UTE), single inversion recovery UTE (IR-UTE), dual-inversion recovery UTE (Dual-IR-UTE), double-inversion recovery UTE (Double-IR-UTE), and zero echo time (ZTE) sequences. The contrast mechanisms as well as the advantages and disadvantages of each technique are discussed.

Artificial neural network to estimate micro-architectural properties of cortical bone using ultrasonic attenuation: A 2-D numerical study

The goal of this study is to estimate micro-architectural parameters of cortical porosity such as pore diameter (φ), pore density (ρ) and porosity (ν) of cortical bone from ultrasound frequency dependent attenuation using an artificial neural network (ANN). First, heterogeneous structures with controlled pore diameters and pore densities (mono-disperse) were generated, to mimic simplified structure of cortical bone. Then, more realistic structures were obtained from high resolution CT scans of human cortical bone. 2-D finite-difference time-domain simulations were conducted to calculate the frequency-dependent attenuation in the 1-8 MHz range. An ANN was then trained with the ultrasonic attenuation at different frequencies as the input feature vectors while the output was set as the micro-architectural parameters (pore diameter, pore density and porosity). The ANN is composed of three fully connected dense layers with 24, 12 and 6 neurons, connected to the output layer. The dataset was trained over 6000 epochs with a batch size of 16. The trained ANN exhibits the ability to predict the micro-architectural parameters with high accuracy and low losses. ANN approaches could potentially be used as a tool to help inform physics-based modelling of ultrasound propagation in complex media such as cortical bone. This will lead to the solution of inverse-problems to retrieve bone micro-architectural parameters from ultrasound measurements for the non-invasive diagnosis and monitoring osteoporosis.

Short-T2 MRI: Principles and recent advances

Among current modalities of biomedical and diagnostic imaging, MRI stands out by virtue of its versatile contrast obtained without ionizing radiation. However, in various cases, e.g., water protons in tissues such as bone, tendon, and lung, MRI performance is limited by the rapid decay of resonance signals associated with short transverse relaxation times T₂ or T₂*. Efforts to address this shortcoming have led to a variety of specialized short-T₂ techniques. Recent progress in this field expands the choice of methods and prompts fresh considerations with regard to instrumentation, data acquisition, and signal processing. In this review, the current status of short-T₂ MRI is surveyed. In an attempt to structure the growing range of techniques, the presentation highlights overarching concepts and basic methodological options. The most frequently used approaches are described in detail, including acquisition strategies, image reconstruction, hardware requirements, means of introducing contrast, sources of artifacts, limitations, and applications.

Applications of PET-MRI in musculoskeletal disease

New integrated PET-MRI systems potentially provide a complete imaging modality for diagnosis and evaluation of musculoskeletal disease. MRI is able to provide excellent high-resolution morphologic information with multiple contrast mechanisms that has made it the imaging modality of choice in evaluation of many musculoskeletal disorders. PET offers incomparable abilities to provide quantitative information about molecular and physiologic changes that often precede structural and biochemical changes. In combination, hybrid PET-MRI can enhance imaging of musculoskeletal disorders through early detection of disease as well as improved diagnostic sensitivity and specificity. The purpose of this article is to review emerging applications of PET-MRI in musculoskeletal disease. Both clinical applications of malignant musculoskeletal disease as well as new opportunities to incorporate the molecular capabilities of nuclear imaging into studies of nononcologic musculoskeletal disease are discussed. Lastly, we discuss some of the technical considerations and challenges of PET-MRI as they specifically relate to musculoskeletal disease.

LEVEL OF EVIDENCE

5 TECHNICAL EFFICACY: Stage 3 J. Magn. Reson. Imaging 2018;48:27-47.

Cortical bone vessel identification and quantification on contrast-enhanced MR images

Background

Cortical bone porosity is a major determinant of bone strength. Despite the biomechanical importance of cortical bone porosity, the biological drivers of cortical porosity are unknown. The content of cortical pore space can indicate pore expansion mechanisms; both of the primary components of pore space, vessels and adipocytes, have been implicated in pore expansion. Dynamic contrast-enhanced MRI (DCE-MRI) is widely used in vessel detection in cardiovascular studies, but has not been applied to visualize vessels within cortical bone. In this study, we have developed a multimodal DCE-MRI and high resolution peripheral QCT (HR-pQCT) acquisition and image processing pipeline to detect vessel-filled cortical bone pores.

Methods

For this in vivo human study, 19 volunteers (10 males and 9 females; mean age =63±5) were recruited. Both distal and ultra-distal regions of the non-dominant tibia were imaged by HR-pQCT (82 µm nominal resolution) for bone structure segmentation and by 3T DCE-MRI (Gadavist; 9 min scan time; temporal resolution =30 sec; voxel size 230×230×500 µm³) for vessel visualization. The DCE-MRI was registered to the HR-pQCT volume and the voxels within the MRI cortical bone region were extracted. Features of the DCE data were calculated and voxels were categorized by a 2-stage hierarchical kmeans clustering algorithm to determine which voxels represent vessels. Vessel volume fraction (volume ratio of vessels to cortical bone), vessel density (average vessel count per cortical bone volume), and average vessel volume (mean volume of vessels) were calculated to quantify the status of vessel-filled pores in cortical bone. To examine spatial resolution and perform validation, a virtual phantom with 5 channel sizes and an applied pseudo enhancement curve was processed through the proposed image processing pipeline. Overlap volume ratio and Dice coefficient was calculated to measure the similarity between the detected vessel map and ground truth.

Results

In the human study, mean vessel volume fraction was 2.2%±1.0%, mean vessel density was 0.68±0.27 vessel/mm³, and mean average vessel volume was 0.032±0.012 mm³/vessel. Signal intensity for detected vessel voxels increased during the scan, while signal for non-vessel voxels within pores did not enhance. In the validation phantom, channels with diameter 250 µm or greater were detected successfully, with volume ratio equal to 1 and Dice coefficient above 0.6. Both statistics decreased dramatically for channel sizes less than 250 µm.

Conclusions

We have a developed a multi-modal image acquisition and processing pipeline that successfully detects vessels within cortical bone pores. The performance of this technique degrades for vessel diameters below the in-plane spatial resolution of the DCE-MRI acquisition. This approach can be applied to investigate the biological systems associated with cortical pore expansion.

Predicting Structural Properties of Cortical Bone by Combining Ultrasonic Attenuation and an Artificial Neural Network (ANN): 2-D FDTD Study

The goal of this paper is to predict the micro-architectural parameters of cortical bone such as pore diameter ( ϕ ) and porosity ( v ) from ultrasound attenuation measurements using an artificial neural network (ANN). Slices from a 3-D CT scan of human femur are obtained. The micro-architectural parameters of porosity such as average pore size and porosity are calculated using image processing. When ultrasound waves propagate in porous structures, attenuation is observed due to scattering. Two-dimensional finite-difference time-domain simulations are carried out to obtain frequency dependent attenuation in those 2D structures. An artificial neural network (ANN) is then trained with the input feature vector as the frequency dependent attenuation and output as pore diameter ( ϕ ) and porosity ( v ) . The ANN is composed of one input layer, 3 hidden layers and one output layer, all of which are fully connected. 340 attenuation data sets were acquired and trained over 2000 epochs with a batch size of 32. Data was split into train, validation and test. It was observed that the ANN predicted the micro-architectural parameters of the cortical bone with high accuracies and low losses with a minimum R2 (goodness of fit) value of 0.95. ANN approaches could potentially help inform the solution of inverse-problems to retrieve bone porosity from ultrasound measurements. Ultimately, those inverse-problems could be used for the non-invasive diagnosis and monitoring of osteoporosis.

Fast quantitative 3D ultrashort echo time MRI of cortical bone using extended cones sampling

PURPOSE

To investigate the effect of stretching sampling window on quantitative 3D ultrashort TE (UTE) imaging of cortical bone at 3 T.

METHODS

Ten bovine cortical bone and 17 human tibial midshaft samples were imaged with a 3T clinical MRI scanner using an 8-channel knee coil. Quantitative 3D UTE imaging biomarkers, including T₁ , T 2 ∗ , magnetization transfer ratio and magnetization transfer modeling, were performed using radial or spiral Cones sampling trajectories with various durations. Errors in UTE-MRI biomarkers as a function of sampling time were evaluated using radial sampling as a reference standard.

RESULTS

For both bovine and human cortical bone samples, no significant differences were observed for all UTE biomarkers (single-component T 2 ∗ , bicomponent T 2 ∗ and relative fractions, T₁ , magnetization transfer ratio, and magnetization transfer modeling of macromolecular fraction) for spiral sampling windows of 992 µs to 1600 µs compared with a radial sampling window of 688 µs.

CONCLUSION

The total scan time can be reduced by 76% with quantification errors less than 5%. Quantitative UTE-MRI techniques can be greatly accelerated using longer sampling windows without significant quantification errors.

On the sensitivity of quantitative susceptibility mapping for measuring trabecular bone density

Purpose

To develop a methodological framework to simultaneously measure R2* and magnetic susceptibility in trabecularized yellow bone marrow and to investigate the sensitivity of Quantitative Susceptibility Mapping (QSM) for measuring trabecular bone density using a non‐UTE multi‐gradient echo sequence.

Methods

The ankle of 16 healthy volunteers and two patients was scanned using a time‐interleaved multi‐gradient‐echo (TIMGRE) sequence. After field mapping based on water–fat separation methods and background field removal based on the Laplacian boundary value method, three different QSM dipole inversion schemes were implemented. Mean susceptibility values in regions of different trabecular bone density in the calcaneus were compared to the corresponding values in the R2* maps, bone volume to total volume ratios (BV/TV) estimated from high resolution imaging (in 14 subjects), and CT attenuation (in two subjects). In addition, numerical simulations were performed in a simplified trabecular bone model of randomly positioned spherical bone inclusions to verify and compare the scaling of R2* and susceptibility with BV/TV.

Results

Differences in calcaneus trabecularization were well depicted in susceptibility maps, in good agreement with high‐resolution MR and CT images. Simulations and in vivo scans showed a linear relationship of measured susceptibility with BV/TV and R2*. The ankle in vivo results showed a strong linear correlation between susceptibility and R2* (R² = 0.88, p < 0.001) with a slope and intercept of −0.004 and 0.2 ppm, respectively.

Conclusions

A method for multi‐paramteric mapping, including R2*‐mapping and QSM was developed for measuring trabecularized yellow bone marrow, showing good sensitivity of QSM for measuring trabecular bone density.

The effect of pore size and density on ultrasonic attenuation in porous structures with mono-disperse random pore distribution: A two-dimensional in-silico study

This work proposes a power law model to describe the attenuation of ultrasonic waves in non-absorbing heterogeneous media with randomly distributed scatterers, mimicking a simplified structure of cortical bone. This paper models the propagation in heterogeneous structures with controlled porosity using a two-dimensional finite-difference time domain numerical simulation in order to measure the frequency dependent attenuation. The paper then fits a phenomenological model to the simulated frequency dependent attenuation by optimizing parameters under an ordinary least squares framework. Local sensitivity analysis is then performed on the resulting parameter estimates in order to determine to which estimates the model is most sensitive. This paper finds that the sensitivity of the model to various parameter estimates depends on the micro-architectural parameters, pore diameter (ϕ) and pore density (ρ). In order to get a sense for how confidently model parameters are able to be estimated, 95% confidence intervals for these estimates are calculated. In doing so, the ability to estimate model-sensitive parameters with a high degree of confidence is established. In the future, being able to accurately estimate model parameters from which micro-architectural ones could be inferred will allow pore density and diameter to be estimated via an inverse problem given real or simulated ultrasonic data to be determined.

Transverse signal decay under the weak field approximation: Theory and validation

PURPOSE

To derive an expression for the transverse signal time course from systems in the motional narrowing regime, such as water diffusing in blood. This was validated in silico and experimentally with ex vivo blood samples.

METHODS

A closed-form solution (CFS) for transverse signal decay under any train of refocusing pulses was derived using the weak field approximation. The CFS was validated via simulations of water molecules diffusing in the presence of spherical perturbers, with a range of sizes and under various pulse sequences. The CFS was compared with more conventional fits assuming monoexponential decay, including chemical exchange, using ex vivo blood Carr-Purcell-Meiboom-Gill data.

RESULTS

From simulations, the CFS was shown to be valid in the motional narrowing regime and partially into the intermediate dephasing regime, with increased accuracy with increasing Carr-Purcell-Meiboom-Gill refocusing rate. In theoretical calculations of the CFS, fitting for the transverse relaxation rate (R₂ ) gave excellent agreement with the weak field approximation expression for R₂ for Carr-Purcell-Meiboom-Gill sequences, but diverged for free induction decay. These same results were confirmed in the ex vivo analysis.

CONCLUSION

Transverse signal decay in the motional narrowing regime can be accurately described analytically. This theory has applications in areas such as tissue iron imaging, relaxometry of blood, and contrast agent imaging. Magn Reson Med 80:341-350, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Solid-state 31P and 1H chemical MR micro-imaging of hard tissues and biomaterials with magic angle spinning at very high magnetic field

In this work, we show that it is possible to overcome the limitations of solid-state MRI for rigid tissues due to large line broadening and short dephasing times by combining Magic Angle Spinning (MAS) with rotating pulsed field gradients. This allows recording ex vivo 31P 3D and 2D slice-selected images of rigid tissues and related biomaterials at very high magnetic field, with greatly improved signal to noise ratio and spatial resolution when compared to static conditions. Cross-polarization is employed to enhance contrast and to further depict spatially localized chemical variations in reduced experimental time. In these materials, very high magnetic field and moderate MAS spinning rate directly provide high spectral resolution and enable the use of frequency selective excitation schemes for chemically selective imaging. These new possibilities are exemplified with experiments probing selectively the 3D spatial distribution of apatitic hydroxyl protons inside a mouse tooth with attached jaw bone with a nominal isotropic resolution nearing 100 µm.

Bone mineral density in people living with HIV: a narrative review of the literature

Bone health status is largely absent in South Africa, the main reasons being the absence and cost-effectiveness of specific screening equipment for assessing bone mineral density (BMD). Various risk factors seem to play a role, some of which can be modified to change bone health status. Urbanisation is also a public health concern. Changing nutritional, as well as social behaviour, play integral roles in the prevalence and incidence of decreased BMD. Furthermore, human immunodeficiency virus (HIV) specifically, has a negative impact on BMD and although highly active antiretroviral therapy increases the prognosis for HIV-infected individuals, BMD still seem to decrease further. Dual energy X-ray absorptiometry is considered the gold standard for BMD assessment; however, recent developments have provided more cost-effective screening methods, among which heel quantitative ultrasound appears to be the most widely used in resource limited countries such as South Africa.

Simultaneous Quantification of Bone Edema/Adiposity and Structure in Inflamed Bone Using Chemical Shift-Encoded MRI in Spondyloarthritis

Purpose

To evaluate proton density fat fraction (PDFF) and R2* as markers of bone marrow composition and structure in inflamed bone in patients with spondyloarthritis.

Methods

Phantoms containing fat, water, and trabecular bone were constructed with proton density fat fraction (PDFF) and bone mineral density (BMD) values matching those expected in healthy bone marrow and disease states, and scanned using chemical shift‐encoded MRI (CSE‐MRI) at 3T. Measured PDFF and R2* values in phantoms were compared with reference FF and BMD values. Eight spondyloarthritis patients and 10 controls underwent CSE‐MRI of the sacroiliac joints. PDFF and R2* in areas of inflamed bone and fat metaplasia in patients were compared with normal bone marrow in controls.

Results

In phantoms, PDFF measurements were accurate over the full range of PDFF and BMD values. R2* measurements were positively associated with BMD but also were influenced by variations in PDFF. In patients, PDFF was reduced in areas of inflammation and increased in fat metaplasia compared to normal marrow. R2* measurements were significantly reduced in areas of fat metaplasia.

Conclusion

PDFF measurements reflect changes in marrow composition in areas of active inflammation and structural damage and could be used for disease monitoring in spondyloarthritis. R2* measurements may provide additional information bone mineral density but also are influenced by fat content. Magn Reson Med 79:1031–1042, 2018. © 2017 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Quantitative MRI and spectroscopy of bone marrow

Bone marrow is one of the largest organs in the human body, enclosing adipocytes, hematopoietic stem cells, which are responsible for blood cell production, and mesenchymal stem cells, which are responsible for the production of adipocytes and bone cells. Magnetic resonance imaging (MRI) is the ideal imaging modality to monitor bone marrow changes in healthy and pathological states, thanks to its inherent rich soft‐tissue contrast. Quantitative bone marrow MRI and magnetic resonance spectroscopy (MRS) techniques have been also developed in order to quantify changes in bone marrow water–fat composition, cellularity and perfusion in different pathologies, and to assist in understanding the role of bone marrow in the pathophysiology of systemic diseases (e.g. osteoporosis). The present review summarizes a large selection of studies published until March 2017 in proton‐based quantitative MRI and MRS of bone marrow. Some basic knowledge about bone marrow anatomy and physiology is first reviewed. The most important technical aspects of quantitative MR methods measuring bone marrow water–fat composition, fatty acid composition, perfusion, and diffusion are then described. Finally, previous MR studies are reviewed on the application of quantitative MR techniques in both healthy aging and diseased bone marrow affected by osteoporosis, fractures, metabolic diseases, multiple myeloma, and bone metastases.

Level of Evidence: 3

Technical Efficacy: Stage 2

J. Magn. Reson. Imaging 2018;47:332–353.

Measurement of bound and pore water T1 relaxation times in cortical bone using three-dimensional ultrashort echo time cones sequences

PURPOSE

We present three-dimensional ultrashort echo time Cones (3D UTE Cones) techniques for quantification of total water T1 ( T1TW), bound water T1 ( T1BW), and pore water T1 ( T1PW) in vitro and in vivo using a 3 Tesla (T) scanner.

METHODS

T1TW, T1BW, and T1PW were measured with three-dimensional (3D) Cones and adiabatic inversion recovery Cone (IR-Cone) sequences. Two-dimensional (2D) nonselective ultrashort echo time (UTE) techniques, including saturation recovery, variable repetition times (TRs), and inversion recovery (IR) preparation approaches were compared with 3D-Cones techniques on bovine cortical bone samples (n = 8). The 3D Cones sequences were used to measure T1TW, T1BW, and T1PW in the tibial midshaft of healthy volunteers (n = 8).

RESULTS

Comparable T1 images were achieved for cortical bone between 3D Cones and 2D UTE techniques as well as those published in the literature. The 3D Cones sequences showed a mean T1TW of 208 ± 22 ms, a mean T1PW of 545 ± 28 ms, and a mean T1BW of 131 ± 12 ms for bovine cortical bone; and a mean T1TW of 246 ± 32 ms, a mean T1PW of 524 ± 46 ms, and a mean T1BW of 134 ± 11 ms for the tibial midshaft of healthy volunteers.

CONCLUSIONS

The 3D Cones sequences can be used for fast volumetric assessment of bound and pore water T1 images in vitro and in vivo. Magn Reson Med 77:2136-2145, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Prospects of siRNA applications in regenerative medicine

Small interfering RNA (siRNA) has established its reputation in the field of tissue engineering owing to its ability to silence the proteins that inhibit tissue regeneration. siRNA is capable of regulating cellular behavior during tissue regeneration processes. The concept of using siRNA technology in regenerative medicine derived from its ability to inhibit the expression of target genes involved in defective tissues and the possibility to induce the expression of tissue-inductive factors that improve the tissue regeneration process. To date, siRNA has been used as a suppressive biomolecule in different tissues, such as nervous tissue, bone, cartilage, heart, kidney, and liver. Moreover, various delivery systems have been applied in order to deliver siRNA to the target tissues. This review will provide an in-depth discussion on the development of siRNA and their delivery systems and mechanisms of action in different tissues.