Cardiothoracic Magnetic Resonance Angiography

Catheter-based angiography is regarded as the clinical reference imaging technique for vessel imaging; however, it is invasive and is currently used for intervention or physiologic measurements. Contrast enhanced magnetic resonance angiography (MRA) with gadolinium-based contrast agents can be performed as a three-dimensional (3D) MRA or as a time resolved 3D (4D) MRA without physiologic synchronization, in which case cardiac and respiratory motion may blur the edges of the vessels and cardiac chambers. Ferumoxytol has recently been a popular contrast agent for MRA in patients with chronic renal failure. Noncontrast 3D MRA with ECG gating and respiratory navigation are safe and accurate noninvasive cross-sectional imaging techniques for the visualization of great vessels of the heart and coronary arteries in a variety of cardiovascular disorders including complex congenital heart diseases. Noncontrast flow dependent MRA techniques such as time of flight, phase contrast, and black-blood MRA techniques can be used as complementary or primary techniques. Here we review both conventional and relatively new contrast enhanced and non-contrast enhanced MRA techniques including ferumoxytol enhanced MRA, and bright-blood and water-fat separation based noncontrast 3D MRA techniques.

Non-contrast mDixon MR angiography of the neck: Comparison with time-of-flight MR angiography in normal subjects

We investigated the feasibility of non-contrast three-dimensional modified Dixon (mDixon) magnetic resonance angiography (MRA) to evaluate the carotid artery.We studied 30 normal patients who underwent non-contrast mDixon and conventional time-of-flight (TOF) MRA of the neck with a clinical 3T MR scanner. Carotid artery signal-to-noise ratio (SNR) and contrast-to-noise ratio were compared between mDixon-MRA and TOF-MRA. Two readers independently evaluated vessel sharpness, image contrast, and overall image quality using a 4-point scale.SNR was significantly higher on mDixon-MRA than TOF-MRA (P < .01). There was no significant difference in contrast-to-noise ratio. The visual score for vessel sharpness was significantly higher on mDixon-MRA than TOF-MRA (P < .01), whereas the score for contrast was significantly higher on TOF-MRA (P < .01).Although non-contrast three-dimensional mDixon-MRA showed lower visual contrast than conventional TOF-MRA, it provided images with significantly higher SNR and better vessel sharpness than TOF-MRA.

Non-contrast renal MRA using multi-shot gradient echo EPI at 3-T MRI

OBJECTIVES

The purpose of this study was to investigate the feasibility of non-contrast renal MRA using multi-shot gradient echo planar imaging (MSG-EPI) with a 3-T MRI system.

METHODS

Seventeen healthy volunteers underwent non-contrast renal MRA using MSG-EPI and balanced steady-state free precession (b-SSFP) sequences on a 3-T MRI system. Two radiologists independently recorded the images' contrast, noise, sharpness, artifacts, and overall quality on 4-point scales. The signal-to-noise ratio (SNR) for the renal artery, the contrast ratio (CR) between the renal artery and erector spinae, and acquisition time were compared between the two sequences.

RESULTS

The SNR and CR were significantly higher with MSG-EPI than with the b-SSFP sequence (17.80 ± 3.67 vs. 10.84 ± 2.86 and 0.77 ± 0.05 and 0.66 ± 0.09, respectively; p < 0.05), and the acquisition time was significantly lower (164.5 ± 34.0 vs. 261.5 ± 39.3 s, respectively; p < 0.05). There were significant differences in image contrast, noise, sharpness, artifacts, and overall image quality between the two sequences (p < 0.01).

CONCLUSIONS

The MSG-EPI sequence is a promising technique that can shorten the scan time and improve the image quality of non-contrast renal MRA with a 3-T MRI system.

KEY POINTS

• The multi-shot gradient echo planar imaging with an inversion pulse is a brand-new fast scan technique for an unenhanced renal MRA. • The image quality of multi-shot gradient echo planar imaging is better than that of b-SSFP for an unenhanced renal MRA.

REACT - A novel flow-independent non-gated non-contrast MR angiography technique using magnetization-prepared 3D non-balanced dual-echo dixon method: Preliminary clinical experience

Flow-independent relaxation-based non-contrast MR angiography techniques yield good signal-to-noise ratio and high blood-tissue contrast, complementing non-contrast flow-dependent and contrast-enhanced MR angiography techniques in the assessment of vascular disorders. However, these techniques often suffer from imaging artifacts at high magnetic field strengths or across large fields-of-view. Relaxation-Enhanced Angiography without Contrast and Triggering (REACT) is a recently introduced flow-independent non-gated non-contrast three-dimensional MR angiography technique that has been developed to mitigate some of these issues. We present our initial experience with the clinical applications of REACT in imaging disorders of the central and peripheral vascular systems.

Quadruple inversion-recovery b-SSFP MRA of the abdomen: initial clinical validation

The purpose of this study is to assess the image quality and diagnostic accuracy of non-contrast quadruple inversion-recovery balanced-SSFP MRA (QIR MRA) for detection of aortoiliac disease in a clinical population. QIR MRA was performed in 26 patients referred for routine clinical gadolinium-enhanced MRA (Gd-MRA) for known or suspected aortoiliac disease. Non-contrast images were independently evaluated for image quality and degree of stenosis by two radiologists, using consensus Gd-MRA as the reference standard. Hemodynamically significant stenosis (≥50%) was found in 10% (22/226) of all evaluable segments on Gd-MRA. The sensitivity and specificity for stenosis evaluation by QIR MRA for the two readers were 86%/86% and 95%/93% respectively. Negative predictive value and positive predictive value were 98%/98% and 63%/53% respectively. For stenosis evaluation of the aortoiliac region QIR MRA showed good agreement with the reference standard with high negative predictive value and a tendency to overestimate mild disease presumably due to the flow-dependence of the technique. QIR MRA could be a reasonable alternative to Gd-MRA for ruling out stenosis when contrast is contraindicated due to impaired kidney function or in patients who undergo abdominal MRA for screening purposes. Further work is necessary to improve performance and justify routine clinical use.

Unenhanced respiratory-gated magnetic resonance angiography (MRA) of renal artery in hypertensive patients using true fast imaging with steady-state precession technique compared with contrast-enhanced MRA

OBJECTIVE

This study was aimed to evaluate the accuracy of "True Fast Imaging with Steady-State Precession" (TrueFISP) MR angiography (MRA) for diagnosis of renal arterial stenosis (RAS) in hypertensive patients.

METHODS

Twenty-two patients underwent both TrueFISP MRA and contrast-enhanced MRA (CE-MRA) on a 1.5-T MR imager. Volume of main renal arteries, length of maximal visible renal arteries, number of visualized branches, stenotic grade, and subjective quality were compared. Paired 2-tailed Student t test and Wilcoxon signed rank test were applied to evaluate the significance of these variables.

RESULTS

Volume of main renal arteries, length of maximal visible renal arteries, and number of branches indicated no significant difference between the 2 techniques (P > 0.05). Stenotic degree of 10 RAS was greater on CE-MRA than on TrueFISP MRA. Qualitative scores from TrueFISP MRA were higher than those from CE-MRA (P < 0.05).

CONCLUSIONS

TrueFISP MRA is a reliable and accurate method for evaluating RAS.

Non-enhanced MR angiography of renal arteries: comparison with contrast-enhanced MR angiography

BACKGROUND

The main causes of renal artery stenosis (RAS) are atherosclerosis and fibromuscular dysplasia. Despite contrast-enhanced magnetic resonance angiography (CE-MRA) being a safe and reliable method for diagnosis of RAS especially in young individuals, recently it has been possible to adopt innovative technologies that do not require paramagnetic contrast agents.

PURPOSE

To assess the accuracy of steady-state free-precession (SSFP) non-contrast-enhanced magnetic resonance angiography (NC-MRA) by using a 1.5 T MR scanner for the detection of renal artery stenosis, in comparison with breath-hold CE-MRA as the reference standard.

MATERIAL AND METHODS

Sixty-three patients (33 men, 30 women) with suspected renovascular hypertension (RVHT) were examined by a 1.5T MR scanner; NC-MRA with an electrocardiography (ECG)-gated SSFP sequence was performed in 58.7% (37/63) of patients; in 41.3% (26/63) of patients a respiratory trigger was used in addition to cardiac gating. CE-MRA, with a three-dimensional gradient echo (3D-GRE) T1-weighted sequence, was performed in all patients within the same session. Maximum intensity projection (MIP) image quality, number of renal arteries, and the presence of stenosis were assessed by two observers (independently for NC-MRA and together for CE-MRA). The agreement between NC-MRA and CE-MRA as well as the inter-observer reproducibility were calculated with Bland-Altman plots.

RESULTS

MIP image quality was considered better for NC-MRA. NC-MRA identified 143 of 144 (99.3%) arteries detected by CE-MRA (an accessory artery was not identified). Fourteen stenoses were detected by CE-MRA (11 atherosclerotic, 3 dysplastic) with four of 14 (28.5%) significant stenosis. Bland-Altman plot demonstrated an excellent concordance between NC-MRA and CE-MRA; particularly, the reader A evaluated correctly all investigated arteries, while over-estimation of two stenoses occurred for reader B. Regarding NC-MRA, inter-observer agreement was excellent.

CONCLUSION

NC-MRA is a valid alternative to CE-MRA for the assessment of renal arteries.

Spontaneous renal artery dissection diagnosed by unenhanced magnetic resonance angiography: case report

A 47-year-old patient is presented who was admitted to the emergency department with complaints of right-sided flank pain and hypertension. His creatinine and glomerular filtration rate were 2.5 mg/dl and 37 ml/min respectively, so that contrast media administration was contraindicated. The unenhanced magnetic resonance angiography image obtained with 3D in-flow inversion recovery sequence showed right renal artery dissection, without aortic dissection. Selective renal angiography confirmed the diagnosis and a stent was placed in the renal artery. The patient was free of pain after stenting, with normalized laboratory values and blood pressure.

Inversion-recovery-prepared dixon bSSFP: initial clinical experience with a novel pulse sequence for renal MRA within a breathhold

PURPOSE

To evaluate the capability of a new breathhold non-contrast-enhanced MRA method (Non-contrast Outer Radial Inner Square k-space Scheme, NORISKS) to visualize renal arteries by comparing the method with a routine clinical but significantly longer non-contrast-enhanced (non-CE) MRA technique.

MATERIALS AND METHODS

Eighteen subjects referred for abdominal MRI were examined with NORISKS and a routine non-contrast-enhanced MRA technique. Two versions of NORISKS were evaluated: with and without ECG gating. The images were then scored independently and in blinded manner by two radiologists on 5-point scales for visualization of the proximal and distal renal arteries and quality of fat suppression.

RESULTS

No statistically significant difference was detected between NORISKS and routine clinical non-CE MRA in all categories except for visualization of the distal renal arteries where ungated NORISKS performed poorer than the routine non-CE MRA (P < 10(-4) ).

CONCLUSION

We have demonstrated a promising non-CE MRA method for acquiring renal angiograms within a breathhold without any compromise in spatial resolution or coverage. ECG-gated NORISKS is able to acquire renal angiograms that are comparable to a routine clinical non-CE MRA method (Inhance IFIR, GE Healthcare), which requires approximately seven times the scan time of NORISKS.

A 3D balanced-SSFP Dixon technique with group-encoded k-space segmentation for breath-held non-contrast-enhanced MR angiography

A three-dimensional balanced steady-state free precession (b-SSFP)-Dixon technique with a novel group-encoded k-space segmentation scheme called GUINNESS (Group-encoded Ungated Inversion Nulling for Non-contrast Enhancement in the Steady State) was developed. GUINNESS was evaluated for breath-held non-contrast-enhanced MR angiography of the renal arteries on 18 subjects (6 healthy volunteers, 12 patients) at 3.0 T. The method provided high signal-to-noise and contrast renal angiograms with homogeneous fat and background suppression in short breath-holds on the order of 20 s with high spatial resolution and coverage. GUINNESS has potential as a short breath-hold alternative to conventional respiratory-gated methods, which are often suboptimal in pediatric subjects and patients with significant diaphragmatic drift/sleep apnea.

Renal artery stenosis evaluation in chronic kidney disease patients: nonenhanced time-spatial labeling inversion-pulse three-dimensional MR angiography with regulated breathing versus DSA

PURPOSE

To evaluate the diagnostic performance of nonenhanced magnetic resonance (MR) angiographic flow-in technique with three-dimensional balanced steady-state free precession (SSFP) (flow-in balanced SSFP), compared with digital subtraction angiography (DSA) as reference standard, for assessment of renal artery stenosis (RAS) in chronic kidney disease (CKD) patients.

MATERIALS AND METHODS

Institutional review board approval and written informed consent were obtained for this prospective HIPAA-compliant study. Twenty-three patients, 13 men (mean age, 67.6 years ± 8.1 [standard deviation]; age range, 58-86 years) and 10 women (mean age 73.1 years ± 12.4; age range, 49-89 years), were evaluated with flow-in balanced SSFP and DSA. Coronal and axial flow-in balanced SSFP images were obtained with 1.5-T system, with regulated breathing (recorded voice instruction). The quality of flow-in balanced SSFP images was visually evaluated; the degree of stenosis was compared between flow-in balanced SSFP source images and DSA images by using the Wilcoxon signed-rank test. Correlation between images from both modalities was calculated as the Spearman rank-order correlation coefficient; bias was examined with Bland-Altman plots.

RESULTS

Diagnostic images were obtained in all patients. Flow-in balanced SSFP image quality was good in 87% (20 of 23) and moderate in 13% (three of 23) of patients. Forty-five renal arteries were included in the statistical analysis. Of 36 stenoses detected with flow-in balanced SSFP, 28 were relevant (degree of stenosis, ≥ 50%). The stenosis measurements of flow-in balanced SSFP were highly correlated (ρ = 0.91, P < .001) with those of DSA. The Bland-Altman plot showed a slight overestimation of the degree of stenosis (mean bias, 2.33% ± 11.95). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of flow-in balanced SSFP relative to DSA for the diagnosis of a stenosis of 50% or greater were 93% (26 of 28), 88% (15 of 17), 93% (26 of 28), 88% (15 of 17), and 91% (41 of 45), respectively.

CONCLUSION

Flow-in balanced SSFP with regulated breathing is an appropriate nonenhanced MR angiographic technique for RAS assessment in CKD patients.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101422/-/DC1.

Non-contrast-enhanced MR imaging of renal artery stenosis at 1.5 tesla

Balanced steady-state free precession (Bal-SSFP) techniques produce excellent anatomic images of renal arteries without the use of contrast agents and are relatively flow-insensitive. Electrocardiography (ECG)-triggered and non-ECG-triggered sequences have been shown to be quite sensitive for detection of regional arterial stenosis (RAS), and the already high specificity is likely to increase with further refinement of the techniques. Bal-SSFP sequences can be used as a screening tool or as an alternative to contrast-enhanced (CE) magnetic resonance angiography (MRA) when contrast agents are contraindicated. In addition to morphologic imaging of RAS, non-CE techniques can be used in functional assessment of hemodynamic significance. The complimentary tools can be used alone or in combination with CE-MRA for MR imaging of renal vascular hypertension.