Reduction of Oxygen-Induced CSF Hyperintensity on FLAIR MR Images in Sedated Children: Usefulness of Magnetization-Prepared FLAIR Imaging

Prominent cerebral veins on susceptibility-weighted angiography in acute meningoencephalitis

BACKGROUND AND PURPOSE

We have commonly observed prominent cerebral veins on susceptibility-weighted angiography (SWAN) in acute meningoencephalitis. This study aimed to investigate the clinical significance of these findings.

METHODS

Cerebral veins on SWAN of 98 patients with acute meningoencephalitis diagnosed from February 2016 through October 2020 were classified into three groups according to the degree of venous prominence (mild, 23; moderate, 53; and prominent, 22). Clinical variables and laboratory findings were compared between these groups. The influence of variables on the prediction of prominent cerebral veins was measured by random forest (RF) and gradient boosting machine (GBM).

RESULTS

As cerebral veins became more prominent, cerebrospinal fluid (CSF) glucose level decreased (69.61 ± 29.05 vs. 59.72 ± 22.57 vs. 48.36 ± 20.29 mg/dL, p = .01) and CSF protein level increased (100.73 ± 82.98 vs. 104.73 ± 70.99 vs. 159.12 ± 118.15 mg/dL, p = .03). The etiology of meningoencephalitis, neurological symptoms, and increased intracranial pressure (ICP) signs differed between groups (p < .05). RF and GBM demonstrated that CSF protein level was the variable with the highest power to predict the prominent cerebral vein (mean decrease in node impurity: 4.19, relative influence: 50.66).

CONCLUSION

The presence of prominent cerebral veins on SWAN in acute meningoencephalitis was significantly associated with a low CSF glucose level and a high CSF protein level, as well as ICP. Thus, the visual grade of the cerebral veins on SWAN may be utilized for the management of patients with acute meningoencephalitis.

Contrast-Enhanced Fluid-Attenuated Inversion Recovery in Neuroimaging: A Narrative Review on Clinical Applications and Technical Advances

While contrast-enhanced fluid-attenuated inversion recovery (FLAIR) has long been regarded as an adjunct sequence to evaluate leptomeningeal disease in addition to contrast-enhanced T1-weighted imaging, it is gradually being used for more diverse pathologies beyond leptomeningeal disease. Contrast-enhanced FLAIR is known to be highly sensitive to low concentrations of gadolinium within the fluid. Accordingly, recent research has suggested the potential utility of contrast-enhanced FLAIR in various kinds of disease, such as Meniere's disease, seizure, stroke, traumatic brain injury, and brain metastasis, in addition to being used for visualizing glymphatic dysfunction. However, its potential applications have been reported sporadically in an unorganized manner. Furthermore, the exact mechanism for its superior sensitivity to low concentrations of gadolinium has not been fully understood. Rapidly developing magnetic resonance technology and unoptimized parameters for FLAIR may challenge its accurate application in clinical practice. This review provides the fundamental mechanism of contrast-enhanced FLAIR, systematically describes its current and potential clinical application, and elaborates on technical considerations for its optimization. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 5.

Interpretation of fluid-attenuated inversion recovery vascular hyperintensity in stroke

Fluid-attenuation inversion recovery (FLAIR) vascular hyperintensity (FVH) is a common presentation on brain magnetic resonance images of patients with acute ischemic stroke. This sign is known as a sluggish collateral flow. Although FVH represents the large ischemic penumbra and collateral circulation, the clinical significance of FVH has not been established. Varying protocols for FLAIR, treatment differences, and heterogeneity of endpoints across studies have complicated the interpretation of FVH in patients with acute stroke. In this review article, we describe the mechanism of FVH, as well as its association with functional outcome, perfusion-weighted images, and large artery stenosis. In addition, we review the technological variables that affect FVH and discuss the future perspectives.

Proper fraction of inspired oxygen for reduction of oxygen-induced canine cerebrospinal fluid hyperintensity on fluid attenuation inversion recovery sequence using low-field magnetic resonance imaging

Oxygen-induced cerebrospinal fluid (CSF) hyperintensity artifact is inevitable in fluid attenuation inversion recovery (FLAIR) magnetic resonance (MR) images of anesthetized animals. This experimental study aimed to confirm the occurrence of this artifact on low-field magnetic resonance imaging (MRI), and to determine the fraction of inspired oxygen (FiO₂) that is safe and does not induce this artifact in canine brain MRI. Six healthy dogs underwent brain FLAIR MR scans under general anesthesia with 21%, 30%, 50%, 70%, and 100% FiO₂. The signal intensity (SI) ratio was calculated as the SI of CSF spaces divided by that of normalizing regions. The SI ratios of 21% FiO₂ images were significantly different from those of 100% FiO₂ images, indicating the presence of artifacts on 100% FiO₂ images. The SI ratios of 30% FiO₂ images were not significantly different from those of 21% FiO₂ images for any of CSF spaces. However, they were significantly different from those of 100% FiO₂ images in the cerebral sulci, third ventricle, interpeduncular cistern, mesencephalic aqueduct, and subarachnoid space at the level of the first cervical vertebra (P<0.05). All dogs had normal partial pressure of arterial oxygen (PaO₂) during inhalation of 30% FiO₂, while two dogs had low PaO₂ during inhalation of 21% FiO₂. Our findings support the hypothesis that high FiO₂ induces CSF hyperintensity artifact on low-field FLAIR MR images in dogs. FiO₂ of 30% is appropriate for obtaining brain FLAIR MR images with fewer artifacts in dogs.