Quantitative MR imaging evaluation of the cartilage thickness and subchondral bone area in patients with ACL-reconstructions 7 years after surgery

OBJECTIVE

To evaluate the cartilage thickness (ThC) and subchondral bone area (tAB) of the operated and contra-lateral non-operated (healthy) knees in patients with anterior cruciate ligament (ACL)-reconstruction 7 years after surgery using a quantitative and regional cartilage MR imaging (qMRI) technique.

METHODS

Charts of 410 patients with ACL-reconstructions were retrospectively reviewed. Fifty-two patients (male/female, 28/24; mean age, 33.3 years) were included. Patients underwent KT-1000 testing and qMRI of both knees using coronal fat-saturated 3D spoiled gradient-recalled echo (SPGR) sequences (TR/TE, 44/4 ms) at 1.5 T. Quantitative analyses of ThC and tAB in the femoro-tibial cartilage plates were performed using a subregional approach. In addition, qualitative and quantitative assessment of femoral condyle shapes was performed. t tests with Bonferroni corrections were used for statistical analysis of side-to-side differences between the operated and non-operated knees.

RESULTS

KT-1000 testing was abnormal in 3/52 patients (6%). Lateral femoral tAB was significantly lower (-9.2%), and medial tibial tAB was significantly larger (+2%) in the operated vs non-operated knee (P<0.001). Regional and subregional ThC side-to-side differences were less than 0.1mm and, except for the external lateral femoral subregion, they were not statistically significant. Flattened and broader shapes of medial femoral condyles (P<0.001) were found in operated knees. No significant association of presence of cartilage or meniscus lesions at surgery with ThC 7 years post-operatively was found (P=0.06-0.98).

CONCLUSION

There is evidence for changes in the tAB and femoral shape 7 years post-ACL-reconstruction, but no side-to-side differences in subregional ThC were found between the operated and contra-lateral non-operated knees.

Self-gated Fourier velocity encoding

Self-gating is investigated to improve the velocity resolution of real-time Fourier velocity encoding measurements in the absence of a reliable electrocardiogram waveform (e.g., fetal magnetic resonance or severe arrhythmia). Real-time flow data are acquired using interleaved k-space trajectories which share a common path near the origin of k-space. These common data provide a rapid self-gating signal that can be used to combine the interleaved data. The combined interleaves cover a greater area of k-space than a single real-time acquisition, thereby providing higher velocity resolution for a given aliasing velocity and temporal resolution. For example, this approach provided velocity spectra with a temporal resolution of 19 ms and velocity resolution of 22 cm/s over an 818 cm/s field-of-view. The method was validated experimentally using a computer-controlled pulsatile flow apparatus and applied in vivo to measure aortic-valve flow in a healthy volunteer.

Diffusion tensor imaging and fiber tractography of the median nerve at 1.5T: optimization of b value

OBJECTIVE

The objective of this study was to systematically assess the optimal b value for diffusion tensor imaging and fiber tractography of the median nerve at 1.5 T.

MATERIALS AND METHODS

This is a prospective study which was carried out with institutional review board approval and written informed consent from the study subjects. Fifteen healthy volunteers (seven men, eight women; mean age, 31.2 years) underwent diffusion tensor imaging of the wrist. A single-shot spin-echo-based echo-planar imaging sequence (TR/TE, 7000/103 ms) was performed in each subject at eight different b values ranging from 325 to 1,550 s/mm(2). Number and length of reconstructed fiber tracts, fiber density index (FDi), fractional anisotropy (FA), and apparent diffusion coefficient (ADC) were calculated for the median nerve. Signal-to-noise ratio (SNR) was also calculated for each acquisition. The overall image quality was assessed by two readers in consensus by ranking representative fiber tract images for each subject using a scale range from 1 to 8 (1 = best to 8 = worst image quality).

RESULTS

Longest fibers were observed for b values between 675 and 1,025 s/mm(2). Maximum FDi was found at b values of 1,025 s/mm(2). FA was between 0.5 and 0.6 for all b values. ADC gradually decreased from 1.44 x 10(-3) to 0.92 x 10(-3) mm(2)/s with increasing b values. Maximum SNR +/- standard deviation (175.4 +/- 72.6) was observed at the lowest b value and decreased with increasing b values. SNR at b values of 1,025 s/mm(2) was 48.5% of the maximum SNR. Optimal fiber tract image quality was found for b values of 1,025 s/mm(2).

CONCLUSIONS

The optimal b value for diffusion tensor imaging and fiber tractography of the median nerve at 1.5 T was 1,025 s/mm(2).

Magnetically-assisted remote control (MARC) steering of endovascular catheters for interventional MRI: a model for deflection and design implications

Current applied to wire coils wound at the tip of an endovascular catheter can be used to remotely steer a catheter under magnetic resonance imaging guidance. In this study, we derive and validate an equation that characterizes the relationship between deflection and a number of physical factors: theta/sin(gamma-theta) = nIABL/EI(A) where theta is the deflection angle, n is the number of solenoidal turns, I is the current, A is the cross-sectional area of the catheter tip, B is the magnetic resonance (MR) scanner main magnetic field, L is the unconstrained catheter length, E is Young's Modulus for the catheter material, and I(A) is the area moment of inertia, and y is the initial angle between the catheter tip and B. Solenoids of 50, 100, or 150 turns were wound on 1.8 F and 5 F catheters. Varying currents were applied remotely using a DC power supply in the MRI control room. The distal catheter tip was suspended within a phantom at varying lengths. Images were obtained with a 1.5 T or a 3 T MR scanner using "real-time" MR pulse sequences. Deflection angles were measured on acquired images. Catheter bending stiffess was determined using a tensile testing apparatus and a stereomicroscope. Predicted relationships between deflection and various physical factors were observed (R2 = 0.98-0.99). The derived equation provides a framework for modeling of the behavior of the specialized catheter tip. Each physical factor studied has implications for catheter design and device implementation.

A new temperature-sensitive contrast mechanism for MRI: Curie temperature transition-based imaging

A temperature-sensitive MRI contrast mechanism is proposed based on the physical property, the Curie temperature (T(c)), at which a ferromagnetic material transitions to paramagnetic state and vice versa. To evaluate the feasibility of this new contrast mechanism, experiments were performed with solid gadolinium metal, which has a T(c) of 20 degrees C. In phantom and ex vivo experiments, the magnetic susceptibility artifact area decreased with increasing temperature transitioning across T(c) (p < 0.05). Similar results would be expected for a variety of ferromagnetic substances with substance-specific T(c) values. Temperature-sensitive MRI contrast agents harnessing this mechanism may be used to (1) indicate regional attainment of specific temperatures in thermotherapy, (2) render an accumulated contrast agent more or less visible by the external application of appropriate heating or cooling, or (3) quantify tissue temperature based on MR image characteristics and magnetic susceptibility artifact caused by a ferromagnetic-paramagnetic transitioning substance.

Free-breathing Motion Compensation Using Template Matching

Modeling tracer kinetics from dynamic magnetic resonance imaging (dMRI) to understand microvascular characteristics typically requires acquisitions longer than 1 breath-hold. This has limited the application of dMRI in assessment of the upper abdomen. Here we present a template-based motion correction strategy for dMRI of liver metastases based on the correlation coefficient (CC), originally developed for tracking coronary arteries. This postprocessing method allows patient free breathing during sagittal dMRI acquisition and allows a more precise parametric mapping using tracer kinetic models. In a study of 6 subjects, a 64 x 64 template was accurately tracked retrospectively with mean CC = 0.72 +/- 0.07. Mean superior-inferior displacement tracked was 1.82 +/- 1.20 pixels, whereas mean anterior-posterior displacement was 7.72 +/- 4.58 pixels. Application of the CC method significantly improved the global fit (chi2) of a tracer kinetic model throughout tumor regions. Therefore, use of the CC postprocessing method for dMRI scans can improve the precision of dMRI tracer kinetic models.

Cartilage T2 assessment: differentiation of normal hyaline cartilage and reparative tissue after arthroscopic cartilage repair in equine subjects

PURPOSE

To prospectively assess T2 mapping characteristics of normal articular cartilage and of cartilage at sites of arthroscopic repair, including comparison with histologic results and collagen organization assessed at polarized light microscopy (PLM).

MATERIALS AND METHODS

Study protocol was compliant with the Canadian Council on Animal Care Guidelines and approved by the institutional animal care committee. Arthroscopic osteochondral autograft transplantation (OAT) and microfracture arthroplasty (MFx) were performed in knees of 10 equine subjects (seven female, three male; age range, 3-5 years). A site of arthroscopically normal cartilage was documented in each joint as a control site. Joints were harvested at 12 (n = 5) and 24 (n = 5) weeks postoperatively and were imaged at 1.5-T magnetic resonance (MR) with a 10-echo sagittal fast spin-echo acquisition. T2 maps of each site (21 OAT harvest, 10 MFx, 12 OAT plug, and 10 control sites) were calculated with linear least-squares curve fitting. Cartilage T2 maps were qualitatively graded as "organized" (normal transition of low-to-high T2 signal from deep to superficial cartilage zones) or "disorganized." Quantitative mean T2 values were calculated for deep, middle, and superficial cartilage at each location. Results were compared with histologic and PLM assessments by using kappa analysis.

RESULTS

T2 maps were qualitatively graded as organized at 20 of 53 sites and as disorganized at 33 sites. Perfect agreement was seen between organized T2 and histologic findings of hyaline cartilage and between disorganized T2 and histologic findings of fibrous reparative tissue (kappa = 1.0). Strong agreement was seen between organized T2 and normal PLM findings and between disorganized T2 and abnormal PLM findings (kappa = .92). Quantitative assessment of the deep, middle, and superficial cartilage, respectively, showed mean T2 values of 53.3, 58.6, and 54.9 msec at reparative fibrous tissue sites and 40.7, 53.6, and 61.6 msec at hyaline cartilage sites. A significant trend of increasing T2 values (from deep to superficial) was found in hyaline cartilage (P < .01). Fibrous tissue sites had no significant change with depth (P > .59).

CONCLUSION

Qualitative and quantitative T2 mapping helped differentiate hyaline cartilage from reparative fibrocartilage after cartilage repair at 1.5-T MR imaging.

Characterizing coronary motion and its effect on MR coronary angiography—Initial experience

PURPOSE

To characterize coronary artery motion as a prescan procedure to select the optimum scan setting that will produce high-resolution images.

MATERIALS AND METHODS

A 2D real-time scan was used to image the major coronary arteries during breath-holding and free-breathing conditions. With the use of the 2D images, motion displacement of each artery was measured along three axes. Motion data obtained from a computer simulation were used to estimate point-spread functions (PSFs) associated with different high-resolution spiral acquisition strategies, including real-time, cardiac-gated, and respiratory-gated acquisitions. The simulation output determined the optimum acquisition and scan parameters that would produce the highest-spatial-resolution images of the coronary arteries. The effects of heart rate (HR), extended breath-holding, and number of slices per heart cycle were also investigated.

RESULTS

Substantial variations in coronary motion occur among individuals, which directly influences the optimum parameters for a high-resolution scan. Lower HRs and longer breath-holds yield substantially increased spatial resolution. The maximum number of slices per heart cycle can also be determined to minimize slice-to-slice distortion.

CONCLUSION

The results suggest that to obtain high-resolution coronary images, one should perform a prescan coronary-motion characterization for each individual so that the scan parameters can be optimized before data acquisition.

A lesion stabilization method for coronary angiography

A method to make a coronary artery segment of interest appear stationary when viewing a sequence of angiographic images is proposed. The purpose of this method is to facilitate the assessment of lesions caused by coronary artery disease by improving detectability. A description of the stabilization algorithm based on template matching is given. Stabilization was performed on 41 clinical coronary angiograms exhibiting various stenoses and was successful in 39/41 cases. A quantitative analysis of stabilization errors was performed by introducing simulated moving vessels of decreasing contrast into sequences of clinical images.

Real-time magnetic resonance with physiologic monitoring for improved scan localization

Imaging of the coronary arteries at diagnostic resolutions is made difficult due to cardiac and respiratory motion during data acquisition. Cardiac gating and respiratory gating or breath holding are effective ways to reduce the effects of motion. The optimal cardiac and respiratory timings vary widely across individuals. This work presents a real-time magnetic resonance imaging approach with physiologic monitoring that can be used to predict the optimal timings on a subject-by-subject basis during a brief real-time prescan. The feasibility of this approach at determining the optimal cardiac trigger delay and respiratory phase is demonstrated.

Adaptive averaging for improved SNR in real-time coronary artery MRI

A technique has been developed for combining a series of low signal-to-noise ratio (SNR) real-time magnetic resonance (MR) images to produce composite images with high SNR and minimal artifact in the presence of motion. The main challenge is identifying a set of real-time images with sufficiently small systematic differences to avoid introducing significant artifact into the composite image. To accomplish this task, one must: 1) identify images identical within the limits of noise; 2) detect systematic errors within such images with sufficient sensitivity. These steps are achieved by evaluating the correlation coefficient (CC) between regions in prospective images and a template containing the anatomy of interest. Images identical within noise are selected by comparing the measured CC values to the theoretical distribution expected due to noise. Sensitivity for systematic error depends on the SNR of the CC (=SNR(CCmax)), which in turn depends on the noise, and the template size and structure. By varying the template size, SNR(CCmax) may be altered. Experiments on phantoms and coronary artery images demonstrate that the SNR(CCmax) necessary to avoid introducing significant artifact varies with the target composite SNR. The future potential of this technique is demonstrated on high-resolution (approximately 0.9 mm), reduced field-of-view real-time coronary images.

Pulsatile motion effects on 3D magnetic resonance angiography: Implications for evaluating carotid artery stenoses

In-plane carotid artery motion during a 3D MR angiography (MRA) scan can significantly degrade the resulting image resolution. This study characterizes the effect of cardiac pulsatility on 3D contrast-enhanced (CE) MRA with elliptical centric acquisitions using a point-spread function (PSF) analysis. Internal carotid artery (ICA) motion was collected from volunteers and patients using both MR and ultrasound (US) scans. After measuring the carotid artery motion displacement, a simulation was performed which calculated the blurring effects for three different protocols: nongated and two different cardiac gating schemes. The motion sensitivity of each protocol was evaluated for different spatial resolutions. The selection of optimal imaging parameters for a given scan time was investigated. The final results showed that cardiac-gated acquisitions only over a limited region of k-space high spatial frequencies are more time-efficient than cardiac gating for the entire k-space, as it allows for higher resolutions to be achieved and for capturing the arterial phase with low spatial frequencies. Selecting the optimal gating parameters depends directly on the motion characteristics of each individual. Our initial clinical experience is presented, and the need for a real-time tool that characterizes motion behavior for each individual as a prescan protocol is discussed.

Optimized spiral imaging for measurement of myocardial T2 relaxation

Microcirculation oxygen levels and blood volumes should be reflected in measurements of myocardial T(2) relaxation. This work describes the optimization of a spiral imaging strategy for robust myocardial T(2) measurement to minimize the standard deviation of T(2) measurement (sigmaT(2)). Theoretical and experimental studies of blurring at muscle/blood interfaces enabled the derivation of parameter sets which reduce sigma T(2) to the level of 5%. T(2) relaxation mapping within healthy volunteers provided estimation of residual sigmaT(2) within the optimized technique. The standard deviation in T(2) measurement across regions of interest (ROIs) in different locations is about 9%. The standard deviation in T(2) measurement in an ROI across different time points is about 5%.

Factors affecting the correlation coefficient template matching algorithm with application to real-time 2-D coronary artery MR imaging

This paper characterizes factors affecting the accuracy of the correlation coefficient (CC) template matching algorithm, as applied to motion tracking from two-dimensional real-time coronary artery magnetic resonance images. The performance of this algorithm is analyzed in the presence of both random and systematic error. In the presence of random error, it is shown that a necessary and sufficient condition for accurate motion tracking is a large CC difference-to-noise ratio (CCDNR). The CCDNR itself is in turn affected by five factors: image and template size, image and template structure, and the magnitude of the noise. Techniques are introduced for manipulating some of these factors in order to increase the CCDNR for greater motion tracking accuracy. In the presence of superimposed systematic error it is shown that, while large CCDNR is necessary, it alone is not sufficient to ensure accurate motion tracking. Techniques are developed for improving motion tracking accuracy that minimize the effects of systematic error, while maintaining an adequate CCDNR level. The ability of these techniques to improve motion tracking accuracy is demonstrated both in phantoms and in coronary artery images.

Variable-density adaptive imaging for high-resolution coronary artery MRI

Variable-density (VD) spiral k-space acquisitions are used to acquire high-resolution (0.78 mm), motion-compensated images of the coronary arteries. Unlike conventional methods, information for motion compensation is obtained directly from the coronary anatomy itself. Specifically, periods of minimal coronary distortion are identified by applying the correlation coefficient template matching algorithm to real-time images generated from the inner, high-density portions of the VD spirals. Combining the data associated with these images together, high-resolution, motion-compensated coronary images are generated. Because coronary motion is visualized directly, the need for cardiac-triggering, breath-holding, and navigator echoes is eliminated. The motion compensation capability of the technique is determined by the inner-spiral spatial and temporal resolution. Results indicate that the best performance is achieved using inner-spiral images with high spatial resolution (1.6-2.9 mm), even though temporal resolution (four to six independent frames per second) suffers as a result. Image quality within the template region in healthy volunteers was found to be comparable to that achieved with cardiac-triggered breath-hold scans, although extended acquisition times of around 5 min were needed to overcome reduced SNR efficiency.

Methylation of the estrogen receptor gene is associated with aging and atherosclerosis in the cardiovascular system

OBJECTIVE

Methylation of the promoter region of the estrogen receptor gene alpha (ER alpha) occurs as a function of age in human colon, and results in inactivation of gene transcription. In this study, we sought to determine whether such age-related methylation occurs in the cardiovascular system, and whether it is associated with atherosclerotic disease.

METHODS

We used Southern blot analysis to determine the methylation state of the ER alpha gene in human right atrium, aorta, internal mammary artery, saphenous vein, coronary atherectomy samples, as well as cultured aortic endothelial cells and smooth muscle cells.

RESULTS

An age related increase in ER alpha gene methylation occurs in the right atrium (range 6 to 19%, R = 0.36, P < 0.05). Significant levels of ER alpha methylation were detected in both veins and arteries. In addition, ER alpha gene methylation appears to be increased in coronary atherosclerotic plaques when compared to normal proximal aorta (10 +/- 2% versus 4 +/- 1%, P < 0.01). In endothelial cells explanted from human aorta and grown in vitro, ER alpha gene methylation remains low. In contrast, cultured aortic smooth muscle cells contain a high level of ER alpha gene methylation (19-99%).

CONCLUSIONS

Methylation associated inactivation of the ER alpha gene in vascular tissue may play a role in atherogenesis and aging of the vascular system. This potentially reversible defect may provide a new target for intervention in heart disease.

Design of practical T2-selective RF excitation (TELEX) pulses

Traditional T2-based imaging techniques are geared toward imaging long-T2 species. Traditional techniques are, therefore, not optimal in clinical situations where the information of interest lies in the short-T2 species. T2-selective RF excitation (TELEX) is a technique for obtaining a T2-based contrast that highlights short-T2 values while suppressing long-T2 values-opposite to traditional T2 contrast. Previously, TELEX has been demonstrated qualitatively to highlight only very short-T2 values (T2 approximately 0.001 s). When applied to longer T2 values (T2 > or = 0.01 s), TELEX becomes sensitive to deltaB0 non-uniformities. This restricts its application to problems in which the T2 of interest is very short. In this study, TELEX is characterized quantitatively. Furthermore, a bandwidth broadening scheme is developed that reduces the deltaB0 sensitivity of TELEX. This permits the technique to be applied to longer T2 values. The capabilities and limitations of a practical implementation of TELEX are discussed.

Reoperative MIDCAB grafting: 3-year clinical experience

OBJECTIVE

Minimally invasive direct coronary artery bypass (MIDCAB) is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique is used in reoperative patients through various incisions to revascularize one or two areas of the heart. The internal mammary artery, gastroepiploic artery, radial artery, or saphenous vein are used as graft conduits.

METHODS

Anterior coronary targets are grafted with the internal mammary artery via a small anterior thoracotomy. Inferior coronary targets are grafted with the gastroepiploic artery via a small midline epigastric incision. Lateral coronary targets are grafted with radial artery or saphenous vein via a posterior thoracotomy. After partial heparinization, the anastomosis is facilitated by local coronary occlusion and stabilization. Graft follow-up consists of outpatient Doppler examination and selective recatheterization.

RESULTS

Between January 1994 and August 1997, 81 patients underwent reoperative MIDCAB grafting. Twenty-one patients (25.9%) had internal mammary grafting, 39 (48.2%) had gastroepiploic grafting, and 21 (25.9%) had lateral grafting with radial artery or saphenous vein. There were nine early deaths (four cardiac, five non-cardiac), five late deaths (three cardiac, two non-cardiac), and nine myocardial infarctions in remaining patients. Sixteen patients underwent recatheterization; there were one graft occlusion, two graft stenoses, and eight anastomotic stenoses. Mean postoperative length of stay was 3.8 days. Ninety percent (55/61) of patients are free of symptoms at a mean follow-up of 7.8 months (range 0-39).

CONCLUSIONS

Reoperative MIDCAB grafting avoids the risks of resternotomy, aortic manipulation, and cardiopulmonary bypass. The techniques yield an early patency rate of 94%, which includes eight patients who had postoperative catheter-based interventions. Reoperative MIDCAB grafting had lower rates of supraventricular arrhythmia and transfusion when compared with conventional coronary artery bypass grafting, but did not offer an advantage for mortality, stroke or myocardial infarction. This 3-year experience suggests that while reoperative MIDCAB grafting can effectively revascularize focal areas of the heart, patients should be carefully selected to minimize operative risk.

Cost analysis of current therapies for limited coronary artery revascularization

BACKGROUND

Single or double (limited) coronary artery revascularization using percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass (CAB) surgery has recently been enhanced with further innovation in intracoronary stenting and the emergence of minimally invasive direct coronary artery bypass (MIDCAB) grafting. Resource allocation for all modalities is directly dependent on hospitalization costs, length of stay, and clinical results.

METHODS AND RESULTS

Four groups of 25 consecutive patients over 9 months at a single center received either PTCA, stenting, MIDCAB, or conventional CAB for single-vessel coronary disease, primarily of the left anterior descending circulation. Day, supply, and procedural charges were evaluated, along with the total hospital charge. Postprocedural length of stay was calculated and compared with a national database. MIDCAB surgery day charges were less than stenting but greater than PTCA, MIDCAB supply charges were the least of all groups, and MIDCAB procedural charges were less than for conventional CAB. Total charges for MIDCAB grafting were less than for stenting but greater than for PTCA. Postprocedural length of stay for MIDCAB patients was equivalent to PTCA patients and significantly less than for stenting or for conventional CAB.

CONCLUSIONS

MIDCAB grafting provides a new surgical approach that is comparable in charges to catheter-based interventions. The technique markedly reduces length of stay and perioperative morbidity. The selection of medical or surgical limited coronary revascularization can now be based primarily on clinical outcomes without consideration for associated resource allocation.