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Karimian-Jazi K, Vollherbst DF, Schwarz D, Fischer M, Schregel K, Bauer G, Kocharyan A, Sturm V, Neuberger U, Jesser J, Herweh C, Ulfert C, Hilgenfeld T, Seker F, Preisner F, Schmitt N, Charlet T, Hamelmann S, Sahm F, Heiland S, Wick W, Ringleb PA, Schirmer L, Bendszus M, Möhlenbruch MA, Breckwoldt MO. MR microscopy to assess clot composition following mechanical thrombectomy predicts recanalization and clinical outcome. J Neurointerv Surg 2024; 16:830-837. [PMID: 37527928 DOI: 10.1136/jnis-2023-020594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/16/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard of care for patients with a stroke and large vessel occlusion. Clot composition is not routinely assessed in clinical practice as no specific diagnostic value is attributed to it, and MT is performed in a standardized 'non-personalized' approach. Whether different clot compositions are associated with intrinsic likelihoods of recanalization success or treatment outcome is unknown. METHODS We performed a prospective, non-randomized, single-center study and analyzed the clot composition in 60 consecutive patients with ischemic stroke undergoing MT. Clots were assessed by ex vivo multiparametric MRI at 9.4 T (MR microscopy), cone beam CT, and histopathology. Clot imaging was correlated with preinterventional CT and clinical data. RESULTS MR microscopy showed red blood cell (RBC)-rich (21.7%), platelet-rich (white,38.3%) or mixed clots (40.0%) as distinct morphological entities, and MR microscopy had high accuracy of 95.4% to differentiate clots. Clot composition could be further stratified on preinterventional non-contrast head CT by quantification of the hyperdense artery sign. During MT, white clots required more passes to achieve final recanalization and were not amenable to contact aspiration compared with mixed and RBC-rich clots (maneuvers: 4.7 vs 3.1 and 1.2 passes, P<0.05 and P<0.001, respectively), whereas RBC-rich clots showed higher probability of first pass recanalization (76.9%) compared with white clots (17.4%). White clots were associated with poorer clinical outcome at discharge and 90 days after MT. CONCLUSION Our study introduces MR microscopy to show that the hyperdense artery sign or MR relaxometry could guide interventional strategy. This could enable a personalized treatment approach to improve outcome of patients undergoing MT.
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Affiliation(s)
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuel Fischer
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Schregel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Gregor Bauer
- Neurology Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Kocharyan
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Volker Sturm
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tim Hilgenfeld
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabian Preisner
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Charlet
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Hamelmann
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Wick
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter A Ringleb
- Neurology Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael O Breckwoldt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Pandey S, Kutuk T, Abdalah MA, Stringfield O, Ravi H, Mills MN, Graham JA, Latifi K, Moreno WA, Ahmed KA, Raghunand N. Prediction of radiologic outcome-optimized dose plans and post-treatment magnetic resonance images: A proof-of-concept study in breast cancer brain metastases treated with stereotactic radiosurgery. Phys Imaging Radiat Oncol 2024; 31:100602. [PMID: 39040435 PMCID: PMC11261135 DOI: 10.1016/j.phro.2024.100602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 06/14/2024] [Accepted: 06/20/2024] [Indexed: 07/24/2024] Open
Abstract
Background and purpose Information in multiparametric Magnetic Resonance (mpMR) images is relatable to voxel-level tumor response to Radiation Treatment (RT). We have investigated a deep learning framework to predict (i) post-treatment mpMR images from pre-treatment mpMR images and the dose map ("forward models"), and, (ii) the RT dose map that will produce prescribed changes within the Gross Tumor Volume (GTV) on post-treatment mpMR images ("inverse model"), in Breast Cancer Metastases to the Brain (BCMB) treated with Stereotactic Radiosurgery (SRS). Materials and methods Local outcomes, planning computed tomography (CT) images, dose maps, and pre-treatment and post-treatment Apparent Diffusion Coefficient of water (ADC) maps, T1-weighted unenhanced (T1w) and contrast-enhanced (T1wCE), T2-weighted (T2w) and Fluid-Attenuated Inversion Recovery (FLAIR) mpMR images were curated from 39 BCMB patients. mpMR images were co-registered to the planning CT and intensity-calibrated. A 2D pix2pix architecture was used to train 5 forward models (ADC, T2w, FLAIR, T1w, T1wCE) and 1 inverse model on 1940 slices from 18 BCMB patients, and tested on 437 slices from another 9 BCMB patients. Results Root Mean Square Percent Error (RMSPE) within the GTV between predicted and ground-truth post-RT images for the 5 forward models, in 136 test slices containing GTV, were (mean ± SD) 0.12 ± 0.044 (ADC), 0.14 ± 0.066 (T2w), 0.08 ± 0.038 (T1w), 0.13 ± 0.058 (T1wCE), and 0.09 ± 0.056 (FLAIR). RMSPE within the GTV on the same 136 test slices, between the predicted and ground-truth dose maps, was 0.37 ± 0.20 for the inverse model. Conclusions A deep learning-based approach for radiologic outcome-optimized dose planning in SRS of BCMB has been demonstrated.
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Affiliation(s)
- Shraddha Pandey
- Department of Cancer Physiology, Moffitt Cancer Center, Tampa, FL 33612, USA
- Department of Electrical Engineering, University of South Florida, Tampa, FL 33612, USA
| | - Tugce Kutuk
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Mahmoud A. Abdalah
- Quantitative Imaging Shared Service, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Olya Stringfield
- Quantitative Imaging Shared Service, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Harshan Ravi
- Department of Cancer Physiology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Matthew N. Mills
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Jasmine A. Graham
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Wilfrido A. Moreno
- Department of Electrical Engineering, University of South Florida, Tampa, FL 33612, USA
| | - Kamran A. Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Natarajan Raghunand
- Department of Cancer Physiology, Moffitt Cancer Center, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
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Correlation of MRI signal characteristics of intracranial melanoma metastases with BRAF mutation status. Melanoma Res 2022; 32:373-378. [PMID: 35979667 DOI: 10.1097/cmr.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BRAF V600 mutations (BRAFmut) are associated with more pigmentation in primary melanomas, but data on melanin content of metastases are limited. This study compares signal characteristics of BRAFmut and BRAF-wildtype (BRAFwt) intracranial melanoma metastases (IMM). MRI brain examinations at first diagnosis of IMM were identified, all performed at 3-Tesla including 1 mm volumetric pre- and postcontrast T1-weighted imaging and susceptibility-weighted imaging (SWI). Individual metastases were assessed by a neuroradiologist, stratified by size (≥10 mm, 'larger', vs. 2-9 mm, 'small'; up to 10 per group); presence of intrinsic T1-hyperintensity (T1H) and, if present, whether confidently attributable to melanin as opposed to haemorrhage; evidence of haemorrhage; presence of central necrosis. A total of 267 IMM in 73 patients were assessed (87 larger IMM, 180 small). The proportion of larger IMM was similar in both groups (31% BRAFmut and 36% BRAFwt). In small IMM, MRI evidence of melanin was more common in BRAFmut patients (42% vs. 26%; P = 0.038). Haemorrhage was more common in larger IMM (51%, vs. 20% of small IMM; P < 0.0001), but did not differ based on BRAF status. Central necrosis was more common in larger IMM (44% vs. 7%; P < 0.0001) and in BRAFmut IMM (23% vs. 11%; P = 0.011). In the BRAFmut cohort, central necrosis was more common in patients without previous anti-BRAF therapy (33% vs. 7%; P = 0.0001). T1H attributable to melanin is only slightly more common in BRAFmut IMM than BRAFwt. Higher rates of central necrosis in BRAFmut patients without previous anti-BRAF therapy suggest that anti-BRAF therapy may affect the patterns of IMM growth.
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Bai S, Wang Z, Wang M, Li J, Wei Y, Xu R, Du J. Tumor-Derived Exosomes Modulate Primary Site Tumor Metastasis. Front Cell Dev Biol 2022; 10:752818. [PMID: 35309949 PMCID: PMC8924426 DOI: 10.3389/fcell.2022.752818] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/10/2022] [Indexed: 12/12/2022] Open
Abstract
Tumor-derived exosomes (TDEs) are actively produced and released by tumor cells and carry messages from tumor cells to healthy cells or abnormal cells, and they participate in tumor metastasis. In this review, we explore the underlying mechanism of action of TDEs in tumor metastasis. TDEs transport tumor-derived proteins and non-coding RNA to tumor cells and promote migration. Transport to normal cells, such as vascular endothelial cells and immune cells, promotes angiogenesis, inhibits immune cell activation, and improves chances of tumor implantation. Thus, TDEs contribute to tumor metastasis. We summarize the function of TDEs and their components in tumor metastasis and illuminate shortcomings for advancing research on TDEs in tumor metastasis.
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Affiliation(s)
- Suwen Bai
- Longgang District People´s Hospital of Shenzhen, The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen, China.,School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Zunyun Wang
- School of Basic Medical Sciences, Anhui Medical University, Hefei, China
| | - Minghua Wang
- Longgang District People´s Hospital of Shenzhen, The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen, China
| | - Junai Li
- Longgang District People´s Hospital of Shenzhen, The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen, China
| | - Yuan Wei
- Longgang District People´s Hospital of Shenzhen, The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen, China
| | - Ruihuan Xu
- Longgang District People´s Hospital of Shenzhen, The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen, China
| | - Juan Du
- Longgang District People´s Hospital of Shenzhen, The Second Affiliated Hospital of The Chinese University of Hong Kong, Shenzhen, China
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Deike-Hofmann K, Dancs D, Paech D, Schlemmer HP, Maier-Hein K, Bäumer P, Radbruch A, Götz M. Pre-examinations Improve Automated Metastases Detection on Cranial MRI. Invest Radiol 2021; 56:320-327. [PMID: 33259442 DOI: 10.1097/rli.0000000000000745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
MATERIALS AND METHODS Our local ethics committee approved this retrospective monocenter study.First, a dual-time approach was assessed, for which the CNN was provided sequences of the MRI that initially depicted new MM (diagnosis MRI) as well as of a prediagnosis MRI: inclusion of only contrast-enhanced T1-weighted images (CNNdual_ce) was compared with inclusion of also the native T1-weighted images, T2-weighted images, and FLAIR sequences of both time points (CNNdual_all).Second, results were compared with the corresponding single time approaches, in which the CNN was provided exclusively the respective sequences of the diagnosis MRI.Casewise diagnostic performance parameters were calculated from 5-fold cross-validation. RESULTS In total, 94 cases with 494 MMs were included. Overall, the highest diagnostic performance was achieved by inclusion of only the contrast-enhanced T1-weighted images of the diagnosis and of a prediagnosis MRI (CNNdual_ce, sensitivity = 73%, PPV = 25%, F1-score = 36%). Using exclusively contrast-enhanced T1-weighted images as input resulted in significantly less false-positives (FPs) compared with inclusion of further sequences beyond contrast-enhanced T1-weighted images (FPs = 5/7 for CNNdual_ce/CNNdual_all, P < 1e-5). Comparison of contrast-enhanced dual and mono time approaches revealed that exclusion of prediagnosis MRI significantly increased FPs (FPs = 5/10 for CNNdual_ce/CNNce, P < 1e-9).Approaches with only native sequences were clearly inferior to CNNs that were provided contrast-enhanced sequences. CONCLUSIONS Automated MM detection on contrast-enhanced T1-weighted images performed with high sensitivity. Frequent FPs due to artifacts and vessels were significantly reduced by additional inclusion of prediagnosis MRI, but not by inclusion of further sequences beyond contrast-enhanced T1-weighted images. Future studies might investigate different change detection architectures for computer-aided detection.
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Affiliation(s)
| | - Dorottya Dancs
- From the Department of Radiology, German Cancer Research Center, Heidelberg
| | - Daniel Paech
- From the Department of Radiology, German Cancer Research Center, Heidelberg
| | | | - Klaus Maier-Hein
- Department for Medical Image Computing, German Cancer Research Center, Heidelberg, Germany
| | - Philipp Bäumer
- From the Department of Radiology, German Cancer Research Center, Heidelberg
| | | | - Michael Götz
- Department for Medical Image Computing, German Cancer Research Center, Heidelberg, Germany
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Whole-Body MRI for the Detection of Recurrence in Melanoma Patients at High Risk of Relapse. Cancers (Basel) 2021; 13:cancers13030442. [PMID: 33503861 PMCID: PMC7865287 DOI: 10.3390/cancers13030442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: No standard protocol for surveillance for melanoma patients is established. Whole-body magnetic resonance imaging (whole-body MRI) is a safe and sensitive technique that avoids exposure to X-rays and contrast agents. This prospective study explores the use of whole-body MRI for the early detection of recurrences. Material and Methods: Patients with American Joint Committee on Cancer Staging Manual (seventh edition; AJCC-7) stages IIIb/c or -IV melanoma who were disease-free following resection of macrometastases (cohort A), or obtained a durable complete response (CR) or partial response (PR) following systemic therapy (cohort B), were included. All patients underwent whole-body MRI, including T1, Short Tau Inversion Recovery, and diffusion-weighted imaging, every 4 months the first 3 years of follow-up and every 6 months in the following 2 years. A total body skin examination was performed every 6 months. Results: From November 2014 to November 2019, 111 patients were included (four screen failures, cohort A: 68 patients; cohort B: 39 patients). The median follow-up was 32 months. Twenty-six patients were diagnosed with suspected lesions. Of these, 15 patients were diagnosed with a recurrence on MRI. Eleven suspected lesions were considered to be of non-neoplastic origin. In addition, nine patients detected a solitary subcutaneous metastasis during self-examination, and two patients presented in between MRIs with recurrences. The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were, respectively, 58%, 98%, 58%, 98%, and 98%. Sensitivity and specificity for the detection of distant metastases was respectively 88% and 98%. No patient experienced a clinically meaningful (>grade 1) adverse event. Conclusions: Whole-body MRI for the surveillance of melanoma patients is a safe and sensitive technique sparing patients' cumulative exposure to X-rays and contrast media.
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Ceballos-Ceballos J, Loza-Gallardo DA, Barajas-Romero MA, Cantú-Brito C, Valdés-Ferrer SI. Recognition of Brain Metastases Using Gadolinium-Enhanced SWI MRI: Proof-of-Concept Study. Front Neurol 2020; 11:5. [PMID: 32116996 PMCID: PMC7026362 DOI: 10.3389/fneur.2020.00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/06/2020] [Indexed: 12/23/2022] Open
Abstract
Background and purpose: SWI MRI, a T2*-dominant MRI sequence with T1 shine-through effect, uses intrinsic structural susceptibility to create enhancement among brain structures. We evaluated whether gadolinium-enhanced SWI (SWI-Gd) improves brain metastasis detection in combination with other MRI sequences. Materials and methods: MRI images of 24 patients (46 studies) were prospectively acquired using a 1.5-T scanner. T1-weighted, unenhanced SWI (SWI-U) and SWI-Gd were evaluated blindly to clinical features by two board-certified radiologists. Results: SWI-Gd revealed more significant metastatic lesions than either T1-Gd or SWI-U (p = 0.0004 for either comparator sequence). Moreover, SWI-Gd revealed more lesions only for those patients with ≤5 lesions on T1-Gd (n = 30 studies from 16 patients; p = 0.046). Performing SWI-Gd added <5 min of scanning time with no further additional risk. Conclusions: Our findings suggest that, when added to T1-Gd and other common sequences, SWI-Gd may improve the diagnostic yield of brain metastases with only a few extra minutes of scanning time and no further risk than that of a regular gadolinium-enhanced MRI.
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Affiliation(s)
- Joel Ceballos-Ceballos
- Division of Neuroradiology, Department of Radiology, Hospital San Javier, Guadalajara, Mexico
| | - Diego A Loza-Gallardo
- Division of Neuroradiology, Department of Radiology, Hospital San Javier, Guadalajara, Mexico
| | | | - Carlos Cantú-Brito
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sergio Iván Valdés-Ferrer
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Center for Biomedical Science, Feinstein Institute for Medical Research, Manhasset, NY, United States
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Schwarz D, Bendszus M, Breckwoldt MO. Clinical Value of Susceptibility Weighted Imaging of Brain Metastases. Front Neurol 2020; 11:55. [PMID: 32117017 PMCID: PMC7010951 DOI: 10.3389/fneur.2020.00055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/15/2020] [Indexed: 12/25/2022] Open
Abstract
MRI is used for screening, initial diagnosis and follow-up of brain metastases. Multiparametric MRI protocols encompass an array of image sequences to depict key aspects of metastases morphology and biology. Given the recent safety concerns of Gd-administration and the retention of linear Gd-agents in the brain, non-contrast sequences are currently evaluated regarding their diagnostic value for brain imaging studies. Susceptibility weighted imaging has been established as a valuable clinical and research tool that is heavily used in clinical practice and utilized in diverse pathologies ranging from neuroinflammation, neurovascular disease to neurooncology. We review the value of SWI in the field of brain metastases with an emphasis on its role in early diagnosis, determination of the primary tumor entity, treatment monitoring and discuss therapy-associated changes that can affect SWI. We also review recent insights on the role of “isolated SWI signals” and the controversy on the specificity of SWI for the early detection of brain metastases.
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Affiliation(s)
- Daniel Schwarz
- Neuroradiology Department, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Neuroradiology Department, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael O Breckwoldt
- Neuroradiology Department, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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