[Ultrafast MRI phlebography of the lungs]

[Magnetic resonance imaging of pulmonary perfusion. Technical requirements and diagnostic impact]

With technical improvements in gradient hardware and the implementation of innovative k-space sampling techniques, such as parallel imaging, the feasibility of pulmonary perfusion MRI could be demonstrated in several studies. Dynamic contrast-enhanced 3D gradient echo sequences as used for time-resolved MR angiography have been established as the preferred pulse sequences for lung perfusion MRI. With these techniques perfusion of the entire lung can be visualized with a sufficiently high temporal and spatial resolution. In several trials in patients with acute pulmonary embolism, pulmonary hypertension and airway diseases, the clinical benefit and good correlation with perfusion scintigraphy have been demonstrated. The following review article describes the technical prerequisites, current post-processing techniques and the clinical indications for MR pulmonary perfusion imaging using MRI.

Time-resolved echo-shared parallel MRA of the lung: observer preference study of image quality in comparison with non-echo-shared sequences

The aim of this study was to evaluate the image quality of time-resolved echo-shared parallel MRA of the lung. The pulmonary vasculature of nine patients (seven females, two males; median age: 44 years) with pulmonary disease was examined using a time-resolved MRA sequence combining echo sharing with parallel imaging (time-resolved echo-shared angiography technique, or TREAT). The sharpness of the vessel borders, conspicuousness of peripheral lung vessels, artifact level, and overall image quality of TREAT was assessed independently by four readers in a side-by-side comparison with non-echo-shared time-resolved parallel MRA data (pMRA) previously acquired in the same patients. Furthermore, the SNR of pulmonary arteries (PA) and veins (PV) achieved with both pulse sequences was compared. The mean voxel size of TREAT MRA was decreased by 24% compared with the non-echo-shared MRA. Regarding the sharpness of the vessel borders, conspicuousness of peripheral lung vessels, and overall image quality the TREAT sequence was rated superior in 75-76% of all cases. If the TREAT images were preferred over the pMRA images, the advantage was rated as major in 61-71% of all cases. The level of artifacts was not increased with the TREAT sequence. The mean interobserver agreement for all categories ranged between fair (artifact level) and good (overall image quality). The maximum SNR of TREAT did not differ from non-echo-shared parallel MRA (PA: TREAT: 273+/-45; pMRA: 280+/-71; PV: TREAT: 273+/-33; pMRA: 258+/-62). TREAT achieves a higher spatial resolution than non-echo-shared parallel MRA which is also perceived as an improved image quality.

MR angiography of the chest

Using the described strategies all relevant disease processes of the thoracic vessels can be fully depicted using contrast-enhanced three-dimensional MRA. The aorta and the major neck and arm vessels are well visualized. Vascular pathologies, such as aneurysms, dissections, and occlusions, are readily recognized. With the implementation of high-performance gradients, three-dimensional MRA of the pulmonary vasculature has become possible even in dyspneic patients. Congenital lesions, such as coarctations, are particularly well suited for analysis with these techniques.

Imaging of lung cancer with CT, MRT and PET

The staging of non-small lung cancer has to be performed in an interdisciplinary approach considering all clinical, radiological and histologic results. The staging using imaging procedures is done according to the TNM classification with T describing the extent of the primary tumor, N the presence and location of metastatic lymph nodes and M the presence or absence of distant metastases. It is important to remember that the individual stages of the TNM classification have undergone numerous revisions and thus need to be considered in their most recent version [Chest 111 (1997) 1718; Chest 111 (1997) 1710]. Noninvasive information about the stage of the disease is important for the planning and optimization of therapy. This may be done with imaging procedures such as, CT, MRT or PET.

Contrast-enhanced MRI of the lung

The lung has long been neglected by MR imaging. This is due to unique intrinsic difficulties: (1) signal loss due to cardiac pulsation and respiration; (2) susceptibility artifacts caused by multiple air-tissue interfaces; (3) low proton density. There are many MR strategies to overcome these problems. They consist of breath-hold imaging, respiratory and cardiac gating procedures, use of short repetition and echo times, increase of the relaxivity of existing spins by administration of intravenous contrast agents, and enrichment of spin density by hyperpolarized noble gases or oxygen. Improvements in scanner performance and frequent use of contrast media have increased the interest in MR imaging and MR angiography of the lung. They can be used on a routine basis for the following indications: characterization of pulmonary nodules, staging of bronchogenic carcinoma, in particular assessment of chest wall invasion; evaluation of inflammatory activity in interstitial lung disease; acute pulmonary embolism, chronic thromboembolic pulmonary hypertension, vascular involvement in malignant disease; vascular abnormalities. Future perspectives include perfusion imaging using extracellular or intravascular (blood pool) contrast agents and ventilation imaging using inhalation of hyperpolarized noble gases, of paramagnetic oxygen or of aerosolized contrast agents. These techniques represent new approaches to functional lung imaging. The combination of visualization of morphology and functional assessment of ventilation and perfusion is unequalled by any other technique.

High-resolution pulmonary arterio- and venography using multiple-bolus multiphase 3D-Gd-mRA

The purpose of this study was to demonstrate selective visualization of pulmonary arteries and veins with high spatial resolution for improved detection of vascular pathologies. Time-resolved pulmonary three-dimensional gadolinium-enhanced magnetic resonance angiograms (3D-Gd-MRA) were acquired with an ultrashort 3D fast low-angle shot (FLASH) sequence (TR/TE 2.3/0.9 msec) using asymmetric k-space sampling in readout, phase-encoding, and partition directions. In a single breath-hold four consecutive acquisitions were performed with a scan time of 6.28 seconds for each phase. A spatial resolution of 1.9 x 1.4 x 2 mm(3) could be achieved for a 12 cm thick 3D volume. To exploit the intrinsic enhancement kinetics of the pulmonary vascular system, the infusion of two gadolinium chelate boli was synchronized with the acquisition of the first and third data sets. This infusion strategy created two predominantly pulmonary arterial and venous data sets with the arterial and venous signal being maximally anti-correlated in time. A further separation of arterial and venous signal could be achieved by means of a correlation analysis. Eight patients with suspected thrombi in the pulmonary veins were studied. The calculated correlation angiographies provided high-quality pulmonary arterio- and venograms. Background signal was completely eliminated, allowing maximum intensity projection analysis of the full data set. In 7/8 patients no venous contamination of the arterial phase and vice versa was found. Patency of the pulmonary arteries and veins could be reliably assessed to the level of the segmental vessels. The combination of ultrafast multiphase 3D-Gd-MRA and dual-bolus injection with a correlation analysis of vascular signal provides high-resolution pulmonary arterio- and venograms. This imaging strategy initiates a new competitor to X-ray angiography.