Magnetic resonance elastography of the liver: everything you need to know to get started

Development of fully automated models for staging liver fibrosis using non-contrast MRI and artificial intelligence: a retrospective multicenter study

Background

Accurate staging of liver fibrosis (LF) is essential for clinical management in chronic liver disease. While non-contrast MRI (NC-MRI) yields valuable information for liver assessment, its effectiveness in predicting LF remains underexplored. This study aimed to develop and validate artificial intelligence (AI)-powered models utilizing NC-MRI for staging LF.

Methods

A total of 1726 patients from Shengjing Hospital of China Medical University, registered between October 2003 and October 2022, were retrospectively collected, and divided into development (n = 1208) and internal test (n = 518) cohorts. An external test cohort consisting of 337 individuals from six centers, registered between June 2015 and November 2022, were also included. All participants underwent NC-MRI (T1-weighted imaging, T1WI; and T2-fat-suppressed imaging, T2FS) and liver biopsies. Two classification models (CMs), named T1 and T2FS, were trained on respective image types using 3D contextual transformer networks and evaluated on both test cohorts. Additionally, three CMs-Clinic, Image, and Fusion-were developed using clinical features, T1 and T2FS scores, and their integration via logistic regression. Classification effectiveness of CMs was assessed using the area under the receiver operating characteristic curve (AUC). A comparison was conducted between the optimal models (OMs) with highest AUC and other methods (transient elastography, five serum biomarkers, and six radiologists).

Findings

Fusion models (i.e., OM) yielded the highest AUC among the CMs, achieving AUCs of 0.810 for significant fibrosis, 0.881 for advanced fibrosis, and 0.918 for cirrhosis in the internal test cohort, and 0.808, 0.868, and 0.925, respectively, in the external test cohort. The OMs demonstrated superior performance in AUC, significantly surpassing transient elastography (only for staging ≥ F2 and ≥ F3 grades), serum biomarkers, and three junior radiologists for staging LF. Radiologists, with the aid of the OMs, can achieve a higher AUC in LF assessment.

Interpretation

AI-powered models utilizing NC-MRI, including T1WI and T2FS, accurately stage LF.

Funding

National Natural Science Foundation of China (No. 82071885); General Program of the Liaoning Provincial Department of Education (LJKMZ20221160); Liaoning Province Science and Technology Joint Plan (2023JH2/101700127); the Leading Young Talent Program of Xingliao Yingcai in Liaoning Province (XLYC2203037).

Evaluation of the Reproducibility of MR Elastography Measurements of the Lumbar Back Muscles

BACKGROUND

MR elastography (MRE) may provide quantitative imaging biomarkers of lumbar back muscles (LBMs), complementing MRI in spinal diseases by assessing muscle mechanical properties. However, reproducibility analyses for MRE of LBM are lacking.

PURPOSE

To assess technical failure, within-day and inter-day reproducibility, robustness with the excitation source positioning, and inter-observer agreement of MRE of muscles.

STUDY TYPE

Prospective.

SUBJECTS

Seventeen healthy subjects (mean age 28 ± 4 years; 11 females).

FIELD STRENGTH/SEQUENCE

1.5 T, gradient-echo MRE, T1-weighted turbo spin echo.

ASSESSMENT

The pneumatic driver was centered at L3 level. Four MRE were performed during two visits, 2-4 weeks apart, each consisting of two MRE with less than 10 minutes inter-scan interval. At Visit 1, after the first MRE, the coil and driver were removed, then reinstalled. The MRE was repeated. At Visit 2, following the first MRE, only the driver was moved down 5 cm. The MRE was repeated. Two radiologists segmented the multifidus and erector spinae muscles.

STATISTICAL TESTS

Paired t-test, analysis of variance, intraclass correlation coefficients (ICCs). P-values <0.05 were considered statistically significant.

RESULTS

Mean stiffness of LBM ranged from 1.44 to 1.60 kPa. Mean technical failure rate was 2.5%. Inter-observer agreement was excellent (ICC ranging from 0.82 [0.64-0.96] to 0.99 [0.98-0.99] in the multifidus, and from 0.85 [0.69-0.92] to 0.99 [0.97-0.99] in the erector spinae muscles). Within-day reproducibility was fair in the multifidus (ICC: 0.53 [0.47-0.77]) and good in the erector spinae muscles (ICC: 0.74 [0.48-0.88]). Reproducibility after moving the driver was excellent in both multifidus (ICC: 0.85 [0.69-0.93]) and erector spinae muscles (ICC: 0.84 [0.67-0.92]). Inter-day reproducibility was excellent in the multifidus (ICC: 0.76 [0.48-0.89]) and poor in the erector spinae muscles (ICC: 0.23 [-0.61 to 0.63]).

DATA CONCLUSION

MRE of LBM provides measurements of stiffness with fair to excellent reproducibility and excellent inter-observer agreement. However, inter-day reproducibility in the multifidus muscles indicated that the herein used MRE protocol may not be optimal for this muscle.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1.

Magnetic Resonance Elastography for Staging Liver Fibrosis in the Oncopig

This pilot study investigated the feasibility of using magnetic resonance elastography (MRE) for the non-invasive detection and quantification of liver fibrosis in the Oncopig cancer model. Seven 8-week-old Oncopigs underwent alcoholic liver fibrosis induction and serial MRE imaging and liver biopsy at 1, 2, and 3 months post procedure. MRE was utilized to quantify liver stiffness, and liver fibrosis was histologically graded using the METAVIR system. The primary outcome measure was the capability to detect and quantify liver fibrosis using MRE with radiologic-pathologic correlation. Liver fibrosis induction, MRE imaging, and liver biopsy were successfully performed. MRE liver fibrosis was evident in 57% (4/7), 50% (3/6), and 40% (2/5) animal subjects 1, 2, and 3 months after fibrosis induction, with mean liver stiffness of 2.94, 3.25, and 2.91 kPa, respectively. Histological liver fibrosis was noted in 71% (5/7), 100% (5/5), and 100% (5/5) of animal subjects with available tissue samples. There was no significant statistical correlation between the MRE-measured liver stiffness and the METAVIR fibrosis scores. In conclusion, quantifiable liver fibrosis may be induced in the Oncopig. MRE has potential utility in non-invasively detecting liver stiffness in this large-animal preclinical model, though tissue biopsy was more sensitive in demonstrating disease.

Assessment of Tumor Cell Invasion and Radiotherapy Response in Experimental Glioma by Magnetic Resonance Elastography

BACKGROUND

Gliomas are highly invasive brain neoplasms. MRI is the most important tool to diagnose and monitor glioma but has shortcomings. In particular, the assessment of tumor cell invasion is insufficient. This is a clinical dilemma, as recurrence can arise from MRI-occult glioma cell invasion.

HYPOTHESIS

Tumor cell invasion, tumor growth and radiotherapy alter the brain parenchymal microstructure and thus are assessable by diffusion tensor imaging (DTI) and MR elastography (MRE).

STUDY TYPE

Experimental, animal model.

ANIMAL MODEL

Twenty-three male NMRI nude mice orthotopically implanted with S24 patient-derived glioma cells (experimental mice) and 9 NMRI nude mice stereotactically injected with 1 μL PBS (sham-injected mice).

FIELD STRENGTH/SEQUENCE

2D and 3D T2-weighted rapid acquisition with refocused echoes (RARE), 2D echo planar imaging (EPI) DTI, 2D multi-slice multi-echo (MSME) T2 relaxometry, 3D MSME MRE at 900 Hz acquired at 9.4 T (675 mT/m gradient strength).

ASSESSMENT

Longitudinal 4-weekly imaging was performed for up to 4 months. Tumor volume was assessed in experimental mice (n = 10 treatment-control, n = 13 radiotherapy). The radiotherapy subgroup and 5 sham-injected mice underwent irradiation (3 × 6 Gy) 9 weeks post-implantation/sham injection. MRI-/MRE-parameters were assessed in the corpus callosum and tumor core/injection tract. Imaging data were correlated to light sheet microscopy (LSM) and histology.

STATISTICAL TESTS

Paired and unpaired t-tests, a P-value ≤0.05 was considered significant.

RESULTS

From week 4 to 8, a significant callosal stiffening (4.44 ± 0.22 vs. 5.31 ± 0.29 kPa) was detected correlating with LSM-proven tumor cell invasion. This was occult to all other imaging metrics. Histologically proven tissue destruction in the tumor core led to an increased T2 relaxation time (41.65 ± 0.34 vs. 44.83 ± 0.66 msec) and ADC (610.2 ± 12.27 vs. 711.2 ± 13.42 × 10-6 mm2/s) and a softening (5.51 ± 0.30 vs. 4.24 ± 0.29 kPa) from week 8 to 12. Radiotherapy slowed tumor progression.

DATA CONCLUSION

MRE is promising for the assessment of key glioma characteristics.

EVIDENCE LEVEL

NA TECHNICAL EFFICACY: Stage 2.

Phantoms for Quantitative Body MRI: a review and discussion of the phantom value

In this paper, we review the value of phantoms for body MRI in the context of their uses for quantitative MRI methods research, clinical trials, and clinical imaging. Certain uses of phantoms are common throughout the body MRI community, including measuring bias, assessing reproducibility, and training. In addition to these uses, phantoms in body MRI methods research are used for novel methods development and the design of motion compensation and mitigation techniques. For clinical trials, phantoms are an essential part of quality management strategies, facilitating the conduct of ethically sound, reliable, and regulatorily compliant clinical research of both novel MRI methods and therapeutic agents. In the clinic, phantoms are used for development of protocols, mitigation of cost, quality control, and radiotherapy. We briefly review phantoms developed for quantitative body MRI, and finally, we review open questions regarding the most effective use of a phantom for body MRI.

Quantitative Liver Imaging in Children

ABSTRACT

In children and adults, quantitative imaging examinations determine the effectiveness of treatment for liver disease. However, pediatric liver disease differs in presentation from liver disease in adults. Children also needed to be followed for a longer period from onset and have less control of their bodies, showing more movement than adults during imaging examinations, which leads to a greater need for sedation. Thus, it is essential to appropriately tailor and accurately perform noninvasive imaging tests in these younger patients. This article is an overview of updated imaging techniques used to assess liver disease quantitatively in children. The common initial imaging study for diffuse liver disease in pediatric patients is ultrasound. In addition to preexisting echo analysis, newly developed attenuation imaging techniques have been introduced to evaluate fatty liver. Ultrasound elastography is also now actively used to evaluate liver conditions, and the broad age spectrum of the pediatric population requires caution to be taken even in the selection of probes. Magnetic resonance imaging (MRI) is another important imaging tool used to evaluate liver disease despite requiring sedation or anesthesia in young children because it allows quantitative analysis with sequences such as fat analysis and MR elastography. In addition to ultrasound and MRI, we review quantitative imaging methods specifically for fatty liver, Wilson disease, biliary atresia, hepatic fibrosis, Fontan-associated liver disease, autoimmune hepatitis, sinusoidal obstruction syndrome, and the transplanted liver. Lastly, concerns such as growth and motion that need to be addressed specifically for children are summarized.

Individualized driver amplitude in liver MR elastography: a linear regression study

BACKGROUND

Current liver magnetic resonance elastography (MRE) scans often require adjustments to driver amplitude to produce acceptable images. This could lead to time wastage and the potential loss of an opportunity to capture a high-quality image.

PURPOSE

To construct a linear regression model of individualized driver amplitude to improve liver MRE image quality.

MATERIAL AND METHODS

Data from 95 liver MRE scans of 61 participants, including abdominal missing volume ratio (AMVR), breath-holding status, the distance from the passive driver on the skin surface to the liver edge (Dd-l), body mass index (BMI), and lateral deflection of the passive driver with respect to the human sagittal plane (Angle α), were continuously collected. The Spearman correlation analysis and lasso regression were conducted to screen the independent variables. Multiple linear regression equations were developed to determine the optimal amplitude prediction model.

RESULTS

The optimal formula for linear regression models: driver amplitude (%) = -16.80 + 78.59 × AMVR - 11.12 × breath-holding (end of expiration = 1, end of inspiration = 0) + 3.16 × Dd-l + 1.94 × BMI + 0.34 × angle α, with the model passing the F test (F = 22.455, P <0.001) and R2 value of 0.558.

CONCLUSION

The individualized amplitude prediction model based on AMVR, breath-holding status, Dd-l, BMI, and angle α is a valuable tool in liver MRE examination.

Intravoxel incoherent motion assessment of liver fibrosis staging in MASLD

PURPOSE

Partial correlation analysis was performed to account for the interference of steatosis changes and inflammatory factors, to determine the true correlation between fibrosis and IVIM parameters (Dfast, Dslow, and F), and to evaluate the diagnostic efficacy of IVIM for liver fibrosis.

METHODS

A total of 106 patients with metabolic dysfunction-associated steatotic liver disease (MASLD) examined by IVIM from November 2016 to November 2023 at our hospital were retrospectively included. Preliminary analysis of each IVIM parameter and correlations with pathological findings were performed using Spearman correlation analysis, and partial correlation analysis was used to exclude the interference of other pathological factors, thus yielding the true correlations between IVIM parameters (Dfast, Dslow, and F) and pathology. The diagnostic efficacy of IVIM parameters for diagnosing MASLD was assessed via receiver operating characteristic (ROC) curve analysis.

RESULTS

Spearman correlation analysis of all the IVIM parameters revealed correlations with steatosis, lobular inflammation, and ballooning. Partial correlation analysis indicated that Dfast was correlated with the pathological fibrosis stage (r = - 0.593, P < 0.001), Dslow was correlated with the pathological steatosis score (r = - 0.313, P < 0.05), and F was correlated with the pathological fibrosis stage and steatosis score (r = - 0.456 and 0.255, P < 0.001 and P < 0.05). In the diagnosis of hepatic fibrosis, significant hepatic fibrosis, advanced liver fibrosis and cirrhosis, Dfast achieved areas under the ROC curve of 0.763, 0.801, 0.853, and 0.897, respectively. The threshold values for diagnosing different fibrosis stages using Dfast (10-3 mm2/s) were 57.613, 54.587, 52.714, and 51.978, respectively.

CONCLUSION

According to our partial correlation analysis, there was a moderate correlation between Dfast and F according to fibrosis stage, and Dfast was not influenced by inflammation or steatosis when diagnosing fibrosis in MASLD patients. A relatively close Dfast threshold is insufficient for accurately and noninvasively assessing various stages of MASLD fibrosis. In clinical practice, this approach can be considered an alternative method for the preliminary assessment of fibrosis in MASLD patients.

Review article: New developments in biomarkers and clinical drug development in alpha-1 antitrypsin deficiency-related liver disease

BACKGROUND

Alpha-1 antitrypsin liver disease (AATLD) occurs in a subset of patients with alpha-1 antitrypsin deficiency. Risk factors for disease progression and specific pathophysiologic features are not well known and validated non-invasive assessments for disease severity are lacking. Currently, there are no approved treatments for AATLD.

AIMS

To outline existing understanding of AATLD and to identify knowledge gaps critical to improving clinical trial design and development of new treatments.

METHODS

This report was developed following a multi-stakeholder forum organised by the Alpha-1 Antitrypsin Deficiency Related Liver Disease Expert Panel in which experts presented an overview of the available literature on this topic.

RESULTS

AATLD results from a 'gain of toxic function' and primarily manifests in those with the homozygous Pi*ZZ genotype. Accumulation of misfolded 'Z' AAT protein in liver cells triggers intracellular hepatocyte injury which may ultimately lead to hepatic fibrosis. Male gender, age over 50 years, persistently elevated liver tests, concomitant hepatitis B or C virus infection, and metabolic syndrome, including obesity and type 2 diabetes mellitus, are known risk factors for adult AATLD. While the gold standard for assessing AATLD disease activity is liver histology, less invasive measures with low intra- and inter-observer variability are needed. Measurement of liver stiffness shows promise; validated thresholds for staging AATLD are in development. Such advances will help patients by enabling risk stratification and personalised surveillance, along with streamlining the development process for novel therapies.

CONCLUSIONS

This inaugural forum generated a list of recommendations to address unmet needs in the field of AATLD.

This Is What Metabolic Dysfunction-Associated Steatotic Liver Disease Looks Like: Potential of a Multiparametric MRI Protocol

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent condition with a broad spectrum defined by liver biopsy. This gold standard method evaluates three features: steatosis, activity (ballooning and lobular inflammation), and fibrosis, attributing them to certain grades or stages using a semiquantitative scoring system. However, liver biopsy is subject to numerous restrictions, creating an unmet need for a reliable and reproducible method for MASLD assessment, grading, and staging. Noninvasive imaging modalities, such as magnetic resonance imaging (MRI), offer the potential to assess quantitative liver parameters. This review aims to provide an overview of the available MRI techniques for the three criteria evaluated individually by liver histology. Here, we discuss the possibility of combining multiple MRI parameters to replace liver biopsy with a holistic, multiparametric MRI protocol. In conclusion, the development and implementation of such an approach could significantly improve the diagnosis and management of MASLD, reducing the need for invasive procedures and paving the way for more personalized treatment strategies.

Noninvasive tests for liver fibrosis in 2024: are there different scales for different diseases?

Liver fibrosis is the common pathway from various chronic liver diseases and its progression leads to cirrhosis which carries a significant risk for the development of portal hypertension-related complications and hepatocellular carcinoma. It is crucial to identify and halt the worsening of liver fibrosis given its important prognostic implication. Liver biopsy is the gold standard for assessing the degree of liver fibrosis but is limited due to its invasiveness and impracticality for serial monitoring. Many noninvasive tests have been developed over the years trying to assess liver fibrosis in a practical and accurate way. The tests are mainly laboratory- or imaging-based, or in combination. Laboratory-based tests can be derived from simply routine blood tests to patented laboratory parameters. Imaging modalities include ultrasound and magnetic resonance elastography, in which vibration-controlled transient elastography is the most widely validated and adopted whereas magnetic resonance elastography has been proven the most accurate liver fibrosis assessment tool. Nonetheless, noninvasive tests do not always apply to all liver diseases, nor does a common cut-off value of a test mean the same degree of liver fibrosis in different scenarios. In this review, we discuss the diagnostic and prognostic performance, as well as the confounders and limitations, of different noninvasive tests on liver fibrosis assessment in various liver diseases.

The staging of nonalcoholic fatty liver disease fibrosis: A comparative study of MR elastography and the quantitative DCE-MRI exchange model

Objectives

To evaluate the efficacy and image processing time of the dynamic contrast-enhanced MRI (DCE-MRI) exchange model in liver fibrosis staging and compare it to the efficacy of magnetic resonance elastography (MRE).

Methods

The subjects were 45 patients with nonalcoholic fatty liver disease (NAFLD) who underwent MRE and DCE-MRI in our hospital. Liver biopsy results were available for all patients. Spearman rank correlation coefficients were used to compare the correlations among MRE, DCE-MRI and liver fibrosis parameters. Quantitative DCE-MRI parameters, MRE-derived liver stiffness measurement (LSM), and the results of a combined DCE-MRI + MRE logistic regression model were compared in terms of the area under the receiver operating characteristic curve (AUC). We also compared the scanning and postprocessing times of the MRE and DCE-MRI techniques.

Results

The correlation coefficients between the following parameters of interest and liver fibrosis were as follows: capillary permeability-surface area product (PS; DCE-MRI parameter), -0.761; portal blood flow (Fp; DCE-MRI parameter), -0.754; MRE-LSM, 0.835. Some DCE-MRI parameters (PS, Fp) had slightly greater AUC values than MRE-LSM for diagnosing the presence or absence of liver fibrosis, and the combined model had the highest AUC value for all stages except F4, but there was no significant difference in the diagnostic efficacy of the DCE-MRI, MRE, and combined models for any stage of fibrosis. The average scanning times for MRE and DCE-MRI were 17 s and 330 s, respectively, and the average postprocessing times were 45.5 s and 342.7 s, respectively.

Conclusions

In the absence of MRE equipment, DCE-MRI represents an alternative technique. However, MRE is a quicker and simpler method for assessing fibrosis than DCE-MRI in the clinic.

Imaging of Alcohol-Associated Liver Disease

Alcohol-associated liver disease (ALD) continues to be a global health concern, responsible for a significant number of deaths worldwide. Although most individuals who consume alcohol do not develop ALD, heavy drinkers and binge drinkers are at increased risk. Unfortunately, ALD is often undetected until it reaches advanced stages, frequently associated with portal hypertension and hepatocellular carcinoma (HCC). ALD is now the leading indication for liver transplant. The incidence of alcohol-associated hepatitis (AH) surged during the COVID-19 pandemic. Early diagnosis of ALD is therefore important in patient management and determination of prognosis, as abstinence can halt disease progression. The spectrum of ALD includes steatosis, steatohepatitis, and cirrhosis, with steatosis the most common manifestation. Diagnostic techniques including ultrasound, CT, and MRI provide useful information for identifying ALD and excluding other causes of liver dysfunction. Heterogeneous steatosis and transient perfusion changes on CT and MRI in the clinical setting of alcohol-use disorder are diagnostic of severe AH. Elastography techniques are useful for assessing fibrosis and monitoring treatment response. These various imaging modalities are also useful in HCC surveillance and diagnosis. This review discusses the imaging modalities currently used in the evaluation of ALD, highlighting their strengths, limitations, and clinical applications.

Phase-regularized and displacement-regularized compressed sensing for fast magnetic resonance elastography

Liver magnetic resonance elastography (MRE) is a noninvasive stiffness measurement technique that captures the tissue displacement in the phase of the signal. To limit the scanning time to a single breath-hold, liver MRE usually involves advanced readout techniques such as simultaneous multislice (SMS) or multishot methods. Furthermore, all these readout techniques require additional in-plane acceleration using either parallel imaging capabilities, such as sensitivity encoding (SENSE), or k -space undersampling, such as compressed sensing (CS). However, these methods apply a single regularization function on the complex image. This study aims to design and evaluate methods that use separate regularization on the magnitude and phase of MRE to exploit their distinct spatiotemporal characteristics. Specifically, we introduce two compressed sensing methods. The first method, termed phase-regularized compressed sensing (PRCS), applies a two-dimensional total variation (TV) prior to the magnitude and two-dimensional wavelet regularization to the phase. The second method, termed displacement-regularized compressed sensing (DRCS), exploits the spatiotemporal redundancy using 3D total variation on the magnitude. Additionally, DRCS includes a displacement fitting function to apply wavelet regularization to the displacement phasor. Both DRCS and PRCS were evaluated with different levels of compression factors in three datasets: an in silico abdomen dataset, an in vitro tissue-mimicking phantom, and an in vivo liver dataset. The reconstructed images were compared with the full sampled reconstruction, zero-filling reconstruction, wavelet-regularized compressed sensing, and a low rank plus sparse reconstruction. The metrics used for quantitative evaluation were the structural similarity index (SSIM) of magnitude (M-SSIM), displacement (D-SSIM), and shear modulus (S-SSIM), and mean shear modulus. Results from highly undersampled in silico and in vitro datasets demonstrate that the DRCS method provides higher reconstruction quality than the conventional compressed sensing method for a wide range of stiffness values. Notably, DRCS provides 24% and 22% increase in D-SSIM compared with CS for the in silico and in vitro datasets, respectively. Comparison with liver stiffness measured from full sampled data and highly undersampled data (CR=4) demonstrates that the DRCS method provided the strongest correlation ( R 2 =0.95), second-lowest mean bias (-0.18 kPa, lowest for CS with -0.16 kPa), and lowest coefficient of variation (CV=3.6%). Our results demonstrate the potential of using DRCS to improve the reconstruction quality of accelerated MRE.

Conventional and artificial intelligence-based computed tomography and magnetic resonance imaging quantitative techniques for non-invasive liver fibrosis staging

Chronic liver disease (CLD) ultimately develops into liver fibrosis and cirrhosis and is a major public health problem globally. The assessment of liver fibrosis is important for patients with CLD for prognostication, treatment decisions, and surveillance. Liver biopsies are traditionally performed to determine the stage of liver fibrosis. However, the risks of complications and technical limitations restrict their application to screening and sequential monitoring in clinical practice. CT and MRI are essential for evaluating cirrhosis-associated complications in patients with CLD, and several non-invasive methods based on them have been proposed. Artificial intelligence (AI) techniques have also been applied to stage liver fibrosis. This review aimed to explore the values of conventional and AI-based CT and MRI quantitative techniques for non-invasive liver fibrosis staging and summarized their diagnostic performance, advantages, and limitations.

Liver Fibrosis, Fat, and Iron Evaluation with MRI and Fibrosis and Fat Evaluation with US: A Practical Guide for Radiologists

Quantitative imaging biomarkers of liver disease measured by using MRI and US are emerging as important clinical tools in the management of patients with chronic liver disease (CLD). Because of their high accuracy and noninvasive nature, in many cases, these techniques have replaced liver biopsy for the diagnosis, quantitative staging, and treatment monitoring of patients with CLD. The most commonly evaluated imaging biomarkers are surrogates for liver fibrosis, fat, and iron. MR elastography is now routinely performed to evaluate for liver fibrosis and typically combined with MRI-based liver fat and iron quantification to exclude or grade hepatic steatosis and iron overload, respectively. US elastography is also widely performed to evaluate for liver fibrosis and has the advantage of lower equipment cost and greater availability compared with those of MRI. Emerging US fat quantification methods can be performed along with US elastography. The author group, consisting of members of the Society of Abdominal Radiology (SAR) Liver Fibrosis Disease-Focused Panel (DFP), the SAR Hepatic Iron Overload DFP, and the European Society of Radiology, review the basics of liver fibrosis, fat, and iron quantification with MRI and liver fibrosis and fat quantification with US. The authors cover technical requirements, typical case display, quality control and proper measurement technique and case interpretation guidelines, pitfalls, and confounding factors. The authors aim to provide a practical guide for radiologists interpreting these examinations. ^© RSNA, 2023 See the invited commentary by Ronot in this issue. Quiz questions for this article are available in the supplemental material.

Comparison of Magnetic Resonance-Based Elastography and Ultrasound Shear Wave Elastography in Patients With Suspicion of Nonalcoholic Fatty Liver Disease

ABSTRACT

This study investigated the correlation between magnetic resonance elastography (MRE) and shear wave ultrasound elastography (SWE) in patients with clinically diagnosed or suspected nonalcoholic fatty liver disease (NAFLD). Subjects with or at risk of NAFLD identified by magnetic resonance imaging (MRI) proton density fat fraction (PDFF) were prospectively enrolled. For each patient, 6 valid 2-dimensional SWE measurements were acquired using a Logiq E10 scanner (GE HealthCare, Waukesha, WI). A reliability criterion of an interquartile range to median ratio of ≤15% was used for SWE to indicate quality dataset. Magnetic resonance elastography, and MR-fat quantification data were collected the same day as part of the patient's clinical standard of care. Magnetic resonance imaging PDFF was used as a reference to quantify fat with >6.4% indicating NAFLD. Pearson correlation and t-test were performed for statistical analyses. A total of 140 patients were enrolled, 112 of which met SWE reliability measurement criteria. Magnetic resonance elastography and 2-dimensional SWE showed a positive correlation across all study subjects ( r = 0.27; P = 0.004). When patients were grouped according to steatosis and fibrosis state, a positive correlation was observed between MRE and SWE in patients with fibrosis ( r = 0.30; P = 0.03), without fibrosis ( r = 0.27; P = 0.03), and with NAFLD ( r = 0.28; P = 0.02). No elastography technique correlated with liver fat quantification ( P > 0.52). Magnetic resonance elastography was significantly different between patients with and without fibrosis ( P < 0.0001). However, this difference was not apparent with SWE ( P = 0.09). In patients with suspected or known NAFLD, MRE, and SWE demonstrated a positive correlation. In addition, these noninvasive imaging modalities may be useful adjunct techniques for monitoring NAFLD.

Magnetic resonance elastography in evaluation of liver fibrosis in children with chronic liver disease

BACKGROUND

Magnetic resonance elastography (MRE) has been used to stage liver fibrosis in adults. We aimed to assess the agreement between the Ishak scoring system and magnetic resonance elastography-measured liver stiffness (MRE-LS) in children. This study included all the children who underwent abdominal MRE and liver biopsies between February 2018 and January 2021. The correlation between MRE-LS and Ishak fibrosis stage, MRE parameters, and clinical and biochemical markers affecting this relationship was investigated.

RESULTS

A total of 52 patients (31 male; a median age of 11.8 years) were included in the study. The MRE-LS values were significantly different between Ishak fibrosis stages (p = 0.036). With a cut-off value of 2.97 kilopascals, MRE-LS had sensitivity, specificity, PPV, NPV and accuracy values of 90.9%, 82.9%, 58.8%, 97.1%, and 84.6%, respectively, for differentiating mild/moderate fibrosis (F0, 1, 2, 3) from severe fibrosis (F ≥ 4). Although MRE-LS was moderately correlated with Ishak fibrosis score and histological activity index and weakly correlated with aspartate aminotransferase, hepatic steatosis, and R2*, only Ishak fibrosis score was a significant predictor of MRE-LS. MRE-measured spleen stiffness was weakly correlated with the Ishak fibrosis score.

CONCLUSIONS

MRE has high sensitivity and specificity for evaluating liver fibrosis in children. MRE may be used to evaluate liver fibrosis in pediatric patients.

Confounder-corrected T1 mapping in the liver through simultaneous estimation of T1 , PDFF, R 2 * , and B 1 + in a single breath-hold acquisition

PURPOSE

Quantitative volumetric T₁ mapping in the liver has the potential to aid in the detection, diagnosis, and quantification of liver fibrosis, inflammation, and spatially resolved liver function. However, accurate measurement of hepatic T₁ is confounded by the presence of fat and inhomogeneous B 1 + $$ {B}_1^{+} $$ excitation. Furthermore, scan time constraints related to respiratory motion require tradeoffs of reduced volumetric coverage and/or increased acquisition time. This work presents a novel 3D acquisition and estimation method for confounder-corrected T₁ measurement over the entire liver within a single breath-hold through simultaneous estimation of T₁ , fat and B 1 + $$ {B}_1^{+} $$ .

THEORY AND METHODS

The proposed method combines chemical shift encoded MRI and variable flip angle MRI with a B 1 + $$ {B}_1^{+} $$ mapping technique to enable confounder-corrected T₁ mapping. The method was evaluated theoretically and demonstrated in both phantom and in vivo acquisitions at 1.5 and 3.0T. At 1.5T, the method was evaluated both pre- and post- contrast enhancement in healthy volunteers.

RESULTS

The proposed method demonstrated excellent linear agreement with reference inversion-recovery spin-echo based T₁ in phantom acquisitions at both 1.5 and 3.0T, with minimal bias (5.2 and 45 ms, respectively) over T₁ ranging from 200-1200 ms. In vivo results were in general agreement with reference saturation-recovery based 2D T₁ maps (SMART₁ Map, GE Healthcare).

CONCLUSION

The proposed 3D T₁ mapping method accounts for fat and B 1 + $$ {B}_1^{+} $$ confounders through simultaneous estimation of T₁ , B 1 + $$ {B}_1^{+} $$ , PDFF and R 2 * $$ {R}_2^{\ast } $$ . It demonstrates strong linear agreement with reference T₁ measurements, with low bias and high precision, and can achieve full liver coverage in a single breath-hold.

Magnetic resonance elastography: from invention to standard of care

In 1995, a vivid image of diffracting waves in red and blue was published on the cover of the journal SCIENCE. An article in that issue described a new imaging technology called magnetic resonance elastography (MRE) (Muthupillai in Science 269:1854-1857, 1995). In 2004, quantitative images of liver stiffness in vivo, obtained with MRE, were demonstrated for the first time at the annual meeting of the International Society for Magnetic Resonance in Medicine. Only five years later, the technology had become widely available as an FDA-cleared diagnostic tool for patient care. MRE has emerged as a reliable non-invasive diagnostic method for detecting and staging liver fibrosis. Deployed on more than 2000 MRI systems worldwide, MRE has received a Category I CPT code from the American Medical Association, based on clinical availability and efficacy. For many patients, MRE now provides a safe, more comfortable, and much less expensive alternative to liver biopsy for diagnosing liver fibrosis. Although progress in radiology is notable for a history of very rapid translation of technology innovations to patient care, the path is rarely linear. This article reflects on the story of MRE, the advances and the setbacks, and the lessons that were learned in the process.

A tailored passive driver for liver MRE in pediatric patients

Objectives

Magnetic resonance elastography (MRE) is increasingly used in the pediatric population for diagnosis and staging of liver fibrosis. However, the MR-compatible driver and sequences are usually those used for adult patients. Our feasibility study aimed to adapt the standardized adult MRE passive driver and vibrational parameters to a pediatric population.

Methods

We designed an elliptic passive driver shaped on a torus equipped with an elastic membrane and adapted to children's morphologies. As a first step, eight children (aged 8-18 years) were enrolled in a prospective pilot study aiming to determine the threshold vibrational amplitude for MRE using a custom passive driver, based on phase aliasing assessment and the occurrence of signal void artifacts on magnitude MR images. In the second step, the practicality and the consistency of the custom driver were assessed in a further 11 pediatric patients (aged 7-18 years). In the third step, we compared our custom driver vs. the commercial driver on six adult volunteers, in terms of the reliable region of interest area within the acquired MRE slices, the shear wave maps' quality, and measured stiffness values obtained.

Results

Based on pediatric patient data, the threshold vibrational amplitude expressed as percentage of maximum output was found to be 0.4 and 1.1 times the body weight (kg) at 40 and 60 Hz frequencies, respectively. In comparison to the commercial passive driver, the custom driver improved threefold the contact with the body surface, also enabling a more comfortable examination as self-assessed by the volunteers.

Conclusions

Our custom driver was more comfortable for the volunteers and was able to generate more homogenous shear waves, yielding larger usable hepatic area, and more reliable stiffness values.