The contribution of fast-FLAIR MRI for lesion detection in the brain of patients with systemic autoimmune diseases

Evaluation of the Aggregated Time Savings in Adopting Fast Brain MRI Techniques for Outpatient Brain MRI

INTRODUCTION

Clinical validation studies have demonstrated the ability of accelerated MRI sequences to decrease acquisition time and motion artifact while preserving image quality. The operational benefits, however, have been less explored. Here, we report our initial clinical experience in implementing fast MRI techniques for outpatient brain imaging during the COVID-19 pandemic.

METHODS

Aggregate acquisition times were extracted from the medical record on consecutive imaging examinations performed during matched pre-implementation (7/1/2019-12/31/2019) and post-implementation periods (7/1/2020-12/31/2020). Expected acquisition time reduction for each MRI protocol was calculated through manual collection of acquisition times for the conventional and accelerated sequences performed during the pre- and post-implementation periods. Aggregate and expected acquisition times were compared for the five most frequently performed brain MRI protocols: brain without contrast (BR-), brain with and without contrast (BR+), multiple sclerosis (MS), memory loss (MML), and epilepsy (EPL).

RESULTS

The expected time reductions for BR-, BR+, MS, MML, and EPL protocols were 6.6 min, 11.9 min, 14 min, 10.8 min, and 14.1 min, respectively. The overall median aggregate acquisition time was 31 [25, 36] min for the pre-implementation period and 18 [15, 22] min for the post-implementation period, with a difference of 13 min (42%). The median acquisition time was reduced by 4 min (25%) for BR-, 14.0 min (44%) for BR+, 14 min (38%) for MS, 11 min (52%) for MML, and 16 min (35%) for EPL.

CONCLUSION

The implementation of fast brain MRI sequences significantly reduced the acquisition times for the most commonly performed outpatient brain MRI protocols.

Combined Brain/Heart Magnetic Resonance Imaging in Systemic Lupus Erythematosus

Cardiovascular Disease (CVD) in Systemic Lupus Erythematosus (SLE) and Neuropsychiatric SLE (NPSLE) has an estimated prevalence of 50% and 40%, respectively and both constitute major causes of death among SLE patients. In this review, a combined brain/heart Magnetic Resonance Imaging (MRI) for SLE risk stratification has been proposed. The pathophysiologic background of NPSLE includes microangiopathy, macroscopic infarcts and accelerated atherosclerosis. Classic brain MRI findings demonstrate lesions suggestive of NPSLE in 50% of the NPSLE cases, while advanced MRI indices can detect pre-clinical lesions in the majority of them, but their clinical impact still remains unknown. Cardiac involvement in SLE includes myo-pericarditis, valvular disease/endocarditis, Heart Failure (HF), coronary macro-microvascular disease, vasculitis and pulmonary hypertension. Classic and advanced Cardiovascular Magnetic Resonance (CMR) indices allow function and tissue characterization for early diagnosis and treatment follow-up of CVD in SLE. Although currently, there are no clinical data supporting the combined use of brain/heart MRI in asymptomatic SLE, it may have a place in cases with clinical suspicion of brain/heart involvement, especially in patients at high risk for CVD/stroke such as SLE with antiphospholipid syndrome (SLE/APS), in whom concurrent cardiac and brain lesions have been identified. Furthermore, it may be of value in SLE with multi-organ involvement, NPSLE with concurrent cardiac involvement, and recent onset of arrhythmia and/or heart failure.

Study of MRI brain findings and carotid US features in systemic sclerosis patients, relationship with disease parameters

Background/objectives

Systemic sclerosis (SSc) is an autoimmune disease associated with immune abnormalities and widespread vascular lesions, including increased intimal and medial thickness. These changes may be reflected in early atherosclerosis and cardiovascular risks. We aimed in this study to examine the carotid artery intima-media thickness and MRI brain findings in SSc patients and compared them to a group of normal controls. A relationship between these parameters and clinical measures in SSc was also sought.

Methods

Seventy-two SSc patients with no central nervous system (CNS) symptoms and 42 healthy controls were included. Clinical and laboratory measures, Medsger’s severity scale, and Doppler ultrasound common carotid artery intima-media thickness (CCA-IMT) were measured. Brain fluid-attenuated inversion recovery (FLAIR)-MRI and diffusion-weighted MRI (DWI) were also done.

Results

SSc patients had more CCA-IMT, higher CRP, and more brain MRI hyperintense lesions than controls (P < 0.05). Significant positive correlations existed between CCA-IMT and Medsger vascular (r = 0.7, P = 0.02). The FLAIR-MRI showed multiple hyperintense lesions in 24 patients (33%), ranging 0–36 lesions. SSc patients with more lesions (positive MRI) had longer disease duration (P = 0.001) and left and right carotid artery atheromata (P = 0.001, and 0.013, respectively) than SSc patients with negative MRIs; Medsger vascular score did not separate the SSc groups (P = 0.08).

Conclusions

In systemic sclerosis patients without central nervous system symptoms, MRI lesion numbers correlated with CCA-IMT. MRI abnormalities were found more frequently if CRP was elevated, if the Medsger SSc Severity Scale was increased, or if there was thickened carotid IMT.

Advanced and Conventional Magnetic Resonance Imaging in Neuropsychiatric Lupus

Neuropsychiatric lupus is a major diagnostic challenge, and a main cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Magnetic resonance imaging (MRI) is, by far, the main tool for assessing the brain in this disease. Conventional and advanced MRI techniques are used to help establishing the diagnosis, to rule out alternative diagnoses, and recently, to monitor the evolution of the disease. This review explores the neuroimaging findings in SLE, including the recent advances in new MRI methods.

Quantitative magnetic resonance imaging analyses and clinical significance of hyperintense white matter lesions in systemic lupus erythematosus patients

OBJECTIVE

To analyze the clinical significance of hyperintense white matter (WM) lesions in both symptomatic and asymptomatic systemic lupus erythematosus (SLE) patients.

METHODS

We studied 120 consecutive SLE patients and 44 healthy volunteers. Fluid attenuated inversion recovery and T2-weighted magnetic resonance images (MRI) were used for visual and semiautomatic volumetric measurements.

RESULTS

At baseline, 61 MRI were normal and 59 had hyperintense WM lesions. Mean volumes of WM lesions were 96.14 (SD = 85.14) mm(3) in T2 weighted and 197.2 (161.13) mm(3) in FLAIR images. The volume of WM lesions was associated with age (r = 0.45; p = 0.01), total corticosteroid dose (r = 0.53; p = 0.001), and Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index scores (r = 0.55; p = 0.002). After a median follow-up time of 24 months (SD = 2.3; range = 12-28 months), 20 patients had still normal MRIs, 30 patients had stable MRI findings, and 30 had new WM lesions. Predictors for new or increased WM lesions were past central nervous system manifestations (p = 0.001; OR = 12.2; 95% CI = 3.5-21.2), antiphospholipid antibodies (p = 0.003; OR = 6.9; 95% CI = 2.1-15.3); Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index scores (p = 0.002; OR = 7.2; 95% CI = 1.4-17.8) and higher dose of total corticosteroid dose (p = 0.01; OR = 2.4; 95% CI = 1.4-6.7).

CONCLUSION

Small hyperintense WM lesions in SLE are associated with central nervous system symptoms and antiphospholipid antibodies, and progress over time in patients with more severe SLE. Therefore, in the context of SLE, these lesions are likely consequences of central nervous system damage and not mere incidental finding.

Wegener's granulomatosis and posterior ischemic optic neuropathy: Atypical associated conditions

We report the atypical course of two patients with posterior ischemic optic neuropathy (PION) and Wegener's granulomatosis (WG). The first case suggests that the optic nerve could be the primary and unique localization of WG. The second case suggests retrobulbar neuritis as another manifestation of WG, secondary to the autoimmune diathesis underlying this disease.

Central nervous system disease in primary Sjögren’s syndrome: The role of magnetic resonance imaging

OBJECTIVES

To examine the frequency of central nervous system (CNS) disease in primary Sjogrens syndrome (pSS) and indicate ways in which cerebral magnetic resonance imaging (MRI) may help determine the significance of CNS involvement.

METHODS

The current review was based on a Medline (Pubmed) literature search through May 2003, focused on Sjogrens syndrome, other vasculitides, multiple sclerosis (MS), specific MRI techniques, and MRI findings with regard to the above-mentioned diseases. Additional literature was identified in the reference sections of articles listed in Medline.

RESULTS

Severe CNS manifestations reminiscent of MS have been described in pSS patients. Moreover, the prevalence of nonfocal neuropsychological abnormalities has been found to be elevated in some pSS patient populations. MRI studies suggest discrete cerebral tissue damage even in neurologically asymptomatic patients. However, small white matter lesions are nonspecific and may be related to age or cerebrovascular risk factors such as hypertension. A large controlled study, complementing established T2-weighted MRI with fluid-attenuated inversion recovery (FLAIR) to achieve high sensitivity in lesion detection, could indicate the disease specificity of white matter lesions in pSS. Newer MR techniques, such as spectroscopy and magnetization transfer imaging, applied, for example, in MS and systemic lupus erythematosus (SLE) to evaluate CNS tissue injury, could help determine the extent and mechanisms of macroscopic and microscopic CNS lesions in pSS.

CONCLUSIONS

Future controlled studies will be necessary to more precisely estimate the prevalence of CNS lesions in pSS, specifically of discrete white matter abnormalities. Newer MRI techniques have the potential to provide information on the severity and pathophysiological mechanisms of CNS tissue damage.

Differentiation of multiple sclerosis from other inflammatory disorders and cerebrovascular disease: value of spinal MR imaging

PURPOSE

To determine the value of magnetic resonance (MR) imaging in the spinal cord to differentiate multiple sclerosis (MS) from other inflammatory disorders and cerebrovascular diseases (together, other neurologic disease [OND]).

MATERIALS AND METHODS

The study population included 66 patients with OND and 25 patients with MS, who were matched for age, sex, and symptom duration or severity. Brain MR imaging included gadolinium-enhanced T1-weighted and dual-echo T2-weighted spin-echo sequences to assess the number, size, and appearance of lesions, contrast enhancement, and compatibility with diagnostic criteria for MS. Spinal cord MR imaging included cardiac-triggered gadolinium-enhanced sagittal T1-weighted spin-echo and dual-echo T2-weighted sequences to assess the general appearance (normal, focal lesion, diffuse abnormality) and number or size of focal lesions. Images obtained in MS and OND patients were compared. Specificity, sensitivity, accuracy, and positive and negative predictive values with MR images were calculated.

RESULTS

Brain images were abnormal in all MS patients and in 65% of OND patients. Abnormal cord images were found in 92% of MS and 6% of OND patients. The combination of brain and spinal cord images increased accuracy of diagnosis compared with use of brain images alone.

CONCLUSION

In contrast to MS, cord lesions are very uncommon in OND. This finding can help differentiate these disorders.

Diagnosis and management of patients with neuropsychiatric systemic lupus erythematosus (NPSLE)

Neuropsychiatric systemic lupus erythematosus (NPSLE) involves a wide range of focal and diffuse central and peripheral nervous system disorders and affects up to 75% of SLE patients. NPSLE can occur any time in the course of SLE, even during periods in which no SLE disease activity is detected, and is likely to be caused by multiple factors, including autoantibody production, microvasculopathy and pro-inflammatory cytokines. Central to the diagnosis of NPSLE is the question of whether the presenting neuropsychiatric symptoms are due to SLE-mediated organ dysfunction, infection, medication side-effects or metabolic abnormalities (e.g. uraemia), or are due to an unrelated condition. The diagnostic inference of NPSLE can be made only after these secondary causes have been excluded. There is no one single diagnostic tool specific to NPSLE, and clinical diagnostic impressions must be based on the combined use of immunoserological testing, functional and/or structural neuroimaging and standardized neurological, rheumatological, psychiatric and neuropsychological assessments. The management of NPSLE includes symptomatic and/or immunosuppressive treatment strategies depending on the specific presenting neuropsychiatric symptoms and whether these occur in the setting of an SLE disease activity flare.

Frequency and patterns of subclinical cognitive impairment in patients with ANCA-associated small vessel vasculitides

We investigated the prevalence of disease-related cognitive impairment in patients with anti-neutrophil cytoplasmic antibodies (ANCA)-associated small vessel vasculitides (SVV). We studied 43 patients with ANCA-associated SVV (Wegener's granulomatosis (WG), Churg-Strauss syndrome (CSS) and microscopic polyangiitis (MP)), with no evidence of focal neurological deficits and dementia and in whom other potential causes of cognitive decline were carefully excluded. All patients underwent a detailed neuropsychological evaluation and their performances were compared with those of matched healthy controls. Patients were considered to be affected by subclinical cognitive impairment when they had abnormal results in at least two neuropsychological tests. Magnetic resonance imaging (MRI) scans of the brain were also obtained in 11 patients.The average neuropsychological test scores were not significantly different between the SVV patients and the control subjects. Thirteen patients had abnormal results in two tests (seven patients) or three or more tests (six patients). Most frequently, abnormal tests were the Rey Figure Recall (six cases), the Wisconsin Card Sorting Test (six cases), and the reaction times (eight cases). The frequency and extent of brain MRI abnormalities were higher in impaired than in unimpaired patients. This study demonstrates that 30% of clinically nondemented SVV patients can have a subclinical neuropsychological impairment, characterized by mild abstract reasoning loss, mental speed reduction and nonverbal memory impairment. MRI findings in impaired patients are consistent with the presence of an SVV-mediated subcortical damage of the brain.

Neuroimaging techniques in the diagnostic work-up of patients with the antiphospholipid syndrome

The detection of multisystemic involvement often leads to a correct diagnosis of the antiphospholipid syndrome (APS), even in cases with predominant neurologic manifestations. However, when central nervous system deficits are isolated and have a relapsing-remitting or a progressive course, other conditions must be carefully considered. In this context, the diagnostic accuracy of conventional magnetic resonance imaging (MRI) is hampered by its limited pathologic specificity, which is one of the reasons why no or only modest correlations have been found between the burden of MRI-visible lesions and other clinical or laboratory measures of disease severity in patients with APS. Neuroimaging techniques with a higher pathologic specificity than conventional MRI show promise in achieving diagnostic confidence earlier in the course of APS and in better monitoring the efficacy of therapeutic interventions.

Cervical cord magnetic resonance imaging findings in systemic immune-mediated diseases

Brain magnetic resonance imaging (MRI) findings in patients with systemic immune-mediated diseases (SID) affecting the central nervous system (CNS) are heterogeneous and lack diagnostic specificity. In the present study, we evaluated the potential role of cervical cord MRI for increasing confidence when making a diagnosis of SID. Sagittal, T2-weighted images of the cervical cord were obtained in patients affected by systemic lupus erythematosus (SLE) with (NSLE, n=9) and without clinical CNS involvement (n=15), Behçet disease (BD, n=5), Wegener granulomatosis (WG, n=9), antiphospholipid antibody syndrome (APLAS, n=6) and multiple sclerosis (MS, n=10). Spinal cord hyperintense lesions were found in 9/10 MS patients, while no lesions were visible in the cervical cord of any patient with SID, regardless of the presence or absence of brain abnormalities. Cervical cord MRI can be useful in diagnosing patients suspected of having a SID.