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de Jong CMM, Kroft LJM, van Mens TE, Huisman MV, Stöger JL, Klok FA. Modern imaging of acute pulmonary embolism. Thromb Res 2024; 238:105-116. [PMID: 38703584 DOI: 10.1016/j.thromres.2024.04.016] [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: 11/24/2023] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) - a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed.
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Affiliation(s)
- C M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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2
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Singh A, Hernandez M, Calimano-Ramirez LF, Gumus KZ, Marfori W, Kee-Sampson JW, Lall C, Gopireddy DR. Quality assurance for magnetic resonance angiography of the chest in patients suspected of pulmonary embolism during iodinated contrast shortage in the emergency department setting. J Clin Imaging Sci 2023; 13:28. [PMID: 37810183 PMCID: PMC10559390 DOI: 10.25259/jcis_3_2023] [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: 01/14/2023] [Accepted: 06/02/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives COVID-19 lockdowns resulted in a global shortage of iodinated contrast media. Therefore, alternative imaging protocols were devised to evaluate patients arriving to the emergency department (ED) with suspicion of pulmonary embolism (PE). This quality assurance (QA) aims to compare diagnostic potential between alternative magnetic resonance angiography (MRA) protocol over the gold standard computed tomography angiography (CTA) by evaluating MRA imaging quality, scanner type/imaging sequence, and any risk of misdiagnosis in patients with symptoms of PE. Material and Methods This retrospective study compromised of 55 patients who arrived to ED and underwent MRA of the chest for suspicion of PE during the months of May to June 2022. Data regarding their chief complaints, imaging sequence, and MRA results were collected. Two fellowship-trained faculty radiologists reviewed the MRA scans of the patients and scored the quality using a Likert scale. Results Two patients were positive for PE and 53 patients showed negative results. Regarding the scan quality issues, motion was noted in 80% of the 55 studies that we reviewed. Significant associations (P < 0.009) between Likert scale scores and initial complaint category were found. The characteristic symptoms associated with suspicion of PE, namely, shortness of breath, chest pain, and cough were distributed among the 1 and 2 categories, reflecting the most optimal vessel opacification scores. We found no risk of misdiagnosis after reviewing the electronic medical record for follow-up appointments within 6 months of ED visit. Conclusion Patients were screened for PE with MRA as an alternative imaging tool during times of contrast shortage. Further, evaluation of MRA with CTA, side by side, in a larger patient population is required to increase the validity of our QA study.
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Affiliation(s)
- Anmol Singh
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
| | - Mauricio Hernandez
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, Florida, United States
| | - Luis Fernando Calimano-Ramirez
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
| | - Kazim Z. Gumus
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
| | - Wanda Marfori
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
| | - Joanna W. Kee-Sampson
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
| | - Chandana Lall
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
| | - Dheeraj R. Gopireddy
- Department of Radiology, University of Florida Health Jacksonville School of Medicine, Jacksonville, Florida, United States
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Bergmann LL, Ackman JB, Starekova J, Moeller A, Reeder S, Nagle SK, Schiebler ML. MR Angiography of Pulmonary Vasculature. Magn Reson Imaging Clin N Am 2023; 31:475-491. [PMID: 37414473 DOI: 10.1016/j.mric.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Pulmonary MR angiography (MRA) is a useful alternative to computed tomographic angiography (CTA) for the study of the pulmonary vasculature. For pulmonary hypertension and partial anomalous pulmonary venous return, a cardiac MR imaging and the pulmonary MRA are useful for flow quantification and planning treatment. For the diagnosis of pulmonary embolism (PE), MRA-PE has been shown to have non-inferior outcomes at 6 months when compared with CTA-PE. Over the last 15 years, pulmonary MRA has become a routine and reliable examination for the workup of pulmonary hypertension and the primary diagnosis of PE at the University of Wisconsin.
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Affiliation(s)
- Liisa L Bergmann
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, HX332E, Lexington, KY 40536-0293, USA; Department of Medicine, University of Kentucky College of Medicine, 800 Rose Street, HX332E, Lexington, KY 40536-0293, USA.
| | - Jeanne B Ackman
- Massachusetts General Hospital, Department of Radiology, Division of Thoracic Imaging and Intervention Austin Building 202, 55 Fruit Street, Boston, MA 02114, USA
| | - Jitka Starekova
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Alexander Moeller
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Scott Reeder
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA.
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Ferumoxytol-enhanced MR demonstration of changes to internal placental structure in placenta accreta spectrum: Preliminary findings. Placenta 2023; 134:1-8. [PMID: 36807998 DOI: 10.1016/j.placenta.2023.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION The goal of this pilot study is to determine if ferumoxytol-enhanced MR might provide a new approach to the diagnosis of placenta accreta spectrum (PAS), and if so, to identify signs of PAS. METHODS Ten pregnant women were referred for MRI evaluation for PAS. MR studies consisted of pre-contrast SSFSE, SSFP, DWI, and ferumoxytol-enhanced sequences. Post-contrast images were rendered as MIP and MinIP images to separately display the maternal and fetal circulations respectively. Two readers examined the images for architectural changes to placentone (fetal cotyledon) that might distinguish PAS cases from normal. Attention was given to the size and morphology of the placentone, villous tree, and vascularity. In addition, the images were examined for evidence of fibrin/fibrinoid, intervillous thrombus, basal and chorionic plate bulges. Interobserver agreement was characterized with kappa coefficients and levels of confidence for feature identification was recorded on a 10-point scale. RESULTS At delivery, there were five normal placentas and five with PAS (one accreta, two increta, two percreta). The ten changes of placental architecture in PAS included: focal/regional expansion of placentone(s); lateral displacement and compression of the villous tree; disruption of a regular pattern of normal placentones; bulging of the basal plate; bulging of the chorionic plate; transplacental stem villi; linear/nodular bands at basal plate; non-tapering villous branches; intervillous hemorrhage; and dilated subplacental vessels. All these changes were more common in PAS; the first five achieved statistical significance in this small sample. The interobserver agreement and confidence for the identification of these features was good to excellent except for dilated subplacental vessels. DISCUSSION Ferumoxytol-enhanced MR imaging appears to depict derangements of the internal architecture of placentas with PAS, thereby suggesting a promising new strategy to diagnose PAS.
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Kliewer MA, Bagley AR, Reeder SB, Iruretagoyena JI, Bockoven CG, Fritsch MK. Normal placental structural anatomy: ultrasound and doppler features elucidated with US-MR image fusion and ferumoxytol-enhanced MRI. Abdom Radiol (NY) 2023; 48:744-751. [PMID: 36462034 DOI: 10.1007/s00261-022-03758-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE To elucidate ultrasound features of normal placental anatomy through correlation of gray-scale and ultrasound Doppler with ferumoxytol-enhanced MRI features using US-MR image fusion. METHODS All patients referred to MR for ultrasound findings worrisome for PAS (placenta accreta spectrum) were included in this retrospective study. MR studies included a ferumoxytol-enhanced T1-weighted MRI. Ultrasound imaging included gray-scale, color Doppler, power Doppler, and spectral Doppler techniques. After the MR, US-MRI fusion was performed by co-registering a MR acquisition to real-time US, which allowed precise, point-to-point correlation of placental features. RESULTS Fourteen patients at risk for PAS were studied using the US-MR image fusion. At delivery, there were six cases without PAS (gestational age range: 24 weeks 3 days to 34 weeks 0 days), and these composed the study cohort. Placental features that were on high signal intensity on post-ferumoxytol acquisitions represent spaces with maternal blood flow and corresponded to hypoechoic areas on ultrasound created by a paucity of reflective interfaces (villi). Color and spectral Doppler allowed the separation of maternal and fetal circulations in individual perfusional domains and demonstrated spiral artery inflow, circulation around the villous tree, and return of blood flow to the basal plate. Recognizable histopathologic features by ultrasound included the central cavity, villous tree, and venous return channels. CONCLUSION Internal placental architecture can be discerned on ultrasound. This anatomy can be correlated and confirmed with ferumoxytol-MR through US-MR fusion. Understanding this structural anatomy on ultrasound could serve as a basis to identify normal and abnormal placental features.
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Affiliation(s)
- Mark A Kliewer
- Department of Radiology, University of Wisconsin - Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-3252, USA.
| | - Anjuli R Bagley
- Department of Radiology, The University of Vermont, 111 Colchester Avenue, Main Campus, McClure, Level 1, Burlington, VT, 05401-1473, USA
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin - Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-3252, USA
| | - Jesus Igor Iruretagoyena
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin Medical School, 4th Floor McConnell Hall, 1010 Mound St, Madison, WI, 53715, USA
| | - Crystal G Bockoven
- Department of Pathology and Laboratory Medicine, University of WI-Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-8550, USA
| | - Michael K Fritsch
- Department of Pathology and Laboratory Medicine, University of WI-Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-8550, USA
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Kliewer MA, Bockoven CG, Reeder SB, Bagley AR, Fritsch MK. Ferumoxytol-enhanced magnetic resonance imaging with volume rendering: A new approach for the depiction of internal placental structure in vivo. Placenta 2023; 131:104-110. [PMID: 36577278 DOI: 10.1016/j.placenta.2022.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/26/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Placental function is vitally important, but placental assessment is limited by current imaging methods in vivo. The goal of this study is to determine if ferumoxytol-enhanced MR studies might be used to depict placental structure during pregnancy. METHODS Ten pregnant women were referred for MRI evaluation of abnormal placentation. The study group was composed five of these patients whose placentas were normal at pathology. MR studies consisted of pre-contrast SSFSE (single-shot fast spin-echo), SSFP (steady-state free procession), diffusion, and ferumoxytol-enhanced acquisitions. The post-contrast sequences were compared to pre-contrast SSFSE, SSFP, and diffusion acquisitions for features of correspondence. MR images were also compared to histopathology for anatomic landmarks including the three-ring pattern of the functional vascular exchange unit (the placentone) created by this central cavity surrounded by a ring of clustered villi, and an outer ring of dispersed villi corresponding to the maternal venous outflow channel. The measured sizes of these features on MR were compared to reported sizes. RESULTS Post-ferumoxytol images showed enhancement of the maternal blood within the placenta, notably the intervillous space and the myometrial vessels. The unenhanced fetal vessels were most visible on the MinIP (minimum intensity projection) images; the enhanced maternal vessels were most visible on the MIP (maximum intensity projection) images. Composite MIP/MinIP images show the relation of maternal and fetal circulations. The signal intensities replicate the relative contributions from enhanced maternal blood and unenhanced chorionic villi. DISCUSSION Ferumoxytol-enhanced MR imaging can depict the internal anatomy of the placenta in vivo of clarity and detail. This could represent a new diagnostic approach to placental disorders.
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Affiliation(s)
- Mark A Kliewer
- Department of Radiology, University of Wisconsin - Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-3252, USA.
| | - Crystal G Bockoven
- Department of Pathology and Laboratory Medicine, University of Wisconsin - Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-8550, USA.
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin - Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-3252, USA.
| | - Anjuli R Bagley
- The University of Vermont, Department of Radiology, 111 Colchester Avenue Main Campus, McClure, Level 1, Burlington, VT, 05401-1473, USA.
| | - Michael K Fritsch
- Department of Pathology and Laboratory Medicine, University of Wisconsin - Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-8550, USA.
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Ludwig DR, Raptis CA, Bhalla S. Emergent Magnetic Resonance Angiography for Evaluation of the Thoracoabdominal and Peripheral Vasculature. Magn Reson Imaging Clin N Am 2022; 30:465-477. [PMID: 35995474 DOI: 10.1016/j.mric.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thoracoabdominal and peripheral vasculature pathologies include a variety of severe and life threatening conditions that may be encountered in the emergent setting. Computed tomography angiography (CTA) is the first-line modality for imaging of the vasculature in this context, but magnetic resonance angiography (MRA) also plays an important and emerging role in the evaluation of carefully selected patients. Intravenous (IV) iodinated contrast is necessary for CTA, although MRA is most useful in patients who cannot receive IV iodinated contrast for reasons including prior severe allergic-like reaction to iodinated contrast, poor IV access, or severe renal insufficiency. Gadolinium-based contrast agents are administered for MRA when possible, as they generally improve the diagnostic quality and shorten the duration of the exam. In most clinical situations, however, noncontrast MRA is sufficient to obtain a diagnostic evaluation. In this review, we discuss the key strengths and limitations of MRA performed in the emergent setting, highlighting the role of MRA in the diagnosis of acute aortic syndromes, aortitis, aortic aneurysm, pulmonary embolism, and peripheral vascular disease.
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Affiliation(s)
- Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA.
| | - Constantine A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA.
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Computed tomography and magnetic resonance imaging for pulmonary embolus evaluation in children: up-to-date review on practical imaging protocols. Pediatr Radiol 2022:10.1007/s00247-022-05451-2. [PMID: 35864243 PMCID: PMC9303848 DOI: 10.1007/s00247-022-05451-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/22/2022] [Accepted: 06/30/2022] [Indexed: 11/26/2022]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that requires immediate medical intervention. Although PE was previously thought to occur infrequently in the pediatric population, recent studies have found a higher-than-expected prevalence of PE in the pediatric population of up to 15.5%. The imaging modality of choice for detecting PE in the pediatric population is multi-detector CT angiography, although MRI is assuming a growing and more important role as a potential alternative modality. Given the recent advances in both computed tomography pulmonary angiography (CTPA) and MRI techniques, a growing population of pediatric patients with complex comorbidities (such as children with a history of surgeries for congenital heart disease repair), and the recent waves of coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C), which are associated with increased risk of PE, there is new and increased need for an up-to-date review of practical CT and MRI protocols for PE evaluation in children. This article provides guidance for up-to-date CT and MR imaging techniques, reviews key recent studies on the imaging of pediatric PE, and discusses relevant pediatric PE imaging pearls and pitfalls, in hopes of providing readers with up-to-date and accurate practice for imaging evaluation of PE in children.
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Reeder SB, Hess CP, Zaharchuk G, Moy L. Editorial for "Magnetic Resonance Imaging as an Alternative to Contrast-Enhanced Computed Tomography to Mitigate Iodinated Contrast Shortages in the United States: Recommendations From the International Society for Magnetic Resonance in Medicine". J Magn Reson Imaging 2022; 56:655-656. [PMID: 35652484 DOI: 10.1002/jmri.28282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/11/2022] Open
Affiliation(s)
- Scott B Reeder
- Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA.,Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Christopher P Hess
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, California, USA
| | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Linda Moy
- Department of Radiology, Langone Medical Center, New York University, New York, New York, USA
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Debnath J, Sharma V. Diagnosing pulmonary thromboembolism: Concerns and controversies. Med J Armed Forces India 2022; 78:17-23. [PMID: 35035039 PMCID: PMC8737094 DOI: 10.1016/j.mjafi.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/24/2021] [Indexed: 01/03/2023] Open
Abstract
Pulmonary thromboembolism (PTE) is an important cause of mortality/morbidity even today despite advancement in clinical understanding as well as diagnostic facilities. Clinical diagnosis of PTE is often challenging because of nonspecific sign/symptoms. Adherence to clinical decision-making protocols and appropriate use of diagnostic modalities like computed tomography pulmonary angiography can resolve the diagnostic dilemma in most cases and help in the overall management of PTE. This article deals with various concerns as well as controversies surrounding accurate diagnosis of PTE as on date.
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Affiliation(s)
- Jyotindu Debnath
- Consultant, Professor & Head (Radiodiagnosis), Army Hospital (R&R), Delhi Cantt, India,Corresponding author.
| | - Vivek Sharma
- Professor (Radiodiagnosis), Bharati Vidyapeeth Medical College, Pune, India
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Role of MRI in the Evaluation of Thoracoabdominal Emergencies. Top Magn Reson Imaging 2021; 29:355-370. [PMID: 33264275 DOI: 10.1097/rmr.0000000000000252] [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
Thoracic and abdominal pathology are common in the emergency setting. Although computed tomography is preferred in many clinical situations, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as powerful techniques that often play a complementary role to computed tomography or may have a primary role in selected patient populations in which radiation is of specific concern or intravenous iodinated contrast is contraindicated. This review will highlight the role of MRI and MRA in the emergent imaging of thoracoabdominal pathology, specifically covering acute aortic pathology (acute aortic syndrome, aortic aneurysm, and aortitis), pulmonary embolism, gastrointestinal conditions such as appendicitis and Crohn disease, pancreatic and hepatobiliary disease (pancreatitis, choledocholithiasis, cholecystitis, and liver abscess), and genitourinary pathology (urolithiasis and pyelonephritis). In each section, we will highlight the specific role for MRI, discuss basic imaging protocols, and illustrate the MRI features of commonly encountered thoracoabdominal pathology.
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Sin D, McLennan G, Rengier F, Haddadin I, Heresi GA, Bartholomew JR, Fink MA, Thompson D, Partovi S. Acute pulmonary embolism multimodality imaging prior to endovascular therapy. Int J Cardiovasc Imaging 2020; 37:343-358. [PMID: 32862293 PMCID: PMC7456521 DOI: 10.1007/s10554-020-01980-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
Abstract
The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.
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Affiliation(s)
- David Sin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gordon McLennan
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Fabian Rengier
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ihab Haddadin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - John R Bartholomew
- Section of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Matthias A Fink
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dustin Thompson
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA.
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Salehi Ravesh M, Tesch K, Lebenatus A, Koktzoglou I, Edelman RR, Eden M, Langguth P, Graessner J, Jansen O, Both M. Clinical Value of Noncontrast-Enhanced Radial Quiescent-Interval Slice-Selective (QISS) Magnetic Resonance Angiography for the Diagnosis of Acute Pulmonary Embolism Compared to Contrast-Enhanced Computed Tomography and Cartesian Balanced Steady-State Free Precession. J Magn Reson Imaging 2020; 52:1510-1524. [PMID: 32537799 DOI: 10.1002/jmri.27240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Free-breathing noncontrast-enhanced (non-CE) magnetic resonance angiography (MRA) techniques are of considerable interest for the diagnosis of acute pulmonary embolism (APE), due to the possibility for repeated examinations, avoidance of side effects from iodine-based contrast agents, and the absence of ionizing radiation exposure as compared to CE-computed tomographic angiography (CTA). PURPOSE To analyze the clinical performance of free-breathing and electrocardiogram (ECG)-gated radial quiescent-interval slice-selective (QISS)-MRA compared to CE-CTA and to Cartesian balanced steady-state free precession (bSSFP)-MRA. STUDY TYPE Prospective. SUBJECTS Thirty patients with confirmed APE and 30 healthy volunteers (HVs). FIELD STRENGTH/SEQUENCE Radial QISS- and bSSFP-MRA at 1.5T. ASSESSMENT Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were computed to compare the pulmonary imaging quality between MRA methods. The pulmonary arterial tree was divided into 25 branches and an ordinal scoring system was used to assess the image quality of each pulmonary branch. The clinical performance of the two MRA techniques in accurately assessing APE was evaluated with respect to CE-CTA as the clinical reference standard. STATISTICAL TESTS Wilcoxon signed-rank and Spearman's correlation tests were performed. Sensitivity and specificity of the MRA techniques were determined using CE-CTA as the clinical reference standard. RESULTS Thrombus-mimicking artifacts appeared more frequently in lobar and peripheral arteries of patients with Cartesian bSSFP than with radial QISS-MRA (pulmonary trunk: 12.2% vs. 14.0%, P = 0.64; lobar arteries: 35.6% vs. 22.0%, P = 0.005, peripheral arteries: 74.4% vs. 49.0%, P < 0.001). The relative increases in SNR and of CNR provided by radial QISS-MRA with respect to Cartesian bSSFP-MRA were 30-35% (P-values of SNR/CNR, HVs: 0.09/0.09, patients: 0.03/0.02). The image quality of pulmonary arterial branches was considered good to excellent in 77.2% of patients with radial QISS-MRA and in 43.2% with Cartesian bSSFP-MRA (P < 0.0001). The clinical performance of radial QISS-MRA was higher than Cartesian bSSFP-MRA for grading embolism, with a total sensitivity of 86.0% vs. 80.6% and a specificity of 93.3% vs. 84.0%, respectively. DATA CONCLUSION Radial QISS-MRA is a reliable and safe non-CE angiographic technique with promising clinical potential compared to Cartesian bSSFP-MRA and as an alternative technique to CE-CTA for the diagnosis of APE. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Mona Salehi Ravesh
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany.,Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Karolin Tesch
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Annett Lebenatus
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Ioannis Koktzoglou
- Department of Radiology, NorthShore University HealthSystem, Evanston, Illinois, USA.,Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Robert R Edelman
- Department of Radiology, NorthShore University HealthSystem, Evanston, Illinois, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthias Eden
- Department for Internal Medicine III, Molecular Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Patrick Langguth
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | | | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Marcus Both
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
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14
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Allen BD, Schiebler ML, François CJ. Pulmonary Vascular Disease Evaluation with Magnetic Resonance Angiography. Radiol Clin North Am 2020; 58:707-719. [PMID: 32471539 DOI: 10.1016/j.rcl.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pulmonary vascular assessment commonly relies on computed tomography angiography (CTA), but continued advances in magnetic resonance angiography have allowed pulmonary magnetic resonance angiography (pMRA) to become a reasonable alternative to CTA without exposing patients to ionizing radiation. pMRA allows the evaluation of pulmonary vascular anatomy, hemodynamic physiology, lung parenchymal perfusion, and (optionally) right and left ventricular function with a single examination. This article discusses pMRA techniques and artifacts; performance in commonly encountered pulmonary vascular diseases, specifically pulmonary embolism and pulmonary hypertension; and recent advances in both contrast-enhanced and noncontrast pMRA.
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Affiliation(s)
- Bradley D Allen
- Department of Radiology, Northwestern University Feinberg School of Medicine, 737 North Michigan Avenue, Suite 1600, Chicago, IL 60611, USA.
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
| | - Christopher J François
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
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15
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Ludwig DR, Shetty AS, Broncano J, Bhalla S, Raptis CA. Magnetic Resonance Angiography of the Thoracic Vasculature: Technique and Applications. J Magn Reson Imaging 2020; 52:325-347. [PMID: 32061029 DOI: 10.1002/jmri.27067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/05/2020] [Accepted: 01/07/2020] [Indexed: 12/12/2022] Open
Abstract
Magnetic resonance angiography (MRA) is a powerful clinical tool for evaluation of the thoracic vasculature. MRA can be performed on nearly any magnetic resonance imaging (MRI) scanner, and provides images of high diagnostic quality without the use of ionizing radiation. While computed tomographic angiography (CTA) is preferred in the evaluation of hemodynamically unstable patients, MRA represents an important tool for evaluation of the thoracic vasculature in stable patients. Contrast-enhanced MRA is generally performed unless there is a specific contraindication, as it shortens the duration of the exam and provides images of higher diagnostic quality than noncontrast MRA. However, intravenous contrast is often not required to obtain a diagnostic evaluation for most clinical indications. Indeed, a variety of noncontrast MRA techniques are used for thoracic imaging, often in conjunction with contrast-enhanced MRA, each of which has a differing degree of reliance on flowing blood to produce the desired vascular signal. In this article we review contrast-enhanced MRA, with a focus on contrast agents, methods of bolus timing, and considerations in imaging acquisition. Next, we cover the mechanism of contrast, strengths, and weaknesses of various noncontrast MRA techniques. Finally, we present an approach to protocol development and review representative protocols used at our institution for a variety of thoracic applications. Further attention will be devoted to additional techniques employed to address specific clinical questions, such as delayed contrast-enhanced imaging, provocative maneuvers, electrocardiogram and respiratory gating, and phase-contrast imaging. The purpose of this article is to review basic techniques and methodology in thoracic MRA, discuss an approach to protocol development, and illustrate commonly encountered pathology on thoracic MRA examinations. Level of Evidence 5 Technical Efficacy Stage 3.
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Affiliation(s)
- Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anup S Shetty
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jordi Broncano
- Cardiothoracic Imaging Section, Health Time, Hospital de la Cruz Roja and San Juan de Dios, Cordoba, Spain
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Constantine A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
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16
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Zucker EJ. Cross-sectional imaging of congenital pulmonary artery anomalies. Int J Cardiovasc Imaging 2019; 35:1535-1548. [PMID: 31175525 DOI: 10.1007/s10554-019-01643-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/31/2019] [Indexed: 02/06/2023]
Abstract
Congenital pulmonary artery (PA) anomalies comprise a rare and heterogeneous spectrum of disease, ranging from abnormal origins to complete atresia. They may present in early infancy or more insidiously in adulthood, often in association with congenital heart disease such as tetralogy of Fallot or other syndromes. In recent years, cross-sectional imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), has become widely utilized for the noninvasive assessment of congenital PA diseases, supplementing echocardiography and at times supplanting invasive angiography. In this article, modern CT and MRI techniques for imaging congenital PA disorders are summarized. The key clinical features, cross-sectional imaging findings, and treatment options for the most commonly encountered entities are then reviewed. Emphasis is placed on the ever-growing role of cross-sectional imaging options in facilitating early and accurate diagnosis and tailored treatment.
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Affiliation(s)
- Evan J Zucker
- Department of Radiology, Stanford University School of Medicine, 725 Welch Road, Stanford, CA, 94305, USA.
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17
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Update on MR imaging of the pulmonary vasculature. Int J Cardiovasc Imaging 2019; 35:1483-1497. [PMID: 31030315 DOI: 10.1007/s10554-019-01603-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/11/2019] [Indexed: 01/01/2023]
Abstract
Magnetic resonance imaging (MRI) plays an increasingly important role in the non-invasive evaluation of the pulmonary vasculature. MR angiographic (MRA) techniques provide morphological information, while MR perfusion techniques provide functional information of the pulmonary vasculature. Contrast-enhanced MRA can be performed at high spatial resolution using 3D T1-weighted spoiled gradient echo sequence or at high temporal resolution using time-resolved techniques. Non-contrast MRA can be performed using 3D steady state free precession, double inversion fast spin echo, time of flight or phase contrast sequences. MR perfusion can be done using dynamic contrast-enhanced technique or using non-contrast techniques such as arterial spin labelling and time-resolved imaging of lungs during free breathing with Fourier decomposition analysis. MRI is used in the evaluation of acute and chronic pulmonary embolism, pulmonary hypertension and other vascular abnormalities, congenital anomalies and neoplasms. In this article, we review the different MR techniques used in the evaluation of pulmonary vasculature and its clinical applications.
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18
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Kaya F, Ufuk F, Karabulut N. Diagnostic performance of contrast-enhanced and unenhanced combined pulmonary artery MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism. Br J Radiol 2019; 92:20180695. [PMID: 30629460 DOI: 10.1259/bjr.20180695] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE: We aimed to determine the diagnostic performance of the contrast-enhanced and unenhanced combined pulmonary arterial MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism (VTE). METHODS: 44 patients who underwent CT pulmonary angiography (CTPA) for suspected PE constituted the study population. Patients underwent combined pulmonary and lower extremity MRI, and Doppler ultrasonography within 72 h after CTPA. Combined MRI included two sequences: unenhanced steady-state free precession (SSFP) and contrast-enhanced three-dimensional (3D) gradient echo (GRE). The presence of emboli in pulmonary arteries and thrombi in lower extremity veins on 3D-GRE and SSFP sequences was recorded. RESULTS: CTPA showed a total of 244 emboli in 33 (75%) patients whereas contrast-enhanced 3D-GRE MRI showed deep vein thrombosis (DVT) in 34 (77%) subjects. Sensitivities for SSFP vs 3D-GRE MRI respectively in PE detection were 87.9 vs 100% on a per-patient basis, and 53.7 vs 73% on a per-embolus basis. Of 34 patients with established DVT, 31 (91%) were detected by Doppler ultrasound and 29 (85%) were detected by SSFP technique respectively. CONCLUSION: Both contrast-enhanced and unenhanced combined MRI of acute PE and DVT are feasible one-stop-shopping techniques in patients with suspected thromboembolism. ADVANCES IN KNOWLEDGE: Pulmonary VTE is a common disease with high mortality. Non-invasive techniques withhigh accuracy are required for the assessment of VTE. CT-related radiation and contrast material risks cause concerns. MRI is a radiation-free technique evaluating the vessels with and without contrast. Combined contrast enhancedor unenhanced pulmonary and lower extremity MRI is feasible in patients with suspected thromboembolism.
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Affiliation(s)
- Furkan Kaya
- 1 Department of Radiology, Afyonkarahisar Health Sciences University , Afyonkarahisar , Turkey
| | - Furkan Ufuk
- 2 Department of Radiology, Pamukkale University School of Medicine, Kinikli , Denizli , Turkey
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19
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Batra K, Chamarthy MR, Reddick M, Roda MS, Wait M, Kalva SP. Diagnosis and interventions of vascular complications in lung transplant. Cardiovasc Diagn Ther 2018; 8:378-386. [PMID: 30057884 DOI: 10.21037/cdt.2018.03.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Though rare, pulmonary vascular complications after lung transplantation carry high morbidity and mortality. Knowledge of the normal and abnormal appearance of lung transplant vasculature is essential for timely and appropriate diagnosis and management of complications. Appropriate selection of surgical and endovascular treatments depend on the availability of expertise and requires a multidisciplinary approach to ensure the best outcomes.
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Affiliation(s)
- Kiran Batra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Murthy R Chamarthy
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mark Reddick
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Manohar S Roda
- Department of Radiology, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael Wait
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjeeva P Kalva
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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