Interventional cardiovascular procedures guided by real-time MR imaging: an interactive interface using multiple slices, adaptive projection modes and live 3D renderings

PURPOSE: To develop and test a novel interactive real-time MRI environment that facilitates image-guided cardiovascular interventions. MATERIALS AND METHODS: Color highlighting of device-mounted receiver coils, accelerated imaging of multiple slices, adaptive projection modes, live three-dimensional (3D) renderings and other interactive features were utilized to enhance navigation of devices and targeting of tissue. RESULTS: Images are shown from several catheter-based interventional procedures performed in swine that benefit from this custom interventional MRI interface. These include endograft repair of aortic aneurysm, balloon septostomy of the cardiac interatrial septum, angioplasty and stenting, and endomyocardial cell injection, all using active catheters containing MRI receiver coils. CONCLUSION: Interactive features not available on standard clinical scanners enhance real-time MRI for guiding cardiovascular interventional procedures.     

MRI in guiding and assessing intramyocardial therapy

Cardiovascular intervention, using MRI guidance, is challenging for clinical applications. Real-time imaging sequences with high spatial resolution are needed for monitoring intramyocardial delivery of drug, gene, or stem cell therapies. New generation MR scanners make local intramyocardial and vascular wall therapies feasible. Contrast-enhanced MRI is used for assessing myocardial ischemia, infarction, and scar tissue. Active (microcoils) and passive (T1 and T2* mechanisms) tracking methods have been used for visualization of endovascular catheters. Safety issues related to potential heating of endovascular devices is still a major obstacle for MRI-guided interventions. Fabrication of MRI-compatible interventional devices is limited. Noninvasive imaging strategies will be critical in defining spatial and temporal characteristics of angiogenesis and myocardial repair as well as in assessing the efficacy of new therapies in ischemic heart disease. MRI contrast media improve the capability of MRI by delineating the target and vascular tree. Labeling stem cells enables MRI to trace distribution, differentiation, and survival in myocardium and vascular wall. In the long term, MRI in guiding and assessing intramyocardial therapy may circumvent the limitations of peripherally administered cell therapy, X-ray angiography, and nuclear imaging. MRI represents a highly attractive discipline whose systematic development will foster the implementation of new cardiac and vascular therapies.This revised version was published online in March 2005 with a correction to the last authors name, C. Higgins.     

Improved hepatic arterial phase MRI with 3‐second temporal resolution

Purpose:

To assess 3‐s temporal resolution for arterial phase bolus timing on dynamic liver MRI.

Materials and Methods:

One hundred consecutive patients undergoing fluoro‐triggered dynamic gadoxetate enhanced liver MRI with standard Cartesian k‐space LAVA (Liver Acquisition with Volume Acceleration) were compared with 61 consecutive patients imaged using spiral k‐space LAVA reconstructed at 3‐s temporal resolution with sliding window reconstruction. For qualitative analysis, bolus timing, hepatic artery branch order visualized, and overall image quality were evaluated. For quantitative analysis, contrast to noise ratio between aorta and liver parenchyma, aorta and portal vein, and signal intensity ratio between aorta and liver parenchyma were calculated.

Results:

MR fluoroscopy triggered single phase standard LAVA produced optimal arterial phase timing in 35% patients, compared with 88% with Spiral LAVA (P < 0.0001). Spiral LAVA had superior bolus timing scoring 2.0, compared with 1.0 with standard LAVA (P < 0.0001). Overall image quality and hepatic artery branch order visualization scoring were superior on spiral LAVA, compared with standard LAVA (P < 0.001). The aorta to liver parenchyma signal intensity ratio was also superior on spiral LAVA, compared with standard LAVA (2.8 vs. 2.2; P < 0.001).

Conclusion:

Dynamic liver MRI bolus timing improves using 3‐s temporal resolution. J. Magn. Reson. Imaging 2013;37:1129–1136. © 2013 Wiley Periodicals, Inc.     

Catheter tracking using continuous radial MRI

The guidance of minimally invasive procedures may become a very important future application of MRI. The guidance of interventions requires images of the anatomy as well as the information of the position of invasive devices used. This paper introduces continuous radial MRI for the simultaneous acquisition of the anatomic MR image and the position of one or more small RF-coils (μ-coils), which can be mounted on invasice devices such as catheters or biopsy needles. This approach allows the in-plane tracking of an invasive device without any prolongation of the overall acquisition time. The extension to three-dimensional position tracking is described. Phantom studies are presented demonstrating the capability of this technique for real-time automatic adjustment of the slice position to the current catheter position with a temporal resolution of 100 ms. Simultaneously the in-plane catheter position is depicted in the actually acquired MR image during continuous scanning.     

Retrospective reconstruction of high temporal resolution cine images from real-time MRI using iterative motion correction

Cardiac function has traditionally been evaluated using breath-hold cine acquisitions. However, there is a great need for free breathing techniques in patients who have difficulty in holding their breath. Real-time cardiac MRI is a valuable alternative to the traditional breath-hold imaging approach, but the real-time images are often inferior in spatial and temporal resolution. This article presents a general method for reconstruction of high spatial and temporal resolution cine images from a real-time acquisition acquired over multiple cardiac cycles. The method combines parallel imaging and motion correction based on nonrigid registration and can be applied to arbitrary k-space trajectories. The method is demonstrated with real-time Cartesian imaging and Golden Angle radial acquisitions, and the motion-corrected acquisitions are compared with raw real-time images and breath-hold cine acquisitions in 10 (N = 10) subjects. Acceptable image quality was obtained in all motion-corrected reconstructions, and the resulting mean image quality score was (a) Cartesian real-time: 2.48, (b) Golden Angle real-time: 1.90 (1.00-2.50), (c) Cartesian motion correction: 3.92, (d) Radial motion correction: 4.58, and (e) Breath-hold cine: 5.00. The proposed method provides a flexible way to obtain high-quality, high-resolution cine images in patients with difficulty holding their breath.     

Accelerated bilateral dynamic contrast‐enhanced 3D spiral breast MRI using TSENSE

Purpose

To assess the ability of adaptive sensitivity encoding incorporating temporal filtering (TSENSE) to accelerate bilateral dynamic contrast‐enhanced (DCE) 3D breast MRI.

Materials and Methods

Bilateral DCE breast magnetic resonance imaging (MRI) exams were performed using a dual‐band water‐only excitation and a “stack‐of‐spirals” imaging trajectory. TSENSE was applied in the slab direction with an acceleration factor of 2. Four different techniques for sensitivity map calculation were compared by analyzing resultant contrast uptake curves qualitatively and quantitatively for 10 patient datasets. In addition, image quality and temporal resolution were compared between unaccelerated and TSENSE images.

Results

TSENSE can increase temporal resolution by a factor of 2 in DCE imaging, providing better depiction of contrast uptake curves and good image quality. Of the different methods tested, calculation of static sensitivity maps by averaging late postcontrast frames yields the lowest aliasing artifact level based on ROI analysis.

Conclusion

TSENSE acceleration combined with 3D spiral imaging is very time‐efficient, providing 11‐second temporal resolution and 1.1 × 1.1 × 3 mm³ spatial resolution over a 20 × 20 × 10 cm³ field of view for each breast. J. Magn. Reson. Imaging 2008;28:1425–1434. © 2008 Wiley‐Liss, Inc.     

Three-dimensional spiral MR imaging: Application to renal multiphase contrast-enhanced angiography.

A fast MR pulse sequence with spiral in-plane readout and conventional 3D partition encoding was developed for multiphase contrast-enhanced magnetic resonance angiography (CE-MRA) of the renal vasculature. Compared to a standard multiphase 3D CE-MRA with FLASH readout, an isotropic in-plane spatial resolution of 1.4 x 1.4 mm(2) over 2.0 x 1.4 mm(2) could be achieved with a temporal resolution of 6 sec. The theoretical gain of spatial resolution by using the spiral pulse sequence and the performance in the presence of turbulent flow was evaluated in phantom measurements. Multiphase 3D CE-MRA of the renal arteries was performed in five healthy volunteers using both techniques. A deblurring technique was used to correct the spiral raw data. Thereby, the off-resonance frequencies were determined by minimizing the imaginary part of the data in image space. The chosen correction algorithm was able to reduce image blurring substantially in all MRA phases. The image quality of the spiral CE-MRA pulse sequence was comparable to that of the FLASH CE-MRA with increased spatial resolution and a 25% reduced contrast-to-noise ratio. Additionally, artifacts specific to spiral MRI could be observed which had no impact on the assessment of the renal arteries.     

MR-guided endovascular interventions: a comprehensive review on techniques and applications

The magnetic resonance (MR) guidance of endovascular interventions is probably one of the greatest challenges of clinical MR research. MR angiography is not only an imaging tool for the vasculature but can also simultaneously depict high tissue contrast, including the differentiation of the vascular wall and perivascular tissues, as well as vascular function. Several hurdles had to be overcome to allow MR guidance for endovascular interventions. MR hardware and sequence design had to be developed to achieve acceptable patient access and to allow real-time or near real-time imaging. The development of interventional devices, both applicable and safe for MR imaging (MRI), was also mandatory. The subject of this review is to summarize the latest developments in real-time MRI hardware, MRI, visualization tools, interventional devices, endovascular tracking techniques, actual applications and safety issues.     

Embedded MR fluoroscopy: high temporal resolution real-time imaging during high spatial resolution 3D MRA acquisition.

A method termed "embedded fluoroscopy" for simultaneously acquiring a real-time sequence of 2D images during acquisition of a 3D image is presented. The 2D images are formed by periodically sampling the central phase encodes of the slab-select direction during the 3D acquisition. The tradeoffs in spatial and temporal resolution are quantified by two parameters: the "redundancy" (R), the fraction of the 3D acquisition sampled more than once; and the "effective temporal resolution" (T), the time between temporal updates of the central views. The method is applied to contrast-enhanced MR angiography (CE-MRA). The contrast bolus dynamics are portrayed in real time in the 2D image sequence while a high-resolution 3D image is being acquired. The capability of the 2D acquisition to measure contrast enhancement with only a 5% degradation of the spatial resolution of the 3D CE-MR angiogram is shown theoretically. The method is tested clinically in 15 CE-MRA patient studies of the carotid and renal arteries.     

Time-resolved, undersampled projection reconstruction imaging for high-resolution CE-MRA of the distal runoff vessels.

Imaging of the blood vessels below the knee using contrast-enhanced (CE) MRI is challenging due to the need to coordinate image acquisition and arrival of the contrast in the targeted vessels. Time-resolved acquisitions have been successful in consistently capturing images of the arterial phase of the bolus of contrast agent in the distal extremities. Although time-resolved exams are robust in this respect, higher spatial resolution for the depiction of tight stenoses and the small vessels in the lower leg is desirable. A modification to a high-spatial-resolution T(1)-weighted pulse sequence (projection reconstruction-time resolved imaging of contrast kinetics (PR-TRICKS)) that improves the through-plane spatial resolution by a factor of 2 and maintains a high frame rate is presented. The undersampled PR-TRICKS pulse sequence has been modified to double the spatial resolution in the slice direction by acquiring high-spatial-frequency slice data only after first pass of the bolus of contrast agent. The acquisition reported in the present work (PR-hyperTRICKS) has been used to image healthy volunteers and patients with known vascular disease. The temporal resolution was found to be beneficial in capturing arterial phase images in the presence of asymmetric filling of vessels.     

DIfferential Subsampling with Cartesian Ordering (DISCO): a high spatio-temporal resolution Dixon imaging sequence for multiphasic contrast enhanced abdominal imaging

Purpose:

To develop and evaluate a multiphasic contrast‐enhanced MRI method called DIfferential Sub‐sampling with Cartesian Ordering (DISCO) for abdominal imaging.

Materials and Methods:

A three‐dimensional, variable density pseudo‐random k‐space segmentation scheme was developed and combined with a Dixon‐based fat‐water separation algorithm to generate high temporal resolution images with robust fat suppression and without compromise in spatial resolution or coverage. With institutional review board approval and informed consent, 11 consecutive patients referred for abdominal MRI at 3 Tesla (T) were imaged with both DISCO and a routine clinical three‐dimensional SPGR‐Dixon (LAVA FLEX) sequence. All images were graded by two radiologists using quality of fat suppression, severity of artifacts, and overall image quality as scoring criteria. For assessment of arterial phase capture efficiency, the number of temporal phases with angiographic phase and hepatic arterial phase was recorded.

Results:

There were no significant differences in quality of fat suppression, artifact severity or overall image quality between DISCO and LAVA FLEX images (P > 0.05, Wilcoxon signed rank test). The angiographic and arterial phases were captured in all 11 patients scanned using the DISCO acquisition (mean number of phases were two and three, respectively).

Conclusion:

DISCO effectively captures the fast dynamics of abdominal pathology such as hyperenhancing hepatic lesions with a high spatio‐temporal resolution. Typically, 1.1 × 1.5 × 3 mm spatial resolution over 60 slices was achieved with a temporal resolution of 4–5 s. J. Magn. Reson. Imaging 2012;35:1484–1492. © 2012 Wiley Periodicals, Inc.     

Faster dynamic imaging of speech with field inhomogeneity corrected spiral fast low angle shot (FLASH) at 3 T

Purpose

To evaluate the impact of magnetic field inhomogeneity correction on achievable imaging speeds for magnetic resonance imaging (MRI) of articulating oropharyngeal structures during speech and to determine if sufficient acquisition speed is available for visualizing speech structures with real‐time MRI.

Materials and Methods

We designed a spiral fast low angle shot (FLASH) sequence that combines several acquisition techniques with an advanced image reconstruction approach that includes magnetic field inhomogeneity correction. A simulation study was performed to examine the interaction between imaging speed, image quality, number of spiral shots, and field inhomogeneity correction. Six volunteer subjects were scanned to demonstrate adequate visualization of articulating structures during simple speech samples.

Results

The simulation study confirmed that magnetic field inhomogeneity correction improves the available tradeoff between image quality and speed. Our optimized sequence co‐acquires magnetic field maps for image correction and achieves a dynamic imaging rate of 21.4 frames per second, significantly faster than previous studies. Improved visualization of anatomical structures, such as the soft palate, was also seen from the field‐corrected reconstructions in data acquired on volunteer subjects producing simple speech samples.

Conclusion

Adequate temporal resolution of articulating oropharyngeal structures during speech can be obtained by combining outer volume suppression, multishot spiral imaging, and magnetic field corrected image reconstruction. Correcting for the large, dynamic magnetic field variation in the oropharyngeal cavity improves image quality and allows for higher temporal resolution. J. Magn. Reson. Imaging 2010;32:1228–1237. © 2010 Wiley‐Liss, Inc.     

High temporal resolution phase contrast MRI with multiecho acquisitions.

Velocity imaging with phase contrast (PC) MRI is a noninvasive tool for quantitative blood flow measurement in vivo. A shortcoming of conventional PC imaging is the reduction in temporal resolution as compared to the corresponding magnitude imaging. For the measurement of velocity in a single direction, the temporal resolution is halved because one must acquire two differentially flow-encoded images for every PC image frame to subtract out non-velocity-related image phase information. In this study, a high temporal resolution PC technique which retains both the spatial resolution and breath-hold length of conventional magnitude imaging is presented. Improvement by a factor of 2 in the temporal resolution was achieved by acquiring the differentially flow-encoded images in separate breath-holds rather than interleaved within a single breath-hold. Additionally, a multiecho readout was incorporated into the PC experiment to acquire more views per unit time than is possible with the single gradient-echo technique. A total improvement in temporal resolution by approximately 5 times over conventional PC imaging was achieved. A complete set of images containing velocity data in all three directions was acquired in four breath-holds, with a temporal resolution of 11.2 ms and an in-plane spatial resolution of 2 mm x 2 mm.     

Mixed-bandwidth acquisitions: signal-to-noise ratio and signal-to-noise efficiency

Purpose:

To measure the hemodynamic response to exercise using real‐time velocity mapping magnetic resonance imaging (MRI), incorporating a high temporal resolution spiral phase contrast (PC) sequence accelerated with sensitivity encoding (SENSE).

Materials and Methods:

Twenty healthy adults underwent MRI at rest and during supine exercise at two different exercise levels. Flow volumes were assessed in the ascending aorta using a spiral SENSE real‐time PC sequence. The sequence was validated at rest against a vendor supplied gated PC sequence, and also at rest and during exercise against left ventricular volumes assessed using a radial k‐t SENSE real‐time sequence. Combining the measured flow volumes with simultaneous oscillometric blood pressure measurements, enabled the noninvasive calculations of systemic vascular resistance (SVR) and arterial compliance (C).

Results:

Measured flow volumes correlated very well between the sequences at rest and during exercise. Cardiac output (CO) and heart rate were found to significantly increase during exercise, while SVR and C were found to decrease significantly.

Conclusion:

Hemodynamic response to exercise can be accurately quantified using a high temporal resolution spiral SENSE real‐time flow imaging. This may allow early detection of hypertension and a greater understanding of the early changes in this condition. J. Magn. Reson. Imaging 2010;31:997–1003. ©2010 Wiley‐Liss, Inc.     

Steady-state imaging for visualization of endovascular interventions.

Steady-state imaging techniques offer the potential to couple high spatial and temporal resolution with good signal-to-noise ratio (SNR), which makes them ideally suited for fluoroscopic applications. However, disturbance of the steady state can result in artifacts and substantially reduced signal levels. In this study the use of steady-state imaging techniques was investigated as a means of guiding endovascular interventions with fluoroscopic MRI. Devices containing localized susceptibility defects were shown to disturb the steady-state signal of spins that pass through the magnetic field disturbances. It was demonstrated that these effects are appreciable and can make delineation of interventional devices difficult in the presence of flow. T(1)-shortening contrast agents were shown to dramatically reduce these effects by reducing the time taken to achieve steady state. The addition of a blood pool agent in an in vivo model was found to be necessary for adequate visualization of a dysprosium-marked catheter.     

Target definition and trajectory optimization for interactive MR-guided biopsies of brain tumors in an open configuration MRI system

We present an imaging strategy for planning and guiding brain biopsies in an open configuration MR system. Preprocedure imaging was performed in a 1.5-T MR system and was designed to provide, in a clinically efficient manner, high resolution anatomical and functional/physiologic information for precise definition and tissue characterization of the target, aiming at optimization of the biopsy trajectory for planning a safe and accurate procedure. The interventions were performed in a .5-T open bore magnet, and imaging was optimized to provide the imaging quality and temporal resolution necessary for performing the procedure interactively in near real time. Brain biopsies of 21 patients were performed in a 10-month period. Segmentation and surface rendering analysis of the lesions and vascular structures and dynamic MR perfusion and cortical activation studies provided an efficient and comprehensive way to appreciate the relationship of the target to surrounding vital structures, improved tissue characterization and definition of the tumor margins, and demonstrated the location of essential cortex, allowing appropriate placement of the burr hole and choice of optimal trajectory. Interactive protocols provided good visualization of the target and the interventional devices and offered the operator real-time feedback and control of the procedure. No complications were encountered. Advanced methods of image acquisition and processing for accurate planning of interventional brain procedures and interactive imaging with MR guidance render feasible the performance of safe and accurate neurointerventional procedures.     

High efficiency multishot interleaved spiral‐in/out: Acquisition for high‐resolution BOLD fMRI

Growing demand for high spatial resolution blood oxygenation level dependent (BOLD) functional magnetic resonance imaging faces a challenge of the spatial resolution versus coverage or temporal resolution tradeoff, which can be addressed by methods that afford increased acquisition efficiency. Spiral acquisition trajectories have been shown to be superior to currently prevalent echo‐planar imaging in terms of acquisition efficiency, and high spatial resolution can be achieved by employing multiple‐shot spiral acquisition. The interleaved spiral in/out trajectory is preferred over spiral‐in due to increased BOLD signal contrast‐to‐noise ratio (CNR) and higher acquisition efficiency than that of spiral‐out or noninterleaved spiral in/out trajectories (Law & Glover. Magn Reson Med 2009; 62:829–834.), but to date applicability of the multishot interleaved spiral in/out for high spatial resolution imaging has not been studied. Herein we propose multishot interleaved spiral in/out acquisition and investigate its applicability for high spatial resolution BOLD functional magnetic resonance imaging. Images reconstructed from interleaved spiral‐in and ‐out trajectories possess artifacts caused by differences in T2* decay, off‐resonance, and k‐space errors associated with the two trajectories. We analyze the associated errors and demonstrate that application of conjugate phase reconstruction and spectral filtering can substantially mitigate these image artifacts. After applying these processing steps, the multishot interleaved spiral in/out pulse sequence yields high BOLD CNR images at in‐plane resolution below 1 × 1 mm while preserving acceptable temporal resolution (4 s) and brain coverage (15 slices of 2 mm thickness). Moreover, this method yields sufficient BOLD CNR at 1.5 mm isotropic resolution for detection of activation in hippocampus associated with cognitive tasks (Stern memory task). The multishot interleaved spiral in/out acquisition is a promising technique for high spatial resolution BOLD functional magnetic resonance imaging applications. Magn Reson Med 70:420–428, 2013. © 2012 Wiley Periodicals, Inc.     

3T MRI in paediatrics: challenges and clinical applications

3T MRI is being increasingly performed for clinical purposes in paediatrics, primarily because of the potential to improve spatial and temporal resolution - these can assist in overcoming the unique anatomic, physiologic and behavioural challenges of imaging children. The increased spatial resolution improves the capacity to image small patients; with particular reference to smaller structures such as the inner ear, brachial plexus, biliary system and the vascular system. The challenges inherent to imaging at high field strength remain pertinent especially, the altered T1 contrast, artefacts (susceptibility, chemical shift and B1 inhomogeneity) and safety issues, including specific absorption rate - several of these are circumvented due to software and hardware advances, or by trade off of some of the increased signal. The above mentioned challenges also create opportunities at 3T, with improvement in MR angiography, arterial spin labelling, functional MRI, susceptibility weighted imaging, and MR spectroscopy - all of which have distinctive applications in paediatrics. Whole body imaging also becomes more practical because of the capacity for faster scans. 3T MRI has the potential to image all the systems in paediatrics. However, neonatal brain and paediatric spine imaging have specific challenges at 3T. Several factors also limit cardiac imaging at present. Further improvements in coil technology and newer sequences may help overcome the challenges that remain.     

Large field-of-view real-time MRI with a 32-channel system.

The emergence of parallel MRI techniques and new applications for real-time interactive MRI underscores the need to evaluate performance gained by increasing the capability of MRI phased-array systems beyond the standard four to eight high-bandwidth channels. Therefore, to explore the advantages of highly parallel MRI a 32-channel 1.5 T MRI system and 32-element torso phased arrays were designed and constructed for real-time interactive MRI. The system was assembled from multiple synchronized scanner-receiver subsystems. Software was developed to coordinate across subsystems the real-time acquisition, reconstruction, and display of 32-channel images. Real-time, large field-of-view (FOV) body-survey imaging was performed using interleaved echo-planar and single-shot fast-spin-echo pulse sequences. A new method is demonstrated for augmenting parallel image acquisition by independently offsetting the frequency of different array elements (FASSET) to variably shift their FOV. When combined with conventional parallel imaging techniques, image acceleration factors of up to 4 were investigated. The use of a large number of coils allowed the FOV to be doubled in two dimensions during rapid imaging, with no degradation of imaging time or spatial resolution. The system provides a platform for evaluating the applications of many-channel real-time MRI, and for understanding the factors that optimize the choice of array size.     

Intravascular MR imaging-guided balloon angioplasty with an MR imaging guide wire: feasibility study in rabbits

PURPOSE: To develop a technique for intravascular magnetic resonance (MR)-guided balloon angioplasty with use of an MR imaging guide wire. MATERIALS AND METHODS: An MR imaging guide wire (0.6-mm loopless antenna) that could be placed within a balloon catheter was manufactured. The guide wire was expected to function as either an MR receiver probe in real-time MR imaging or a guide wire for use with interventional devices. Laparotomy was performed in eight rabbits, and a dilatable stenosis was created at the upper abdominal aorta. Balloon angioplasty, validated at pre- and postoperative MR aortography with renal contrast enhancement was performed by using a 1.5-T MR unit with a fast spoiled gradient-echo pulse sequence, short repetition and echo times, and a rate of three frames per second. RESULTS: During MR tracking, the entire length of the MR imaging guide wire was always visible as a band of high signal intensity. In all cases, the MR imaging guide wires were passed through the aortic stenoses dilated by means of balloon inflation. Before balloon angioplasty, flow in the aorta distal to the stenosis was decreased, which caused mild contrast enhancement in each kidney. After balloon angioplasty, distal flow was restored, resulting in substantial renal enhancement. CONCLUSION: The MR imaging guide wire is a potential tool for use in endovascular interventional MR imaging.