Cerebrospinal fluid shunts: flow measurements with MR imaging

The authors describe a technique for determination of shunt patency by quantifying cerebrospinal fluid shunt flow rates with magnetic resonance (MR) imaging. This method uses a modified clinical sequence that is both sensitive to slow flow perpendicular to the imaging plane and capable of achieving oblique angles with a 4-cm field of view. Velocity-dependent phase images were used to quantify flow rates within the shunt. A preliminary study was performed in seven patients with hydrocephalus and cerebrospinal fluid shunts. Two patients were found to have zero flow in the shunt, while the remaining five had flow rates ranging from 4 to 19 mL/h. Results showed that the measurement of flow rates within the shunt lumen with MR imaging is clinically feasible.     

Cerebrospinal fluid pulsation amplitude and its quantitative relationship to cerebral blood flow pulsations: a phase-contrast MR flow imaging study

Our purpose in this investigation was to explain the heterogeneity in the cerebrospinal fluid (CSF) flow pulsation amplitudes. To this end, we determined the contributions of the cerebral arterial and jugular venous flow pulsations to the amplitude of the CSF pulsation. We examined 21 healthy subjects by cine phase-contrast MRI at the C2–3 disc level to demonstrate the CSF and vascular flows as waveforms. Multiple regression analysis was performed to calculate the contributions of (a) the arterial and venous waveform amplitudes and (b) the delay between the maximum systolic slopes of the arterial and venous waveforms (AV delay), in order to predict the amplitude of the CSF waveform. The contribution of the arterial waveform amplitude was positive (r = 0.61; p = 0.003) to the CSF waveform amplitude and that of the venous waveform amplitude was negative (r = −0.50; p = 0.006). Both in combination accounted for 56 % of the variance in predicting the CSF waveform amplitude (p < 0.0006). The contribution of AV delay was not significant. The results show that the variance in the CSF flow pulsation amplitudes can be explained by concurrent evaluation of the CSF and vascular flows. Improvement in the techniques, and controlled experiments, may allow use of CSF flow pulsation amplitudes for clinical applications in the non-invasive assessment of intracranial dynamics by MRI. Received: 3 January 1996 Accepted: 5 June 1996     

Cerebrospinal fluid flow imaging by using phase-contrast MR technique

Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. CSF motion is a combined effect of CSF production rate and superimposed cardiac pulsations. Knowledge of CSF dynamics has benefited considerably from the development of phase-contrast (PC) MRI. There are several disorders such as communicating and non-communicating hydrocephalus, Chiari malformation, syringomyelic cyst and arachnoid cyst that can change the CSF dynamics. The aims of this pictorial review are to outline the PC MRI technique, CSF physiology and cerebrospinal space anatomy, to describe a group of congenital and acquired disorders that can alter the CSF dynamics, and to assess the use of PC MRI in the assessment of various central nervous system abnormalities.     

Breast MR imaging: applications and pitfalls

CONTEXT: Contrast-enhanced magnetic resonance (MR) imaging provides better detail of the breast than either mammography or ultrasound imaging and can be a valuable adjunct to other imaging techniques, particularly for small lesions, in dense or augmented breasts and for treatment planning. OBJECTIVE: To illustrate some common technical problems encountered with MR imaging of the breast and present breast pathologies depicted with MR. RESULTS: Using a case-study approach, the authors discuss breast MR imaging difficulties related to hardware, software, technologist performance and patient cooperation. They also present examples of contralateral breast cancer, recurrent breast carcinoma and local staging of breast cancer with MR imaging. Summary MR imaging of the breast has important advantages over other techniques, despite occasional technical problems.     

Cerebrospinal fluid flow in patients with dilated ventricles studied with MR imaging

The purpose of this study was to measure the cerebrospinal fluid (CSF) velocity and flow in the aqueduct in patients with wide ventricles with or without signs of normal pressure hydrocephalus (NPH) before and after shunt surgery. We studied 18 patients with wide ventricles with MRI and measured the CSF velocity values in the aqueducts. Twelve patients with the clinical triad of NPH were examined. Six patients were studied only before shunt surgery and 6 patients were studied both before and after shunt surgery. Three patients with wide ventricles without clinical triad of NPH, and 3 patients with hydrocephalus following subarachnoid hemorrhage were also examined. Seven NPH patients with hyperdynamic CSF flow and three NPH patients with normal CSF velocity and flow values showed a positive clinical response to shunt surgery. Two of the three patients with hydrocephalus and hyperdynamic CSF flow values in the aqueduct secondary to subarachnoid bleeding responded to shunt surgery. One patient with same disease and low CSF velocity and flow values did not respond. No change was detected in the CSF flow values of the aqueduct when measurements before and after shunt surgery were compared. Ventriculoperitoneal shunting does not change the CSF dynamics in the aqueduct. Received: 8 March 1999; Revised: 30 November 1999; Accepted: 23 February 2000     

Cerebrospinal fluid cleft with cortical dimple: MR imaging marker for focal cortical dysgenesis

PURPOSE: To determine whether the magnetic resonance (MR) imaging feature of a cerebrospinal fluid (CSF) cleft and cortical dimple can be used as a marker for cortical dysgenesis. MATERIALS AND METHODS: MR images in 875 patients with epilepsy were evaluated for the following features of focal cortical dysgenesis: cortical thickening, indistinct junction between gray and white matter, macrogyria, and abnormal sulcal pattern. Images with these features were reevaluated to determine the relationship between the CSF cleft-cortical dimple complex and focal cortical dysgenesis and its contribution to diagnosis. The cleft-dimple complex was defined as a prominent CSF space associated with a region of cortical volume loss adjacent to the dysgenesis. RESULTS: Seventy-one patients had cortical dysgenesis, including 27 with cellular proliferation abnormalities, 18 with migration abnormalities, 25 with cortical organization abnormalities, and one with miscellaneous anomalies. Histologic correlation was available in 20 patients. There was an associated cortical dimple in 29 (41%) patients. This association was strongest in patients with cortical organization abnormalities: It was present in 22 of the 25 (88%) patients. In 12 (48%) patients with abnormalities of cortical organization, the CSF cleft was easier to detect than other features of cortical dysgenesis or contributed directly to the MR imaging diagnosis. CONCLUSION: The cleft-dimple complex is a marker for subtle cases of focal cortical dysgenesis and may be due to maldevelopment. In patients with seizures, the presence of a cleft-dimple complex should alert the physician to scrutinize adjacent regions for developmental anomalies.     

Cerebrospinal fluid flow in children with normal and dilated ventricles studied by MR imaging

Purpose: To quantify the cerebrospinal fluid (CSF) dynamics in the aqueduct of children with normal and dilated ventricles using MR phase-contrast technique.Material and Methods: Eighteen patients (6 months to 17 years of age) with various neurological symptoms underwent routine brain MR imaging and CSF flow measurement in the aqueduct. Nine patients had normal ventricles, 5 had dilated ventricles and 4 had a ventriculoperitoneal shunt.Results: The CSF velocity and flow rates in the aqueduct in patients with normal and dilated ventricles showed marked inter-individual variation and clear overlap. In a patient with tight aqueductal stenosis and increased ventricular pressure, pronounced CSF flow in the aqueduct was measured. Absence of flow in another patient with aqueductal stenosis was detected. Measurable although low flow in the aqueduct in 4 patients with a ventriculoperitoneal shunt was found.Conclusion: Quantitative phase MR flow measurement in the aqueduct demonstrated aqueductal stenosis; these patients had either pronounced flow or no flow in the aqueduct.     

Fat suppression in MR imaging: techniques and pitfalls.

Fat suppression is commonly used in magnetic resonance (MR) imaging to suppress the signal from adipose tissue or detect adipose tissue. Fat suppression can be achieved with three methods: fat saturation, inversion-recovery imaging, and opposed-phase imaging. Selection of a fat suppression technique should depend on the purpose of the fat suppression (contrast enhancement vs tissue characterization) and the amount of fat in the tissue being studied. Fat saturation is recommended for suppression of signal from large amounts of fat and reliable acquisition of contrast material-enhanced images. The main drawbacks of this technique are sensitivity to magnetic field nonuniformity, misregistration artifacts, and unreliability when used with low-field-strength magnets. Inversion-recovery imaging allows homogeneous and global fat suppression and can be used with low-field-strength magnets. However, this technique is not specific for fat, and the signal intensity of tissue with a long T1 and tissue with a short T1 may be ambiguous. Opposed-phase imaging is a fast and readily available technique. This method is recommended for demonstration of lesions that contain small amounts of fat. The main drawback of opposed-phase imaging is unreliability in the detection of small tumors embedded in fatty tissue.     

Thoracic aortic dissection: pitfalls and artifacts in MR imaging

Results of 53 thoracic magnetic resonance (MR) imaging examinations were reviewed to determine the prevalence and severity of artifacts and pitfalls that may occur in the evaluation of acute aortic dissection. Grade 1 artifacts and pitfalls were mimics of aortic dissection on individual images but could be demonstrated not to represent a dissection when other images from the same sequence were evaluated. Grade 2 artifacts and pitfalls required the use of images from other planes or sequences to distinguish them from a dissection. Grade 3 artifacts and pitfalls could not be distinguished from a dissection without the use of other imaging modalities. Of the 53 cases examined, 34 (64%) had artifacts or pitfalls of grade 1 or higher, 10 (19%) had artifacts or pitfalls of grade 2 or higher, and one case (2%) had grade 3 artifacts or pitfalls. Sixteen cases had more than one artifact or pitfall. Pitfalls and artifacts that mimic aortic dissection occur in a significant percentage of thoracic MR imaging examinations. An awareness of their existence, knowledge of normal anatomy, the use of axial images in all cases with the addition of images in other planes as needed, rotation of phase and frequency gradients as needed, and clinical correlation may avert misinterpretation in nearly all cases.     

Cerebrospinal fluid changes after intravenous injection of gadolinium chelate: assessment by FLAIR MR imaging

Fluid-attenuated inversion recovery (FLAIR) sequence is currently used in clinical practice. Some reports emphasize the possibility that, in pathologic conditions, intravenous injection of gadolinium chelates may lead to an increased signal inside the cerebrospinal fluid (CSF). The aim of this study was to evaluate the presence of CSF signal changes in pathologic conditions causing blood-brain barrier disruption or neovascularization when imaging is performed after intravenous injection of gadolinium. We obtained FLAIR sequences after gadolinium injection from 33 patients affected by different intracranial pathologies and 10 control subjects. Patients were affected by ischemic stroke in the subacute phase, from 2 to 7 days from onset of symptoms (12 patients), meningiomas (8 patients), high-grade gliomas (5 patients), previous surgical procedures for intra-axial neoplasms (5 patients), and multiple sclerosis with active plaques (3 patients). Magnetic resonance imaging was performed in patients and controls using a 1.5-T magnet, using T2- and T1-weighted FLAIR sequences. The FLAIR sequence was acquired before and 1–3 h after injection of a standard dose of gadolinium. In those patients affected by ischemic lesions, FLAIR sequences were repeated the next days and 3–4 days later. The CSF signal was visually evaluated by two readers and scored from 0 to 3 depending by the degree of enhancement. The location of CSF signal changes (close to the lesion, hemispheric, or diffuse) was also considered. The CSF signal was markedly increased after 3 h from intravenous injection of gadolinium in all the patients with stroke, in those with previous surgery, and in those with high-grade gliomas whose neoplasm's surface was in contact with the subarachnoid spaces (SAS) or ventricles; a strong enhancement was also evident inside the necrotic component of the tumor. The CSF changes were more evident close to the pathology and/or in the hemisphere involved by the pathology. Moderate CSF enhancement was observed in the SAS close to meningiomas. No signal changes were evident in all the others. In those patients with stroke imaged in the following days, CSF signal showed to be diffuse to both hemispheres the next day and returned to normal values within 2 days. In patients affected by pathologies with blood-brain barrier breakdown or neovascularization close the SAS or the ventricles, CSF changes, related to gadolinium leakage, are likely when FLAIR sequences are acquired 2–24 h after i.v. injection of the contrast. This pattern should be known in order to differentiate it from that of subarachnoid hemorrhage. Electronic Publication     

Cerebrospinal fluid rhinorrhea: depiction with MR cisternography in dogs

Canine cerebrospinal fluid rhinorrhea, which occurs frequently in purebred beagles, was demonstrated in two dogs on magnetic resonance images after cisternal introduction of gadolinium-DTPA dimeglumine.     

Cerebrospinal fluid fistula: detection with MR cisternography.

PURPOSEOur goal was to assess the role of MR cisternography in the examination of patients with suspected CSF rhinorrhea.METHODSMR cisternography was performed as a heavily T2-weighted fast spin-echo study with fat suppression and video reversal of the images in 37 patients over a 3-year interval. Twenty-four of the patients subsequently had exploratory surgery for fistula. Statistical analysis of the surgical results was compared with the findings at MR cisternography.RESULTSMR cisternography showed significant correlation with surgical findings, with sensitivity, specificity, and accuracy of 0.87, 0.57, and 0.78, respectively.CONCLUSIONMR cisternography proved to be an accurate diagnostic imaging technique in the evaluation of suspected CSF rhinorrhea.     

Diffusion-weighted MR imaging of the breast: Advantages and pitfalls

The aim of this paper is to review all clinical applications of diffusion weighted MR imaging (DWI) for breast pathology. The challenge of DWI is to obtain the best compromise between lesion detection and characterization. Technical factors affecting lesion characterization and detection are detailed including the effect of contrast administration, the choice of number of b and of b_max, the variation of diagnostic performance according to the type and the size of lesion studied.     

Osteomyelitis: characteristics and pitfalls of diagnosis with MR imaging

Prospective and retrospective magnetic resonance (MR) imaging (0.35-T) interpretations were compared with final diagnoses in 110 patients suspected to have osteomyelitis. Diagnostic criteria of dark marrow on T1-weighted images and bright marrow on short-tau inversion-recovery images yielded a prospective sensitivity of 98% and a prospective specificity of 75%. Sixty percent of uncomplicated septic joint effusions demonstrated abnormal marrow signal intensity that was mistaken for osteomyelitis. Retrospective review revealed that overall specificity could be improved to 82% without loss of sensitivity if increased marrow signal intensity on T2-weighted images were included as an additional criterion. Specificity may be further increased by use of knowledge of morphologic patterns that distinguish various forms of osteomyelitis. Ten patients (9%) had potential pitfall diagnoses (eg, fracture, infarction, healed infection) that mimic osteomyelitis. MR imaging can be sensitive and specific for osteomyelitis if characteristic appearances and pitfall diagnoses are incorporated into the diagnostic criteria.     

Medial meniscocapsular separation: MR imaging criteria and diagnostic pitfalls

Various magnetic resonance imaging (MRI) signs can be used in the diagnosis of medial meniscocapsular separation. A thorough knowledge of the normal anatomy of the medial meniscocapsular junction is essential to understand these signs. MRI signs used in the diagnosis of meniscocapsular separation include meniscal displacement relative to the tibia, meniscal corner tear, perimeniscal fluid, irregular meniscal outline, meniscofemoral and meniscotibial extension tears, and interposition of contrast medium between the meniscus and the MCL. Potential causes of false positive diagnosis of meniscocapsular separation include MCL bursitis, meniscal cyst, MCL tear, joint effusion, and perimeniscal fat.     

Artifacts and pitfalls in MR imaging of the pelvis

Artifacts are intimately intertwined with MRI. For the practicing radiologist, effective supervision, troubleshooting, and interpretation of diagnostic MR studies require a solid knowledge of the pertinent artifacts. This article seeks to familiarize the reader with commonly encountered artifacts and pitfalls in pelvic imaging, the mechanism behind their generation, and methods of minimizing their negative impact or maximizing their diagnostic yield. It also serves as an exciting tool to learn many aspects of basic and advanced MR physics. Artifacts are categorized into patient- and sequence-related artifacts. Various manifestations of motion and vascular artifacts, susceptibility, altered tissue contrast, blurring, chemical shift artifact, volume averaging, and gadolinium (Gd) pseudolayering are explained, along with their proposed remedies.     

Cerebrospinal fluid flow waveforms: MR analysis in chronic adult hydrocephalus

Henry-Feugeas MC, Idy-Peretti I, Baledent O, et al. Cerebrospinal fluid flow waveforms: MR analysis in chronic adult hydrocephalus. Invest Radiol 2001;36:146-154.RATIONALE AND OBJECTIVES: To analyze changes in cerebrospinal fluid (CSF) hydrodynamics in chronic adult hydrocephalus. METHODS: Phase-contrast cine-MR acquisitions were used to explore the ventricular system and the upper ventral cervical spaces of 16 patients. The aqueductal jet was explored in 32 control subjects. RESULTS: The duration of pulsatile caudal CSF flow (ie, CSF systole) was abnormally short in patients with active idiopathic and obstructive hydrocephalus. The duration of CSF cervical systole was normal in patients with stable hydrocephalus. The aqueductal stroke volume could be increased in stable communicating hydrocephalus. Patients who responded to shunting had shortened CSF systoles and hyperpulsatile ventricular patterns. Successful CSF diversion resulted in longer CSF systoles and CSF ventricular patterns that were no longer hyperpulsatile. CONCLUSIONS: Magnetic resonance analysis of CSF flow can show craniospinal dissociation and limitation of CSF outflow from the ventricles in both obstructive and communicating hydrocephalus; it should help determine the response to shunting in communicating hydrocephalus.     

MR imaging of the normal shoulder: variants and pitfalls.

In 30 volunteers with normal shoulders, the following conclusions were made with regard to normal anatomic features at magnetic resonance (MR) imaging: (a) The supraspinatus tendon has low signal intensity, except for a 1-cm area with intermediate signal intensity in the region of the "critical zone." (b) The deltoid tendon attachment on the inferior surface of the acromion may simulate a subacromial spur if not imaged in continuity. (c) Fluid in the long head of the biceps tendon sheath is normal if not completely surrounding the tendon. (d) The anterolateral branch of the anterior humeral circumflex vessels in the proximal bicipital groove adjacent to the biceps tendon mimics fluid in the tendon sheath. (e) Continuity or obliteration of the subacromial-subdeltoid bursal fat plane is an unreliable diagnostic sign since the fat plane is often focally absent. (f) Fluid is not detected in subacromial-subdeltoid bursae. (g) Undercutting of the anterior glenoid labrum by hyaline cartilage or a closely apposed middle glenohumeral ligament may simulate an anterior labral tear.     

Cerebrospinal fluid: detection of tumors and disk herniations with MR spectroscopy

Cerebrospinal fluid (CSF) samples from 84 patients with confirmed or suspected diseases of the central nervous system were studied with hydrogen-1 magnetic resonance (MR) spectroscopy. In 19 of the patients, clinical chemical tests of the CSF indicated normal protein contents and normal quantities of cells; these samples were used as controls. Preliminary results indicate that tumors may be reflected in the MR spectra of CSF; disk herniations could not be distinguished on the basis of the MR spectral characteristics.