Diffusion and perfusion MRI of the lung and mediastinum

With ongoing technical improvements such as multichannel MRI, systems with powerful gradients as well as the development of innovative pulse sequence techniques implementing parallel imaging, MRI has now entered the stage of a radiation-free alternative to computed tomography (CT) for chest imaging in clinical practice. Whereas in the past MRI of the lung was focused on morphological aspects, current MRI techniques also enable functional imaging of the lung allowing for a comprehensive assessment of lung disease in a single MRI exam.Perfusion imaging can be used for the visualization of regional pulmonary perfusion in patients with different lung diseases such as lung cancer, chronic obstructive lung disease, pulmonary embolism or for the prediction of postoperative lung function in lung cancer patients. Over the past years diffusion-weighted MR imaging (DW-MRI) of the thorax has become feasible with a significant reduction of the acquisition time, thus minimizing artifacts from respiratory and cardiac motion. In chest imaging, DW-MRI has been mainly suggested for the characterization of lung cancer, lymph nodes and pulmonary metastases.In this review article recent MR perfusion and diffusion techniques of the lung and mediastinum as well as their clinical applications are reviewed.     

Lung ventilation‐ and perfusion‐weighted Fourier decomposition magnetic resonance imaging: In vivo validation with hyperpolarized 3He and dynamic contrast‐enhanced MRI

The purpose of this work was to validate ventilation‐weighted (VW) and perfusion‐weighted (QW) Fourier decomposition (FD) magnetic resonance imaging (MRI) with hyperpolarized ³He MRI and dynamic contrast‐enhanced perfusion (DCE) MRI in a controlled animal experiment. Three healthy pigs were studied on 1.5‐T MR scanner. For FD MRI, the VW and QW images were obtained by postprocessing of time‐resolved lung image sets. DCE acquisitions were performed immediately after contrast agent injection. ³He MRI data were acquired following the administration of hyperpolarized helium and nitrogen mixture. After baseline MR scans, pulmonary embolism was artificially produced. FD MRI and DCE MRI perfusion measurements were repeated. Subsequently, atelectasis and air trapping were induced, which followed with FD MRI and ³He MRI ventilation measurements. Distributions of signal intensities in healthy and pathologic lung tissue were compared by statistical analysis. Images acquired using FD, ³He, and DCE MRI in all animals before the interventional procedure showed homogeneous ventilation and perfusion. Functional defects were detected by all MRI techniques at identical anatomical locations. Signal intensity in VW and QW images was significantly lower in pathological than in healthy lung parenchyma. The study has shown usefulness of FD MRI as an alternative, noninvasive, and easily implementable technique for the assessment of acute changes in lung function. Magn Reson Med, 2013. © 2012 Wiley Periodicals, Inc.     

Proton magnetic resonance imaging for assessment of lung function and respiratory dynamics

Since many pulmonary diseases present with a variable regional involvement, modalities for assessment of regional lung function gained increasing attention over the last years. Together with lung perfusion and gas exchange, ventilation, as a result of the interaction of the respiratory pump and the lungs, is an indispensable component of lung function. So far, this complex mechanism is still mainly assessed indirectly and globally. A differentiation between the individual determining factors of ventilation would be crucial for precise diagnostics and adequate treatment. By dynamic imaging of the respiratory pump, the mechanical components of ventilation can be assessed regionally. Amongst imaging modalities applicable to this topic, magnetic resonance imaging (MRI), as a tool not relying on ionising radiation, is the most attractive. Recent advances in MRI technology have made it possible to assess diaphragmatic and chest wall motion, static and dynamic lung volumes, as well as regional lung function. Even though existing studies show large heterogeneity in design and applied methods, it becomes evident that MRI is capable to visualise pulmonary function as well as diaphragmatic and thoracic wall movement, providing new insights into lung physiology. Partly contradictory results and conclusions are most likely caused by technical limitations, limited number of studies and small sample size. Existing studies mainly evaluate possible imaging techniques and concentrate on normal physiology. The few studies in patients with lung cancer and emphysema already give a promising outlook for these techniques from which an increasing impact on improved and quantitative disease characterization as well as better patient management can be expected.     

Accuracy and feasibility of dynamic contrast-enhanced 3D MR imaging in the assessment of lung perfusion: comparison with Tc-99 MAA perfusion scintigraphy

AIM: The aim of this study was to correlate findings of perfusion magnetic resonance imaging (MRI) and perfusion scintigraphy in cases where there was a suspicion of abnormal pulmonary vasculature, and to evaluate the usefulness of MRI in the detection of perfusion deficits of the lung. METHODS: In all, 17 patients with suspected abnormality of the pulmonary vasculature underwent dynamic contrast-enhanced MRI. T1-weighted 3D fast-field echo pulse sequences were obtained (TR/TE 3.3/1.58 ms; flip angle 30 degrees; slice thickness 12 to 15 mm). The dynamic study was acquired in the coronal plane following administration of 0.1 mmol/kg gadopentetate dimeglumine. A total of 8 to 10 sections repeated 20 to 25 times at intervals of 1s were performed. Perfusion lung scintigraphy was carried out a maximum of 48 h before the MR examination in all cases. Two radiologists, who were blinded to the clinical data and results of other imaging methods, reviewed all coronal sections. MR perfusion images were independently assessed in terms of segmental or lobar perfusion defects in the 85 lobes of the 17 individuals, and the findings were compared with the results of scintigraphy. RESULTS: Of the 17 patients, 8 were found to have pulmonary emboli, 2 chronic obstructive pulmonary disease with emphysema, 2 bullous emphysema, 2 Takayasu arteritis and 1 had a hypoplastic pulmonary artery. Pulmonary perfusion was completely normal in 2 cases. In 35 lobes, perfusion defects were detected using both methods, in 4 with MR alone and in 9 only with scintigraphy. There was good agreement between MRI and scintigraphy findings (kappa=0.695). CONCLUSION: Pulmonary perfusion MRI is a new alternative to scintigraphy in the evaluation of pulmonary perfusion for various lung disorders. In addition, this technique allows measurement and quantification of pulmonary perfusion abnormalities.     

Imaging phenotypes of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. COPD is defined by irreversible airflow obstruction. It is a heterogeneous disease affecting the airways and/or the parenchyma with different severity during the course of the disease. These different aspects of COPD can be addressed by imaging using a combination of morphological and functional techniques. Computed tomography (CT) is the technique of choice for morphological imaging of the lung parenchyma and airways. This morphological information is to be accomplished by functional information about ventilation and perfusion, mainly provided by magnetic resonance imaging (MRI). The comprehensive diagnostic possibilities of CT complemented by MRI will allow for a more sensitive detection, phenotype-driven characterization, and dedicated therapy monitoring of the disease.     

Morphological and functional imaging in COPD with CT and MRI: present and future

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. COPD is defined by irreversible airflow obstruction. It is a heterogeneous disease affecting the airways (i.e. chronic bronchitis, airway collapse), the parenchyma (i.e. hyperinflation, air trapping and emphysematous destruction) as well as the vasculature (i.e. hypoxic vasoconstriction, rarefication and pulmonary arterial hypertension) with different severity during the course of the disease. These different aspects of COPD can be best addressed by imaging using a combination of morphological and functional techniques. Three-dimensional high-resolution computed tomography (3D-HRCT) is the technique of choice for morphological imaging of the lung parenchyma and airways. This morphological information is to be accomplished by functional information about perfusion, regional lung mechanics, and ventilation mainly provided by MRI. The comprehensive diagnostic possibilities of CT complemented by MRI will allow for a more sensitive detection, phenotype-driven characterization and dedicated therapy monitoring of COPD as presented in this review.     

肺栓塞的磁共振成像技术应用研究

目的探讨MR I透视触发造影剂团跟踪和动态增强磁共振血管成像(DCE-MRA)扫描技术在肺灌注和肺动脉血管造影中的应用价值。方法8例疑有肺栓塞的患者,应用MR I透视触发造影剂团跟踪和DCE-MRA扫描技术,行肺动脉血管造影和肺灌注成像。结果8例均成功进行肺动脉血管造影和肺灌注扫描,其中2例正常,6例发现肺动脉血栓形成,并有明确动态显示的局部肺叶灌注异常。结论MR I透视触发造影剂团跟踪和DCE-MRA扫描技术的应用,可1次注射造影剂既发现了肺动脉内血栓,又可显示肺内灌注缺损,是较好的肺栓塞诊断方法。     

Pulmonary MR angiography and perfusion imaging—A review of methods and applications

The pulmonary vasculature and its role in perfusion and gas exchange is an important consideration in many conditions of the lung and heart. Currently the mainstay of imaging of the vasculature and perfusion of the lungs lies with CT and nuclear medicine perfusion scans, both of which require ionizing radiation exposure. Improvements in MRI techniques have increased the use of MRI in pulmonary vascular imaging. Here we review MRI methods for imaging the pulmonary vasculature and pulmonary perfusion, both using contrast enhanced and non-contrast enhanced methodology.In many centres pulmonary MR angiography and dynamic contrast enhanced perfusion MRI are now well established in the routine workflow of patients particularly with pulmonary hypertension and thromboembolic disease. However, these imaging modalities offer exciting new directions for future research and clinical use in other respiratory diseases where consideration of pulmonary perfusion and gas exchange can provide insight in to pathophysiology.     

MRT der Lungenperfusion

With technical improvements in gradient hardware and the implementation of innovative k-space sampling techniques, such as parallel imaging, the feasibility of pulmonary perfusion MRI could be demonstrated in several studies. Dynamic contrast-enhanced 3D gradient echo sequences as used for time-resolved MR angiography have been established as the preferred pulse sequences for lung perfusion MRI. With these techniques perfusion of the entire lung can be visualized with a sufficiently high temporal and spatial resolution. In several trials in patients with acute pulmonary embolism, pulmonary hypertension and airway diseases, the clinical benefit and good correlation with perfusion scintigraphy have been demonstrated. The following review article describes the technical prerequisites, current post-processing techniques and the clinical indications for MR pulmonary perfusion imaging using MRI.     

3．0T MRI评价中央型肺癌-与常规CT对照

目的：通过与常规CT对照,评价3．0T删对中央型肺癌的显示能力及诊断价值。方法：对21例中央型肺癌行3．0T MRI成像,通过与常规CT对照分析中央型肺癌基本征象包括病灶部位、大小、支气管改变、肺门肿块、阻塞性改变的检出及显示能力。结果：3．0T MRI对显示中央型肺癌病灶部位、大小、支气管改变、肺门肿块的显示能力与CT比较无明显统计学差异（P〉0．05）。3．0TMRI对显示中央型肺癌肿瘤组织与阻塞性病变的改变方面与CT比较有明显统计学差异（P〈0．05）。结论：3．0 T MRI可以较好地显示中央型肺癌的基本征象,可作为影像学检查的一种有效补充手段。     

Lung morphology assessment using MRI: A robust ultra‐short TR/TE 2D steady state free precession sequence used in cystic fibrosis patients

To evaluate feasibility and diagnostic quality of ultra‐short TR/TE two‐dimensional (2D) steady state free precession (SSFP) MRI for cystic fibrosis (CF) patients. We performed lung MRI at 1.5 Tesla in 20 CF‐patients (6–17 years, 12 males). Axial, coronal, and sagittal sections were acquired in inspiration and expiration with maximum breath‐hold time 10 s. MR and CT images were scored using a modified Brody scoring system to assess bronchiectasis, mucous plugging, atelectasis/consolidations, and air trapping. All images were scored by two experienced observers. A complete MR investigation took maximally 15 min. Maximal breath‐holds were only 10 s and well tolerated. MRI identified major bronchiectasis, mucous plugging and atelectasis. End‐expiratory scans showed patches of parenchyma with reduced signal intensity that may corresponded to areas of trapped air on expiratory CT scans. This MRI protocol based on ultra‐short TR/TE 2D SSFP is quick and well tolerated and provides highly relevant imaging features as seen on CT in CF patients. Most importantly, the SNR of the expiratory scans enables to visualize air trapping. The preliminary results of this study suggest MRI as a noteworthy additional imaging tool for routine monitoring of CF patients. Magn Reson Med 61:299–306, 2009. © 2009 Wiley‐Liss, Inc.     

Non-contrast-enhanced preoperative assessment of lung perfusion in patients with non-small-cell lung cancer using Fourier decomposition magnetic resonance imaging

Objective

To investigate non-contrast-enhanced Fourier decomposition MRI (FD MRI) for assessment of regional lung perfusion in patients with Non-Small-Cell Lung Cancer (NSCLC) in comparison to dynamic contrast-enhanced MRI (DCE MRI).

Methods

Time-resolved non-contrast-enhanced images of the lungs were acquired prospectively in 15 patients using a 2D balanced steady-state free precession (b-SSFP) sequence. After non-rigid registration of the native image data, perfusion-weighted images were calculated by separating periodic changes of lung proton density at the cardiac frequency using FD. DCE MRI subtraction datasets were acquired as standard of reference. Both datasets were analyzed visually for perfusion defects. Then segmentation analyses were performed to describe perfusion of pulmonary lobes semi-quantitatively as percentages of total lung perfusion. Overall FD MRI perfusion signal was compared to velocity-encoded flow measurements in the pulmonary trunk as an additional fully quantitative reference.

Results

Image quality ratings of FD MRI were significantly inferior to those of DCE MRI (P < 0.0001). Sensitivity, specificity, and accuracy of FD MRI for visual detection of perfusion defects were 84%, 92%, and 91%. Semi-quantitative evaluation of lobar perfusion provided high agreement between FD MRI and DCE MRI for both entire lungs and upper lobes, but less agreement in the lower parts of both lungs. FD perfusion signal showed high linear correlation with pulmonary arterial blood flow.

Conclusion

FD MRI is a promising technique that allows for assessing regional lung perfusion in NSCLC patients without contrast media or ionizing radiation. However, for being applied in clinical routine, image quality and robustness of the technique need to be further improved.     

MR imaging of the chest: a practical approach at 1.5T

Magnetic resonance imaging (MRI) is capable of imaging infiltrative lung diseases as well as solid lung pathologies with high sensitivity. The broad use of lung MRI was limited by the long study time as well as its sensitivity to motion and susceptibility artifacts. These disadvantages were overcome by the utilisation of new techniques such as parallel imaging. This article aims to propose a standard MR imaging protocol at 1.5T and presents a spectrum of indications. The standard protocol comprises non-contrast-enhanced sequences. Following a GRE localizer (2D-FLASH), a coronal T2w single-shot half-Fourier TSE (HASTE) sequence with a high sensitivity for infiltrates and a transversal T1w 3D-GRE (VIBE) sequence with a high sensitivity for small lesions are acquired in a single breath hold. Afterwards, a coronal steady-state free precession sequence (TrueFISP) in free breathing is obtained. This sequence has a high sensitivity for central pulmonary embolism. Distinct cardiac dysfunctions as well as an impairment of the breathing mechanism are visible. The last step of the basic protocol is a transversal T2w-STIR (T2-TIRM) in a multi-breath holds technique to visualize enlarged lymph nodes as well as skeletal lesions. The in-room time is approximately 15min. The extended protocol comprises contrast-enhanced sequences (3D-GRE sequence (VIBE) after contrast media; about five additional minutes). Indications are tumorous lesions, unclear (malignant) pleural effusions and inflammatory diseases (vaskulitis). A perfusion analysis can be achieved using a 3D-GRE in shared echo-technique (TREAT) with a high temporal resolution. This protocol can be completed using a MR-angiography (3D-FLASH) with high spatial resolution. The in-room time for the complete protocol is approximately 30min.     

Contrast-enhanced MRI of the lung

The lung has long been neglected by MR imaging. This is due to unique intrinsic difficulties: (1) signal loss due to cardiac pulsation and respiration; (2) susceptibility artifacts caused by multiple air-tissue interfaces; (3) low proton density. There are many MR strategies to overcome these problems. They consist of breath-hold imaging, respiratory and cardiac gating procedures, use of short repetition and echo times, increase of the relaxivity of existing spins by administration of intravenous contrast agents, and enrichment of spin density by hyperpolarized noble gases or oxygen. Improvements in scanner performance and frequent use of contrast media have increased the interest in MR imaging and MR angiography of the lung. They can be used on a routine basis for the following indications: characterization of pulmonary nodules, staging of bronchogenic carcinoma, in particular assessment of chest wall invasion; evaluation of inflammatory activity in interstitial lung disease; acute pulmonary embolism, chronic thromboembolic pulmonary hypertension, vascular involvement in malignant disease; vascular abnormalities. Future perspectives include perfusion imaging using extracellular or intravascular (blood pool) contrast agents and ventilation imaging using inhalation of hyperpolarized noble gases, of paramagnetic oxygen or of aerosolized contrast agents. These techniques represent new approaches to functional lung imaging. The combination of visualization of morphology and functional assessment of ventilation and perfusion is unequalled by any other technique.     

Fast magnetic resonance imaging of the lung.

The impact of fast MR techniques developed for MR imaging of the lung will soon be recognized as equivalent to the high-resolution technique in chest CT imaging. In this article, the difficulties in MR imaging posed by lung morphology and its physiological motion are briefly introduced. Then, fast MR imaging techniques to overcome the problems of lung imaging and recent applications of the fast MR techniques including pulmonary perfusion and ventilation imaging are discussed. Fast MR imaging opens a new exciting window to multi-functional MR imaging of the lung. We believe that fast MR functional imaging will play an important role in the assessment of pulmonary function and disease process.     

Pulmonary circulation

Evaluation of the pulmonary vasculature is mainly indicated in patients with suspected pulmonary thromboembolism. The routine procedure so far is ventilation-perfusion scintigraphy alone or in combination with diagnostic assessment of the legs to rule out deep venous thrombosis. The results are still not reliable for the majority of patients. In the case of equivocal diagnosis, invasive conventional angiography is considered the gold standard. With steady improvements in tomographic imaging techniques, such as computed tomography (CT) or magnetic resonance imaging (MRI), non-invasive alternatives to the routine diagnostic work-up are given. Helical CT and CTA techniques are already in clinical use and estimated to sufficiently serve the demands for detection/exclusion of pulmonary thromboembolism. The disadvantages mainly concern peripheral disease and reconstruction artifacts. MRI and MR angiography have been implemented in the diagnosis of pulmonary vascular disease since the introduction of contrast-enhanced MRA. In breath-hold techniques, the entire lung vascularization can be delineated and thromboemboli can be detected. The clinical experience in this field is limited, but MRI has the potential to demonstrate its superiority over CT due to its improved delineation of the vascular periphery and the more comprehensive three-dimensional reconstruction. Received: 20 January 1998; Accepted: 10 February 1998     

Contrast-enhanced 3D MRI of lung perfusion in children with cystic fibrosis—initial results

This paper is a feasibility study of magnetic resonance imaging (MRI) of lung perfusion in children with cystic fibrosis (CF) using contrast-enhanced 3D MRI. Correlation assessment of perfusion changes with structural abnormalities. Eleven CF patients (9 f, 2 m; median age 16 years) were examined at 1.5 T. Morphology: HASTE coronal, transversal (TR/TE/α/ST: 600 ms/28 ms/180°/6 mm), breath-hold 18 s. Perfusion: Time-resolved 3D GRE pulse sequence (FLASH, TE/TR/α: 0.8/1.9 ms/40°), parallel imaging (GRAPPA, PAT 2). Twenty-five data sets were acquired after intravenous injection of 0.1 mmol/kg body weight of gadodiamide, 3–5 ml/s. A total of 198 lung segments were analyzed by two radiologists in consensus and scored for morphological and perfusion changes. Statistical analysis was performed by Mantel-Haenszel chi-square test. Results showed that perfusion defects were observed in all patients and present in 80% of upper, and 39% of lower lobes. Normal lung parenchyma showed homogeneous perfusion (86%, P<0.0001). Severe morphological changes led to perfusion defects (97%, P<0.0001). Segments with moderate morphological changes showed normal (53%) or impaired perfusion (47%). In conclusion, pulmonary perfusion is easy to judge in segments with normal parenchyma or severe changes. In moderately damaged segments, MRI of lung perfusion may help to better assess actual functional impairment. Contrast-enhanced 3D MRI of lung perfusion has the potential for early vascular functional assessment and therapy control in CF patients.Monika Eichinger and Michael Puderbach contributed equally to this work.     

Combined MR proton lung perfusion/angiography and helium ventilation: potential for detecting pulmonary emboli and ventilation defects.

Three-dimensional (3D) perfusion imaging allows the assessment of pulmonary blood flow in parenchyma and main pulmonary arteries simultaneously. MRI using laser-polarized (3)He gas clearly shows the ventilation distribution with high signal-to-noise ratio (SNR). In this report, the feasibility of combined lung MR angiography, perfusion, and ventilation imaging is demonstrated in a porcine model. Ultrafast gradient-echo sequences have been used for 3D perfusion and angiographic imaging, in conjunction with the use of contrast agent injections. 2D multiple-section (3)He imaging was performed subsequently by inhalation of 450 ml of hyperpolarized (3)He gas. The MR techniques were examined in a series of porcine models with externally delivered pulmonary emboli and/or airway occlusions. With emboli, perfusion deficits without ventilation defects were observed; airway occlusion resulted in matched deficits in perfusion and ventilation. High-resolution MR angiography can unambiguously reveal the location and size of the blood emboli. The combination of the three imaging methods may provide complementary information on abnormal lung anatomy and function.     

In vivo Gd-DTPA concentration for MR lung perfusion measurements: Assessment with computed tomography in a porcine model

A linear relationship between MR signal and contrast-agent concentration (CAC) of the arterial-input function (AIF) is crucial for MR lung-perfusion quantification. The aim was to determine the in-vivo real maximum CAC of the AIF, using cine CT measurements in a porcine model. A dilution series (Gd-DTPA, 0-20 mM) was examined by clinical time-resolved 3D-GRE MRI and by MDCT in cine CT mode. Using the CT setup, data were acquired in five pigs immediately after the injection of 0.05 mmol and 0.07 mmol/kg BW Gd-DTPA. For phantom measurements, mean signal values were determined using a region-of-interest (ROI) analysis and for animal measurements, a ROI was placed in the pulmonary trunk of the cine CT perfusion data sets. The CT phantom measurements were used to calculate the in-vivo maximum CAC corresponding to the HU values obtained in the pulmonary trunk by the cine CT study. Linearity of the AIF of the CT perfusion measurements was verified using the MR phantom measurement results. MR phantom measurements demonstrated linearity for concentrations of 0-4 mM. CT phantom measurements showed linear relation for the entire CAC range. Comparing in-vivo and in-vitro measurements, three of five CA injections at 0.05 mmol/kg and all 0.07 mmol/kg injections exceeded the range of linearity in MRI. The CA dose for quantification of lung perfusion with time-resolved MR studies must be chosen carefully since even with low doses (0.05 mmol/kg) the CAC may exceed the range of linearity in the AIF.     

Lung perfusion measured using magnetic resonance imaging: New tools for physiological insights into the pulmonary circulation

Since the lung receives the entire cardiac output, sophisticated imaging techniques are not required in order to measure total organ perfusion. However, for many years studying lung function has required physiologists to consider the lung as a single entity: in imaging terms as a single voxel. Since imaging, and in particular functional imaging, allows the acquisition of spatial information important for studying lung function, these techniques provide considerable promise and are of great interest for pulmonary physiologists. In particular, despite the challenges of low proton density and short T2* in the lung, noncontrast MRI techniques to measure pulmonary perfusion have several advantages including high reliability and the ability to make repeated measurements under a number of physiologic conditions. This brief review focuses on the application of a particular arterial spin labeling (ASL) technique, ASL-FAIRER (flow sensitive inversion recovery with an extra radiofrequency pulse), to answer physiologic questions related to pulmonary function in health and disease. The associated measurement of regional proton density to correct for gravitational-based lung deformation (the "Slinky" effect (Slinky is a registered trademark of Pauf-Slinky incorporated)) and issues related to absolute quantification are also discussed.