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Contrast-enhanced T1-weighted Fluid-attenuated Inversion-recovery BLADE Magnetic Resonance Imaging of the Brain

Posted Jul 31, 2008 Updated Apr 7, 2023
By Sedat Alibek MD , Boris Adamietz MD , Alexer Cavallaro MD , Alto Stemmer , Katharina Anders MD , Manuel Kramer MD , Werner Bautz MD , Gundula Staatz MD
10 min read

Rationale and Objectives

We compared contrast-enhanced T1-weighted magnetic resonance (MR) imaging of the brain using different types of data acquisition techniques: periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER, BLADE) imaging versus standard k-space sampling (conventional spin-echo pulse sequence) in the unsedated pediatric patient with focus on artifact reduction, overall image quality, and lesion detectability.

Materials and Methods

Forty-eight pediatric patients (aged 3 months to 18 years) were scanned with a clinical 1.5-T whole body MR scanner. Cross-sectional contrast-enhanced T1-weighted spin-echo sequence was compared to a T1-weighted dark-fluid fluid-attenuated inversion-recovery (FLAIR) BLADE sequence for qualitative and quantitative criteria (image artifacts, image quality, lesion detectability) by two experienced radiologists. Imaging protocols were matched for imaging parameters. Reader agreement was assessed using the exact Bowker test.

Results

BLADE images showed significantly less pulsation and motion artifacts than the standard T1-weighted spin-echo sequence scan. BLADE images showed statistically significant lower signal-to-noise ratio but higher contrast-to-noise ratios with superior gray-white matter contrast. All lesions were demonstrated on FLAIR BLADE imaging, and one false-positive lesion was visible in spin-echo sequence images.

Conclusion

BLADE MR imaging at 1.5 T is applicable for central nervous system imaging of the unsedated pediatric patient, reduces motion and pulsation artifacts, and minimizes the need for sedation or general anesthesia without loss of relevant diagnostic information.

Magnetic resonance imaging (MRI) is a well-established imaging technique and the method of choice in the evaluation of central nervous system disorders ( ). Contrast-enhanced (CE) MRI allows classification of morphologic changes; whereas CE T1-weighted (T1w) imaging is the gold standard for displaying pathologic contrast agent uptake ( ). T1w spin-echo (SE) images are widely used to study anatomic detail and pathologic abnormalities of the brain; but this technique does not provide sufficient contrast to differentiate white matter from gray matter ( ). The quality of anatomic brain images can further be degraded by artifacts; such as subject motion ( ); the unsedated pediatric patient is particularly prone to movement. Many technical approaches to reduce motion artifacts have been reported ( ). MRI with periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) proposed by Pipe ( ) offers an alternative approach to imaging in the unsedated child. Almost all published data on the use of PROPELLER MRI technique at 1.5 T used T2w or diffusion weighted imaging (DWI) techniques. Recently published data showed that the T1w FLAIR BLADE technique seems to be capable of replacing T1w SE technique; at least for axial postcontrast imaging to detect brain metastases in the adult ( ). To evaluate the effect of this technique on lesion detectability; imaging artifacts; and overall image quality in the unsedated pediatric patient; which potentially produce more artifacts than adults and have varying T1 times due to immature brain parencyhma; we compared the CE T1w SE technique with a CE T1w FLAIR BLADE sequence in the transverse plane for brain MRI.

Materials and methods

Forty-eight nonsedated pediatric patients (male/female: 26/22; age range, 3 months to 18 years; mean age, 8 years 10 months) with 40 contrast material–uptaking lesions and one developmental venous anomaly (DVA) were examined with a routine brain MRI protocol. These consisted of lesions found in acute disseminated encephalomyelitis (ADEM, n = 11), acute lymphatic leukemia ( n = 12), astrocytoma ( n = 2), and giant cell astrocytoma in patients with a history of neurofibromatosis ( n = 15) ( Table 1 ). Lesions suspicious for malignancy were proven histologically after MRI, and all other lesions were confirmed with follow-up examinations within to 6 months. Pediatric patients younger than 2 years were first fed and then placed on the scanner. All patients’ heads were fixed with the help of commercially available cushions placed on both sides of the head within the coil. Written informed consent from parents was obtained, and the study was approved by the institutional review board.

Table 1

Lesions Detected

Lesions_n_ Giant cell astrocytoma 15 ADEM 11 ALL 12 Astrocytoma 2 DVA 1 Total 41

ALL: acute lymphatic leukaemia; DVA: developmental venous anomaly.

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Figure 1, Placement of regions of interest for quantitative evaluation.

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Results

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Qualitative Assessment

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Motion artifact

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Figure 2, Artifacts on spin-echo sequence image due to in plane head motion ( left, white arrows ), completely suppressed on BLADE image ( right ).

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Pulsation artifacts

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Figure 3, Artifacts on spin-echo sequence image due to pulsation of the transverse sinus in posterior fossa ( left, black arrows ) and internal carotid arteries ( white arrows ), completely suppressed on the BLADE image ( right ).

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Overall imaging artifact

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Anatomic contrast

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Overall image quality/preference of data

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Lesion detection

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Figure 4, Cerebellar developmental venous anomaly (DVA) depicted on both sequences ( left , spin-echo sequence; white arrow ; right , BLADE, black arrow ) with lower contrast in BLADE image.

Figure 5, Three small contrast uptaking lesions, detectable on both sequences ( left , spin-echo sequence; right , BLADE, white arrows ). One false-positive lesion on spin-echo sequence image ( left, black arrow ) not visualized on BLADE image.

Figure 6, Comparable appearance of tumors with both solid ( long black arrow ) and cystic/necrotic portions ( long white arrow ) with spin-echo sequence technique ( left ) and BLADE technique ( right ). Also note the artifacts on the spin-echo sequence image due to in plane head motion ( short white arrow ) and pulsation ( short black arrow ), suppressed with BLADE technique.

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Blood Vessels

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Figure 7, Very good suppression of vessels ( black arrows ) with the FLAIR BLADE technique ( right ) in contrast to the spin-echo sequence technique ( left ) but excellent depiction of pathology (intraventricular lesion) with quantitatively higher SI.

Figure 8, Lesions in acute disseminated encephalomyelitis, two in the left parietal lobe ( black arrows ), one subtle lesion in the left periventricular white matter ( white arrow ), very good delineation in the BLADE image ( right ).

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Quantitative Assessment

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Table 2

Distribution of Mean Signal Intensity in Region of Interest (ROI) for Both Sequences

Region Sequence Mean STD_P_ -Value ⁎ ROI1 BLADE 21.79 5.48 SE 13.69 2.96 <.0001 ROI2 BLADE 300.94 37.85 SE 305.15 39.64 0.2033 ROI3 BLADE 401.34 52.89 SE 376.71 50.92 <.0001 ROI4 BLADE 365.90 42.88 SE 379.44 46.82 0.0002 ROI5 BLADE 413.91 54.37 SE 399.07 54.41 0.0010 ROI6 BLADE 99.44 25.53 SE 169.97 27.95 <.0001

SE: spin echo; STD: standard deviation.

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Table 3

Distribution of Signal-to Noise Ratios (SNRs) of Different Regions of Interest (ROI) in Comparison of Both Sequences

SNR Sequence Mean STD_P_ -Value ⁎ GM (ROI2) BLADE 33.48 10.82 SE 51.79 14.19 <.0001 GM (ROI4) BLADE 40.88 13.90 SE 64.45 17.43 <.0001 WM (ROI3) BLADE 44.84 14.50 SE 64.65 16.79 <.0001 WM (ROI5) BLADE 46.10 14.18 SE 66.43 20.29 <.0001 CSF (ROI6) BLADE 11.28 5.22 SE 29.10 8.93 <.0001

CSF: cerebrospinal fluid; GM: gray matter; SE: spin echo; STD: standard deviation; WM: white matter.

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Table 4

Distribution of Contrast-to-Noise Ratio (CNR) of Different Regions of Interest (ROI) in Comparison of Both Sequences

CNR Sequence Mean STD_P_ -Value ⁎ GM/WM (ROI2) BLADE 11.06 4.21 SE 12.21 4.71 0.1531 GM/WM (ROI4) BLADE 5.60 2.56 SE 4.05 2.46 0.0015 GM/CSF (ROI2) BLADE 22.60 7.38 SE 22.96 7.27 0.7687 GM/CSF (ROI4) BLADE 30.34 10.25 SE 35.45 10.54 0.0086 WM/CSF (ROI3) BLADE 32.96 11.03 SE 34.91 10.28 0.3307 WM/CSF (ROI5) BLADE 33.66 10.89 SE 38.36 11.39 0.0308 Lesion/Surrounding Parenchyma BLADE 37.92 29.46 SE 27.68 22.66 0.0140

CSF: cerebrospinal fluid; GM: gray matter; SE: spin echo; STD: standard deviation; WM: white matter.

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Discussion

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Figure 9, Left , spin-echo sequence sequence; right , BLADE image. Note suppressed signal of contrast-filled vessels on BLADE image ( black arrows ) and pseudo lesions due to pulsation artifacts on the SE image ( white arrows ).

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Study Limitations

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Conclusion

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Academic Radiology, Volume 15, Issue 8
Journals General Radiology
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