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Clinical single-shot diffusion-weighted MRI of the human brain on a short-bore medium-field imager.

Diffusion-weighted MRI (DWI) is becoming important for assessment of acute stroke. Until recently single-shot DWI required expensive technology such as echoplanar imaging (EPI) available only at some research sites. A new medium-field (1.0 T) short-bore MR imager has been developed with which DWI data sets can be acquired. We prospectively studied 169 patients on this 1.0 T commercial system. After conventional imaging, DWI was performed with a single-shot multi-slice sequence with b values 0 an 900 s/mm2, and with the gradients switched in three directions. The apparent diffusion coefficients were calculated with online calculation software. There were 50 patients with totally normal MRI, and 17 had strokes, these strokes were detected as areas of high signal on the images at a maximal b value. There was a drop in the ADC in ischaemic regions: in sub-acute infarcts, the values were between 0.41 and 0.531 x 10(-3) mm2/s. In old infarcts the ADC was 1.15 x 10(-3) mm2/s. Cerebrospinal fluid (CSF) gave low signal whereas areas in the brain had more intermediate intensities (CSF: 3.00; deep white matter: 0.75, cortical grey matter: 0.80, basal ganglia (thalamus): 0.70 and cerebellar white matter: 0.65 x 10(-3) mm2/s. Anisotropy was detected as areas of restricted diffusion along the tracts. These preliminary data show that DWI can be acquired successfully on a medium-field short-bore system. This should allow the technique to be implemented at more sites, therefore facilitating the diagnosis of acute stroke and rendering early intervention feasible.

Brain↗

Diffusion-weighted MRI in cystic or necrotic intracranial lesions.

Our purpose was to investigate the signal intensities of cystic or necrotic intracranial lesions on diffusion-weighted MRI (DWI) and measure their apparent diffusion coefficients (ADC). We examined 39 cystic or necrotic intracranial lesions in 33 consecutive patients: five malignant gliomas, seven metastases, two other necrotic tumours, a haemangioblastoma, three epidermoids, an arachnoid cyst, seven pyogenic abscesses, 12 cases of cysticercosis and one of radiation necrosis. DWI was performed on a 1.5 T unit using a single-shot echo-planar spin-echo pulse sequence with b 1,000 s/mm2. The signal intensity of the cystic or necrotic portion on DWI was classified by visual assessment as markedly low (as low as cerebrospinal fluid), slightly lower than, isointense with, and slightly or markedly higher than normal brain parenchyma. ADC were calculated in 31 lesions using a linear estimation method with measurements from b of 0 and 1,000 s/ mm2. The cystic or necrotic portions of all neoplasms (other than two metastases) gave slightly or markedly low signal, with ADC of more than 2.60 x 10(-3) mm2/s. Two metastases in two patients showed marked high signal, with ADC of 0.50 x 10(-3) mm2/s and 1.23 x 10(-3) mm2/s, respectively. Epidermoids showed slight or marked high signal, with ADC of less than 1.03 x 10(-3) mm2/s. The arachnoid cyst gave markedly low signal, with ADC of 3.00 x 10(-3) mm2/s. All abscesses showed marked high signal, with ADC below 0.95 x 10(-3) mm2/s. The cases of cysticercosis showed variable signal intensity; markedly low in five, slightly low in three and markedly high in four.

Brain↗

Processing and visualization for diffusion tensor MRI.

This paper presents processing and visualization techniques for Diffusion Tensor Magnetic Resonance Imaging (DT-MRI). In DT-MRI, each voxel is assigned a tensor that describes local water diffusion. The geometric nature of diffusion tensors enables us to quantitatively characterize the local structure in tissues such as bone, muscle, and white matter of the brain. This makes DT-MRI an interesting modality for image analysis. In this paper we present a novel analytical solution to the Stejskal-Tanner diffusion equation system whereby a dual tensor basis, derived from the diffusion sensitizing gradient configuration, eliminates the need to solve this equation for each voxel. We further describe decomposition of the diffusion tensor based on its symmetrical properties, which in turn describe the geometry of the diffusion ellipsoid. A simple anisotropy measure follows naturally from this analysis. We describe how the geometry or shape of the tensor can be visualized using a coloring scheme based on the derived shape measures. In addition, we demonstrate that human brain tensor data when filtered can effectively describe macrostructural diffusion, which is important in the assessment of fiber-tract organization. We also describe how white matter pathways can be monitored with the methods introduced in this paper. DT-MRI tractography is useful for demonstrating neural connectivity (in vivo) in healthy and diseased brain tissue.

Brain↗

Diffusion-weighted MRI correlates of subacute methotrexate-related neurotoxicity.

OBJECTIVES: A delayed stroke-like leukoencephalopathy has been observed in patients receiving methotrexate (MTX) for childhood leukemia. Diffusion-weighted MRI (DWI) may help to distinguish between ischemic stroke and chemotherapy-related leukoencephalopathy. Although conventional MRI correlates have been described for this stroke-like syndrome, DWI data are largely unavailable. Our objective is to present a retrospective analysis of the DWI findings in four patients who suffered subacute neurotoxicity after intrathecal MTX. DESIGN: We reviewed the medical records of four patients, who were seen by us between July 2000 and February 2004 for sudden onset of a central neurological syndrome within days of intrathecal MTX. Patients underwent standardized MRI within 48 h of symptom onset; MRI included DWI and apparent diffusion coefficient (ADC) maps. RESULTS: DWI of all patients revealed well-demarcated hyperintense lesions within the subcortical white matter corresponding to areas of restricted proton diffusion on ADC maps. Lesions exceeded the confines of adjacent vascular territories. Complete resolution of symptoms within 1-4 days was accompanied by normalization of ADC abnormalities. CONCLUSIONS: DWI findings in this cohort seem to reflect cytotoxic edema within cerebral white matter suggesting a reversible metabolic derangement, rather than ischemia, as the basis for this syndrome.

Adolescent↗

Diffusion-weighted MRI correlates of subacute methotrexate-related neurotoxicity.

OBJECTIVES: A delayed stroke-like leukoencephalopathy has been observed in patients receiving methotrexate (MTX) for childhood leukemia. Diffusion-weighted MRI (DWI) may help to distinguish between ischemic stroke and chemotherapy-related leukoencephalopathy. Although conventional MRI correlates have been described for this stroke-like syndrome, DWI data are largely unavailable. Our objective is to present a retrospective analysis of the DWI findings in four patients who suffered subacute neurotoxicity after intrathecal MTX. DESIGN: We reviewed the medical records of four patients, who were seen by us between July 2000 and February 2004 for sudden onset of a central neurological syndrome within days of intrathecal MTX. Patients underwent standardized MRI within 48 h of symptom onset; MRI included DWI and apparent diffusion coefficient (ADC) maps. RESULTS: DWI of all patients revealed well-demarcated hyperintense lesions within the subcortical white matter corresponding to areas of restricted proton diffusion on ADC maps. Lesions exceeded the confines of adjacent vascular territories. Complete resolution of symptoms within 1-4 days was accompanied by normalization of ADC abnormalities. CONCLUSIONS: DWI findings in this cohort seem to reflect cytotoxic edema within cerebral white matter suggesting a reversible metabolic derangement, rather than ischemia, as the basis for this syndrome.

Adolescent↗

The influence of flow and motion in MRI of diffusion using a modified CE-FAST sequence.

Severe motion and flow artifacts are a problem in MRI of diffusion in vivo due to the application of strong magnetic field gradients. Here it is shown that image artifacts can be removed by using a modified fast-scan MRI sequence (CE-FAST) in conjunction with averaging of diffusion-weighted images. In phantom studies slow (coherent) flow (less than 1 mm s-1) in the presence of strong diffusion gradients is shown to cause signal losses in diffusion-weighted images that depend on the relative orientations of the flow direction and the diffusion gradient. On the other hand, pulsatile motions of macroscopic dimensions (e.g., 1 mm, 1 Hz, in-plane) lead to smearing and ghosting of signal intensities along the phase-encoding direction of the images. In both phantoms and rabbit brains in vivo motion artifacts were found to be reducible by averaging 8-16 images. Unfortunately, the resulting image contrast no longer represents a "true" diffusion contrast but is affected by additional signal losses due to motion averaging. All experiments were performed on a 40-cm-bore 2.35-T Bruker Medspec system.

Animals↗

Conventional and diffusion-weighted MRI in progressive multifocal leukoencephalopathy: new elements for identification and follow-up.

PURPOSE: Progressive multifocal leukoencephalopathy (PML) is a serious disorder that primarily affects individuals with a suppressed immune system. Few semiological elements help clearly distinguish PML from other diseases included in the differential diagnosis. Moreover, the clinical course of disease may be chronic or rapidly progressive, with different magnetic resonance imaging (MRI) patterns. The purpose of this study was to confirm the diagnostic value of conventional MRI sequences combined with diffusion-weighted imaging (DWI) in PML to identify those patients with worst prognosis. MATERIALS AND METHODS: We used both conventional MRI sequences and DWI to monitor four male patients aged between 40 and 50 years affected by PML. In two patients, the disease rapidly led to death whereas the other two patients presented a chronic course. RESULTS: Conventional MRI sequences enable detection of the extension of white matter lesions. DWI permits more accurate differentiation of the disease progression front, which exhibits low signal intensity in apparent diffusion coefficient (ADC) maps, from the central gliotic area of demyelinisation, characterised by high ADC values. Patients with rapidly evolving PML have a clear progression front on DWI, which seems to be very tenuous, if not absent, during the quiescent phases of the disease. CONCLUSIONS: The addition of DWI sequences to conventional MRI seems to be a valid method for accurately diagnosing PML and establishing the degree of disease progression.

Adult↗

Diffusion-weighted MRI in herpes simplex encephalitis: a report of three cases.

Herpes simplex virus encephalitis (HSVE) is the most frequent fatal viral infection of the brain. Because antiviral treatment may improve the prognosis significantly, early diagnosis is mandatory. Imaging diagnosis rests on conventional MRI for the visualization of lesions in the limbic system, the hallmark of HSVE. Diffusion-weighted MRI (DW-MRI) has not been used for the evaluation of HSVE. We report on the DW-MRI findings in three patients with HSVE, who had cortical diffusion abnormalities in affected brain parenchyma, partially as the initial or most sensitive sign of encephalitis. Sequential imaging showed that the diffusion abnormality started to return to normal after 2 weeks in the presence of persistent contrast uptake. Thus, DW-MRI may be a valuable tool for early detection and diagnosis of HSVE whereas contrast-enhanced images are indispensable after the first week.

Aged↗

Reduction of diffusion-weighted MRI lesion volume after early moderate hypothermia in ischemic stroke.

BACKGROUND: Large areas of restricted diffusion in the middle cerebral artery (MCA) territory are highly predictive of severe and potentially space-occupying MCA stroke. A reduction of diffusion-weighted MRI (DWI) lesions occurs in 20% to 40% of acute stroke patients with early reperfusion. METHODS: We report of a patient with a severe stroke syndrome who was treated with early moderate hypothermia but not thrombolysis. RESULTS: The initially large DWI deficit of the whole MCA territory contrasted to the relatively small final lesion restricted to the basal ganglia on MRI and computed tomography scan. CONCLUSIONS: This case describes an unexpected reduction of a DWI lesion after early moderate hypothermia and spontaneous recanalization 3 days after stroke onset. We discuss potential reasons for the unexpected DWI lesion reduction.

Brain↗

[Usefulness of diffusion-weighted MRI in differentiating benign from malignant musculoskeletal tumors].

PURPOSE: To evaluate the usefulness of diffusion-weighted MRI in distinguishing different components and in differentiating benign from malignant musculoskeletal tumors. MATERIALS AND METHODS: Fifty-seven patients with musculoskeletal tumors underwent MR at our institution from October 1999 to April 2002. We evaluated 57 tumors (9 bone tumors and 48 soft tissue tumors). All tumors were classified into 8 groups (myxomatous, fibrous, cystic, cartilaginous, fatty components, hematomas, other benign tumors, and other malignant tumors). MR examinations were performed with a 1.5-Tesla system. Diffusion-weighted single-shot EPI images were obtained in all patients. Apparent diffusion coefficients (ADCs) were calculated by using b factors of 0 and 1,000 sec/mm2. RESULTS: ADC values of myxomatous, cystic, and cartilaginous components were significantly higher than those of other tumors. In cartilaginous tumors, malignant tumor ADC values (2.33 +/- 0.44) were higher than those of benign tumors (2.13 +/- 0.13). However, there was no significant difference between benign and malignant tumors. Except for high-intensity components on T1-weighted imaging and low or homogeneously very high intensity components on T2-weighted imaging, there was a significant difference in ADC between malignant (1.35 +/- 0.40) and benign (1.97 +/- 0.50) tumors. CONCLUSION: Within the limited number of cases, there was a significant difference in ADC between malignant and benign tumors.

Adolescent↗

Cerebral cortical laminar necrosis on diffusion-weighted MRI in hypoglycaemic encephalopathy.

BACKGROUND: Laminar necrosis of the cerebral cortex characterized neuropathologically by delayed selective neuronal necrosis occurs in hypoglycaemic encephalopathy and other brain diseases. CASE REPORT: A 37-year-old male with insulin-treated Type 1 diabetes mellitus developed hypoglycaemic encephalopathy associated with respiratory failure. Brain diffusion-weighted MRI during the subacute period demonstrated high signals along the cerebral cortex. Brain single-photon emission computed tomography showed diffuse, severe cerebral hypoperfusion. The patient remained comatose and died 1 month later. CONCLUSIONS: High signals along the cortical bands on diffusion-weighted MRI suggest cortical laminar necrosis, although a postmortem examination was unavailable. Sustained hypoglycaemic brain injury, possibly associated with respiratory hypoxia, may be the underlying mechanism.

Adult↗

Cortical hypoxic-ischemic brain damage in shaken-baby (shaken impact) syndrome: value of diffusion-weighted MRI.

Shaken-baby syndrome (SBS) is a type of child abuse caused by violent shaking of an infant, with or without impact, and characterized by subdural hematomas, retinal hemorrhages, and occult bone fractures. Parenchymal brain lesions in SBS may be missed or underestimated on CT scans, but can be detected at an earlier stage with diffusion-weighted MRI (DW-MRI) as areas of restricted diffusion. We demonstrate the value of DW-MRI in a 2-month-old baby boy with suspected SBS. The pattern of diffusion abnormalities indicates that the neuropathology of parenchymal lesions in SBS is due to hypoxic-ischemic brain injuries, and not to diffuse axonal injury.

Brain↗

Comparison of CT with diffusion-weighted MRI in patients with hyperacute stroke.

Tissue changes in ischaemic stroke are detectable by diffusion-weighted MRI (DWI) within minutes of the onset of symptoms. However, in daily routine CT is still the preferred imaging modality for patients with acute stroke. Our purpose of this study was to determine how early and reliably ischaemic brain infarcts can be identified by CT and DWI. Three neuroradiologists, blinded to clinical signs but aware that they were dealing with stroke, analysed the CT and DWI of 31 patients with an acute ischaemic stroke. We calculated kappa-values to analyse inter-rater variability. The ratings were compared with follow-up studies showing the extent of the infarct. The combined assessment of all observers gave positive findings in 77.4% of all CT examinations, with kappa = 0.58. Areas of high signal were seen on all DWI studies by all observers (kappa = 1). Estimation of the extent of the infarct based on DWI yeilded kappa = 0.70 and that based on CT kappa = 0.39. DWI was much more reliable than CT in the detection of early ischaemic lesions and we believe that it should be used in acute ischaemic stroke before aggressive therapeutic intervention.

Aged↗

[Diffusion-weighted MRI--a new parameter for advanced rectal carcinoma?].

PURPOSE: To evaluate the predictive value of apparent diffusion coefficient (ADC) on therapy outcome of combined chemoradiation in patients with primary carcinoma of the rectum. MATERIALS AND METHOD: Prior to standardized, combined, neoadjuvant chemoradiation, 16 patients with primary carcinoma of the rectum (cT3) were examined with magnetic resonance imaging (MRI). Diffusion-weighted spin echo echo-planar images (SE-EPI) and contrast-enhanced T 1 -weighted spin echo (SE) images at 1.5 Tesla were obtained. The mean ADC of the tumor region was calculated and correlated with the therapy outcome substantiated by postsurgical histopathologic staging. RESULTS: Tumor down-staging (pT0-2) occurred in 9 patients (therapy responders) and no down-staging (pT3) in 7 patients (therapy non-responders). The mean ADC measured 0.476 +/- 0.114 x 10(-3) mm 2/s in the responder group and 0.703 +/- 0.085 x 10(-3) mm 2/s in the non-responder group. Comparison of the mean ADC between the groups reached statistical significance (p = 0.001). CONCLUSION: The mean ADC might be a new quantitative parameter to predict therapy outcome of combined preoperative chemoradiation in patients with primary carcinoma of the rectum.

Adenocarcinoma↗

Detection of diffusion-weighted MRI abnormalities in patients with transient ischemic attack: correlation with clinical characteristics.

BACKGROUND AND PURPOSE: Although diffusion-weighted MRI (DWI) has demonstrated clear superiority over other conventional imaging modalities in the detection of hyperacute cerebral ischemia, its value in the evaluation of patients with transient symptoms has received only limited attention. We assessed the utility of DWI in patients with transient ischemic attack (TIA) to further evaluate the usefulness of this technique in these individuals. METHODS: A retrospective analysis was performed on all patients entered in the Stanford Stroke Center database during 1997-2001 who were clinically diagnosed with a TIA and who had also undergone a DWI scan or=1 hour, 16 times more likely to have had motor deficits, and 25 times more likely to have had aphasia than patients with negative DWI scans. The combination of all 3 symptoms was 100% specific for an abnormality on DWI. In 7 of 16 cases (44%), a DWI abnormality was present on both DWI and conventional imaging (T2-weighted imaging or fluid-attenuated inversion recovery [FLAIR]). In all of these cases the DWI clarified the extent or acuity of the lesion (n=7) or identified additional lesions not detected by conventional imaging (n=9). CONCLUSIONS: In TIA patients, symptom duration >or=1 hour, motor deficits, and aphasia were each independently correlated with detecting an abnormality with DWI. DWI was also helpful in differentiating between chronic versus acute lesions. These data may be of value in identifying those TIA patients for whom MRI evaluation with DWI is of greatest clinical utility.

Diffusion Magnetic Resonance Imaging↗

Asymptomatic choroid plexus cysts in the lateral ventricles: an incidental finding on diffusion-weighted MRI.

We assessed the role of diffusion-weighted imaging (DWI) in the detection of choroid plexus cysts. We reviewed more than 1000 patients who had undergone MRI in a 1-year period. We reviewed echo-planar DWI with b=1000 s/mm(2), acquired at 1.0 tesla, for any difference in signal intensity which might indicate choroid plexus cysts. On conventional images, all cystic lesions were isointense with cerebrospinal fluid, and 72 cysts could not be identified. On DWI, 90 rounded high-signal foci were detected in 58 patients; 64 cysts were bilateral. Focal ventricular expansion due to large cysts was observed in nine cases. DWI were found to show choroid plexus cysts undetected within the cerebrospinal fluid on conventional images.

Brain Diseases↗

Purulent meningitis with unusual diffusion-weighted MRI findings.

We describe unusual findings obtained by diffusion-weighted magnetic resonance imaging (MRI) in a patient with acute purulent meningitis caused by penicillin-resistant Streptococcus pneumoniae. Along cerebral convexities and the Sylvian fissure, multiple small intense lesions showed high signal intensity in these sequences. This may be the first report of diffusion-weighted in purulent meningitis.

Brain↗

Statistical artifacts in diffusion tensor MRI (DT-MRI) caused by background noise.

This work helps elucidate how background noise introduces statistical artifacts in the distribution of the sorted eigenvalues and eigenvectors in diffusion tensor MRI (DT-MRI) data. Although it was known that sorting eigenvalues (principal diffusivities) by magnitude introduces a bias in their sample mean within a homogeneous region of interest (ROI), here it is shown that magnitude sorting also introduces a significant bias in the variance of the sample mean eigenvalues. New methods are presented to calculate the mean and variance of the eigenvectors of the diffusion tensor, based on a dyadic tensor representation of eigenvalue-eigenvector pairs. Based on their use it is shown that sorting eigenvalues by magnitude also introduces a bias in the mean and the variance of the sample eigenvectors (principal directions). This required the development of new methods to calculate the mean and variance of the eigenvectors of the diffusion tensor, based on a dyadic tensor representation of eigenvalue-eigenvector pairs. Moreover, a new approach is proposed to order these pairs within an ROI. To do this, a correspondence between each principal axis of the diffusion ellipsoid, an eigenvalue-eigenvector pair, and a dyadic tensor constructed from it is exploited. A measure of overlap between principal axes of diffusion ellipsoids in different voxels is defined that employs projections between these dyadic tensors. The optimal eigenvalue assignment within an ROI maximizes this overlap. Bias in the estimate of the mean and of the variance of the eigenvalues and of their corresponding eigenvectors is reduced in DT-MRI experiments and in Monte Carlo simulations of such experiments. Improvement is most significant in isotropic regions, but some is also observed in anisotropic regions. This statistical framework should enhance our ability to characterize microstructure and architecture of healthy tissue, and help to assess its changes in development, disease, and degeneration. Mitigating these artifacts should also improve the characterization of diffusion anisotropy and the elucidation of fiber-tract trajectories in the brain and in other fibrous tissues. Magn Reson Med 44:41-50, 2000. Published 2000 Wiley-Liss, Inc.

Artifacts↗