Objective: To describe the MR imaging features of hepatic hemangioma with perilesional enhancement. Materials and methods: A search was performed of the MRI section database to identify all cases of hepatic hemangioma with perilesional enhancement between March 2008 and July 2009. All patients underwent MR examinations including precontrast T1- and T2-weighted images and postgadolinium dynamic images. On MR images, characteristics of the hemangioma and perilesional enhancement were evaluated. Results: Seven hemangiomas in seven patients (five men, two women; age range, 41–69 years; mean, 57 years) were included in this study. Lesion size ranged from 7 to 20 mm (mean, 12.4 mm). On hepatic arterial dominant phase, all seven hemangiomas exhibited wedge-shaped perilesional enhancement which faded on two minutes postgadolinium images. Four of these lesions demonstrated adjacent capsular enhancement. Conclusion: All hepatic hemangiomas with perilesional enhancement were < 2 cm capsulebased lesions. This location suggests that these hemangiomas may conscript capsular vessels to account for the perilesional enhancement.

Keywords: Liver; Liver hemangioma; Liver perfusion; Liver contrast enhancement.

Objective: To prospectively compare full dose gadopentetate dimeglumine (Gd-DTPA) with full dose gadobenate dimeglumine (Gd-BOPTA) in the detection of focal hepatic lesions in patients with chronic liver disease on MRI. Materials and Methods: Eight patients with hepatic cirrhosis and a strong suspicion for small hepatocellular carcinoma based on prior MRI underwent contrast-enhanced MR examinations, one with full dose Gd-DTPA and one with full dose Gd-BOPTA. The exams were performed from 72–108 hours apart. Two blinded and independent radiologists evaluated images for lesion number, characterization, enhancement, and subjective preference. Results: There was no statistically significant difference between the two studies for lesion detection or characterization. There was 18% increased lesion enhancement for Gd-BOPTA, compared to Gd-DTPA, of the dominant lesion. Both blinded readers subjectively preferred the images using Gd-BOPTA over Gd-DTPA in the majority of cases, based on greater lesion enhancement and better edge definition. Conclusion: At equivalent full doses, Gd-BOPTA compared similarly with Gd-DTPA in the detection and characterization of focal hepatic lesions in patients with chronic liver disease. However, Gd-BOPTA was superior for increased lesion enhancement and subjective preference of the reader.

Keywords: MultiHance (Gd-BOPTA); Magnevist (Gd-DTPA); Hepatic lesions.

Objetivo: Avaliar a percepção de médicos residentes em radiologia de 4º ano sobre as melhores modalidades de imagem na investigação de neoplasias e trauma. Materiais e Métodos: Vinte e sete médicos residentes de 4º ano de quatro programas de residência em radiologia americanos participaram do estudo. Aos participantes foi perguntado sobre a melhor modalidade de imagem para se avaliar o cérebro e a coluna vertebral, pulmões, abdome e o sistema musculoesquelético. As modalidades de imagem disponíveis foram: RM, TC, ultrassonografia, PET e radiografia simples. Todos os achados foram comparados com os Critérios de Adequação de Exames de Imagem e Radioterapia do ACR. Resultados: A RM foi escolhida como melhor modalidade de imagem para se avaliar neoplasias encefálicas, espinhais, abdominais e musculoesqueléticas por 96,3%, 100%, 70,4% e 63% dos residentes, respectivamente. A TC foi escolhida por 88,9% dos residentes para avaliar neoplasias pulmonares. A modalidade de imagem ótima para se avaliar trauma foi a TC para lesões encefálicas (100%), espinhais (92,6%), pulmonares (96,3%), abdominais (92,6%) e grandes lesões traumáticas musculoesqueléticas (74,1%); a RM foi escolhida para lesões esportivas (96,3%). Observou-se concordância com os critérios de adequação do ACR. Conclusão: Houve concordância entre a percepção dos residentes sobre as melhores modalidades de imagem para avaliação de neoplasias e trauma e os critérios de adequação do ACR.

Keywords: Formação de residentes; Educação médica; Modalidades de imagem.

OBJECTIVE: To evaluate a comprehensive MRI protocol that investigates for cancer, vascular disease, and degenerative/inflammatory disease from the head to the pelvis in less than 40 minutes on a new generation 48-channel 3T system. MATERIALS AND METHODS: All MR studies were performed on a 48-channel 3T MR scanner. A 20-channel head/neck coil, two 18-channel body arrays, and a 32-channel spine array were employed. A total of 4 healthy individuals were studied. The designed protocol included a combination of single-shot T2-weighted sequences, T1-weighted 3D gradientecho pre- and post-gadolinium. All images were retrospectively evaluated by two radiologists independently for overall image quality. RESULTS: The image quality for cancer was rated as excellent in the liver, pancreas, kidneys, lungs, pelvic organs, and brain, and rated as fair in the colon and breast. For vascular diseases ratings were excellent in the aorta, major branch vessel origins, inferior vena cava, portal and hepatic veins, rated as good in pulmonary arteries, and as poor in the coronary arteries. For degenerative/inflammatory diseases ratings were excellent in the brain, liver and pancreas. The inter-observer agreement was excellent. CONCLUSION: A comprehensive and time efficient screening for important categories of disease processes may be achieved with high quality imaging in a new generation 48-channel 3T system.

Keywords: Whole-body MRI; Screening; Protocol; Preliminary results; 3 tesla.

OBJECTIVE: To determine common imaging findings of hepatic epithelioid hemangioendothelioma on magnetic resonance images. MATERIALS AND METHODS: A search was made of three institutional databases between January 2000 and August 2012. Seven patients (mean age, 47 years; range, 21–66 years; 6 women) with pathology-confirmed diagnosis of hepatic epithelioid hemangioendothelioma who had undergone magnetic resonance imaging were identified. None of the patients had received any treatment for hepatic epithelioid hemangioendothelioma at the time of the initial magnetic resonance imaging examination. RESULTS: Hepatic epithelioid hemangioendothelioma tumors appeared as focal masses in 7/7 patients, greater than 5 in number, with a coalescing lesion in 1/5, and peripheral localization in 6/7. Capsular retraction was present in 4/7, and was associated with peripherally located lesions. Early ring enhancement was appreciated in the majority of lesions in 7/7 patients. Centripetal progressive enhancement was shown in 5/7 patients on venous phase that exhibited a distinctive thick inner border of low signal on venous phase images, and a central core of delayed enhancement. Small lesions did not show this. CONCLUSION: The combination of multifocal round-configuration lesions that are predominantly peripheral and exhibit early peripheral ring enhancement and late appearance of an inner thick border of low signal and central core of high signal may represent an important feature for hepatic epithelioid hemangioendothelioma.

Keywords: Liver neoplasms/diagnosis; Epithelioid hemangioendothelioma; Magnetic resonance imaging.

OBJECTIVE: To describe a modified approach to the evaluation of adrenal nodules using a standard abdominal magnetic resonance imaging protocol. MATERIALS AND METHODS: Our sample comprised 149 subjects (collectively presenting with 132 adenomas and 40 nonadenomas). The adrenal signal intensity index was calculated. Lesions were grouped by pattern of enhancement (PE), according to the phase during which the wash-in peaked: arterial phase (type 1 PE); portal venous phase (type 2 PE); and interstitial phase (type 3 PE). The relative and absolute wash-out values were calculated. To test for mean differences between adenomas and nonadenomas, Student’s t-tests were used. Receiver operating characteristic curve analysis was also performed. RESULTS: The mean adrenal signal intensity index was significantly higher for the adenomas than for the nonadenomas (p < 0.0001). Chemical shift imaging showed a sensitivity and specificity of 94.4% and 100%, respectively, for differentiating adenomas from nonadenomas. Of the adenomas, 47.6%, 48.5%, and 3.9%, respectively, exhibited type 1, 2, and 3 PEs. For the mean wash-in proportions, significant differences were found among the enhancement patterns. The wash-out calculations revealed a trend toward better lesion differentiation for lesions exhibiting a type 1 PE, showing a sensitivity and specificity of 71.4% and 80.0%, respectively, when the absolute values were referenced, as well as for lesions exhibiting a type 2 PE, showing a sensitivity and specificity of 68.0% and 100%, respectively, when the relative values were referenced. The calculated probability of a lipid-poor lesion that exhibited a type 3 PE being a nonadenoma was > 99%. CONCLUSION: Subgrouping dynamic enhancement patterns yields high diagnostic accuracy in differentiating adenomas from nonadenomas.

Keywords: Adenoma; Adrenal gland neoplasms; Image enhancement; Contrast media; Magnetic resonance imaging.

Magnetic resonance imaging (MRI) is the modern gold standard for the noninvasive evaluation of the cirrhotic liver. The combination of arterial phase hyperenhancement and delayed wash-out allows a definitive diagnosis of hepatocellular carcinoma (HCC) in patients with liver cirrhosis or chronic liver disease, without the requirement for confirmatory biopsy. That pattern is highly specific and has been endorsed in Western and Asian diagnostic guidelines. However, the sensitivity of the combination is relatively low for small HCCs. In this two-part review paper, we will address MRI of the cirrhotic liver. In this first part, we provide a brief background on liver cirrhosis and HCC, followed by descriptions of imaging surveillance of liver cirrhosis and the diagnostic performance of the different imaging modalities used in clinical settings. We then describe some of the requirements for the basic MRI technique, as well as the standard MRI protocol, and provide a detailed description of the appearance of various types of hepatocellular nodules encountered in the setting of the carcinogenic pathway in the cirrhotic liver, ranging from regenerative nodules to HCC.

Keywords: Magnetic resonance imaging; Liver Cirrhosis; Image enhancement; Contrast media.

In the second part of this review, we will describe the ancillary imaging features of hepatocellular carcinoma (HCC) that can be seen on standard magnetic resonance imaging (MRI) protocol, and on novel and emerging protocols such as diffusion weighted imaging and utilization of hepatocyte-specific/hepatobiliary contrast agent. We will also describe the morphologic sub-types of HCC, and give a simplified non-invasive diagnostic algorithm for HCC, followed by a brief description of the liver imaging reporting and data system (LI-RADS), and MRI assessment of tumor response following locoregional therapy.

Keywords: Magnetic resonance imaging; Liver cirrhosis; Image enhancement; Contrast media.

OBJECTIVE: The purpose of this study was to compare two short-tau inversion recovery (STIR) sequences, Cartesian and radial (BLADE) acquisitions, for breast magnetic resonance imaging (MRI) examinations. MATERIALS AND METHODS: Ninety-six women underwent 1.5 T breast MRI exam (48 Cartesian and 48 BLADE). Qualitative analysis including image artifacts, image quality, fat-suppression, chest-wall depiction, lesion detection, lymph node depiction and overall impression were evaluated by three blinded readers. Signal to noise ratios (SNRs) were calculated. Cronbach’s alpha test was used to assess inter-observer agreement. Subanalyses of image quality, chest-wall depiction and overall impression in 15 patients with implants and image quality in 31 patients with clips were correlated using Pearson test. Wilcoxon rank sum test and t-test were performed. RESULTS: Motion artifacts were present in 100% and in 0% of the Cartesian and the BLADE exams, respectively. Chemical-shift artifacts were present in 8% of the Cartesian exams. Flow artifacts were more frequent on BLADE. BLADE sequence was statistically superior to Cartesian for all qualitative features (p < 0.05) except for fat-suppression (p = 0.054). In the subanalysis, BLADE was superior for implants and clips (p < 0.05). SNR was statistically greater for BLADE (48.35 vs. 16.17). Cronbach ranged from 0.502 to 0.813. CONCLUSION: BLADE appears to be superior to Cartesian acquisition of STIR imaging as measured by improved image quality, fewer artifacts, and improved chest wall and lymph node depiction.

Keywords: Breast MRI; BLADE sequence; Cartesian sequence; Image quality.

OBJECTIVE: To determine whether individuals with proposed gadolinium deposition disease (GDD) have elevated serum levels of pro-inflammatory and pro-fibrotic cytokines, and whether specific cytokines are correlated with certain symptoms. MATERIALS AND METHODS: Twenty-four participants recruited between May 2016 and June 2017 met GDD diagnostic criteria. The 64 control subjects provided serum samples before prophylactic flu vaccination. Serum cytokine levels were obtained with Luminex serum cytokine assay using eBiosciences/Affymetrix human 62-plex kits. Wilcoxon rank-sum tests were performed to assess the difference between the median fluorescence intensity values for the participants and the control group. Generalized linear models were built to evaluate the association between each cytokine of interest and selected participant symptoms. RESULTS: Serum levels of 14 cytokines, including nine pro-inflammatory cytokines, were statistically significantly elevated compared to controls (p ≤ 0.05). Hypotheses regarding pro-fibrotic cytokines and cytokine links to specific symptoms’ intensity were not confirmed. CONCLUSION: The statistically significantly elevated cytokines may be markers of susceptibility to GDD or agents of symptom induction. These findings suggest that individuals developing symptoms characteristic of GDD after a contrast-assisted magnetic resonance imaging should be studied to investigate whether gadolinium retention and elevated cytokines may be related to their symptoms.

Keywords: Cytokines; Pro-inflammatory; Gadolinium; Magnetic resonance imaging; Contrast-enhanced; Gadolinium deposition disease.

OBJECTIVE: The objective of this study was to allow physicians with self-diagnosed gadolinium deposition disease symptoms to report their own experience. MATERIALS AND METHODS: Nine physicians (seven females), with a mean age of 50.5 ± 8.3 years, participated in this case series. Nationalities were American (n = 6), British, Portuguese, and Romanian. Medical practices included internal medicine (n = 2), trauma surgery, ophthalmology, gastroenterology, psychiatry, family medicine, obstetrics/gynecology, and general practice. RESULTS: Genetically, eight of the physicians were of central European origin. Underlying autoimmune conditions were present in four. Symptoms developed after a single injection in one physician and after multiple injections in eight. The precipitating agent was gadobenate dimeglumine in four physicians, gadobutrol in three, gadoterate meglumine in one, and gadopentetate dimeglumine in one. The most consistent symptoms were a burning sensation, brain fog, fatigue, distal paresthesia, fasciculations, headache, and insomnia. Eight of the physicians were compelled to change their practice of medicine. CONCLUSION: In the various physicians, gadolinium deposition disease showed common features and had a substantial impact on daily activity. Physicians are educated reporters on disease, so their personal descriptions should spark interest in further research.

Keywords: Gadolinium/adverse effects; Gadolinium DTPA/adverse effects; Physicians; Contrast media/adverse effects.