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Avant-garde magnetic resonance imaging (MRI) techniques of the spine and spinal cord in children and adults

• B. G. A. Delattre²,
• J. Boto¹,
• J. Gariani²,
• A. Dhouib^two,
• A. Fitsiori¹ &
• J. L. Dietemann³

Insights into Imaging book 9,pages 549–557 (2018)Cite this commodity

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Abstruse

In this article, nosotros illustrate the main advanced magnetic resonance imaging (MRI) techniques used for imaging of the spine and spinal cord in children and adults. This work focuses on daily clinical practice and aims to address the nearly common questions and needs of radiologists. We will also provide tips to solve common problems with which we were confronted. The principal clinical indications for each MR technique, possible pitfalls and the challenges faced in spine imaging because of anatomical and physical constraints will exist discussed. The major advanced MRI techniques dealt with in this article are CSF, (cerebrosopinal fluid) flow, diffusion, diffusion tensor imaging (DTI), MRA, dynamic contrast-enhanced T1-weighted perfusion, MR angiography, susceptibility-weighted imaging (SWI), functional imaging (fMRI) and spectroscopy.

Educational activity Points

• DWI is essential to diagnose string ischaemia in the acute phase.

• MRA is useful to guide surgical planning or endovascular embolisation of AVMs.

• Three Tesla is superior to ane.v T for spine MR angiography and spectroscopy.

• Avant-garde sequences should only be used together with conventional morphological sequences.

Introduction

Advanced MRI techniques applied to the spinal cord have remained hard to put into practice until recently. Until now, advanced imaging techniques of the spine have relied on significant contributions from MR physicists to utilize them to clinical routine.

These techniques are feasible at i.5 and 3 T with a clear advantage of 3 T for magnetic resonance angiography (MRA) and spectroscopy.

Characterisation of intramedullary lesions is challenging with conventional sequences, and, on numerous occasions, it is difficult to identify the origin of the lesion, distinguish between inflammation and ischaemia, and correctly date an ischaemic lesion as acute or hyperacute. Conversely, avant-garde sequences permit a much better delineation of the anatomy, such equally diffusion tensor imaging (DTI) for pre-surgical planning of spinal tumours or MRA to accurately localise the shunt and nidus of an AVM.

In this article, we illustrate the master advanced techniques, such as cerebrospinal fluid (CSF) catamenia, diffusion and improvidence tensor imaging (DTI), dynamic magnetic resonance angiograpy (MRA), dynamic dissimilarity-enhanced T1-weighted perfusion, susceptibility-weighted imaging (SWI), functional imaging and spectroscopy. The main technical challenges faced in spine imaging and the clinical applications of these techniques in children and adults are also discussed.

Advantages and disadvantages of high field strength

The employ of high field forcefulness on MRI in brain imaging has allowed an increased signal-to-noise ratio (SNR) and decreased acquisition time. Even so, the state of affairs is not the aforementioned with advanced sequences in spine and spinal cord imaging. The main challenges faced in spine imaging relate to the modest dimensions of the spinal string (approximately 12 to xiv mm in diameter), inhomogeneity of B0 on T1 imaging, artefacts due to the CSF catamenia, which are more significant on the dorsal spine, and too artefacts due to breathing, patient motion and swallowing [1]. Magnetic susceptibility artefacts are besides important because of interfaces between different structures such as bone, lungs and fat.

Sometimes, high field strength may be a limitation because of the greater issue of susceptibility artefacts (going linearly with the field strength). The distortions of the images are thus important particularly in the spine where the proximity with the lungs creates high susceptibility artefacts. On the other hand, high field strength in the DTI of the cervical spine causes geometric distortion. This has been partially solved by the new sequence types [readout segmentation of long variable echo train (RESOLVE) available on Siemens systems or zoomed EPI available on all systems, for case].

For other sequences such as CSF menses and perfusion imaging, 1.v- or iii-T MR tin exist used with the same final result. Additionally, loftier field strength offers a real added value for MRA and spectroscopy; it produces higher SNRs and faster conquering minimising motion artefacts.

Avant-garde sequences

CSF flow

The application of this sequence in spinal cord imaging is for depicting cystic lesions, such as arachnoid or leptomeningeal cysts (Fig. 1), the latter often resulting from haematomas after trauma, which breakdown into haemosiderin and its derivatives and may crusade arachnoiditis [2, 3]. CSF flow techniques are usually coupled with T2 loftier-resolution sequences, which serve the double purpose of helping to improve depict lesions and too to generate an anatomical mask.

Fig. ane

Sagittal (a) and axial (b) T2WI shows hyperintensity of the cord (arrow), which is deformed (scalpel sign), suggesting an arachnoid web. Sagittal 3D T2WI (b) meliorate demonstrates the spider web (arrow). Sagittal flow sequences (d,eastward) show decreased CSF menstruum posteriorly to the cord due to the arachnoid web

Full size image

Stage contrast MRI is a unique approach to measuring flow in vivo. It relies on the principle that move in a voxel induces additional dephasing of the signal. With an appropriate sequence providing phase images in addition to magnitude images, it is possible to measure the flow velocity in a voxel [4]. A stage encoding gradient can be applied in ane of the 3 directions of space to detect flow in that specific management. If the flow going through the imaging aeroplane needs to measured, the stage encoding gradient is applied in the slice encoding direction. These phase-dissimilarity sequences crave ECG triggering since the blood and CSF menstruation velocities vary during the cardiac cycle.

Flow measurement is performed in the sagittal airplane to visualise in-airplane CSF menses. In this instance, care has to be taken if the phase encoding management is chosen since cardiac and respiratory motility are highly deleterious to image quality and flow quantification.

The velocity encoding gradient in the sequence should be prepare betwixt 10 and twenty cm/s and exist increased if aliasing artefacts are observed. Bunck et al. [5] reported x cm/southward in volunteers and 20 cm/s in patients where a specific pathology could lead to increased velocity due to narrowing of the CSF culvert.

Menstruum can exist measured directly in the three spatial directions to improve sensitivity to both the in- and through-plane velocities and too to make up one's mind the flow direction. This sequence, which provides information in a 3D volume, is promising but has the disadvantage of long acquisition times (12–14 min versus 3–v min for the second sequence [5]).

Three-dimensional MR T2 high resolution

Three-dimensional MR T2 high resolution is an isotropic sequence as well known as the 3D CISS (constructive interference in steady state), 3D True-FISP (fast imaging with steady-state precession) or FIESTA (fast imaging employing steady-state conquering) sequence (Fig. 2).

Fig. 2

CT scan (a,b,c) performed in a 61-year-onetime females lament of back pain later a fall shows several paraspinal lesions (arrows), which are difficult to characterise by this technique. A CISS MR sequence (d) clearly shows these to exist extradural cysts. Note that there is no enhancement on T1 FS Gd (east,f,m)

Total size epitome

This sequence allows skilful depiction of smaller structures because of high spatial resolution, loftier T2 contrast and its isotropic backdrop, which permit visualisation in three planes without distortion.

The primary clinical indications are:

• thin septa in post-traumatic cysts

• walls of arachnoid cysts or arachnoid webs (Figs. ane and 2)

• inner structure of cystic tumours

• normal and dilated vessels on the surface of the spinal cord in dural fistulas and AVMs

• postal service-traumatic pseudomeningoceles

• dural breach and CSF leak in hypotension of CSF

• Tarlov cysts

A larger FOV tin be obtained in the coronal and sagittal planes, but centric images are also possible.

Other 3D T2 sequences such as infinite, CUBE or VISTA, which are spin echo sequences, are less sensitive to menstruation and susceptibility artefacts [6], allowing clear delineation of the nervus root sheaths. The most common pitfall of these sequences is the Gibbs artefact mimicking superficial siderosis [vi] (Fig. 3).

Fig. 3

FSE T2 shows an enlarged ependymal canal at the C5 level (white arrow in a). Annotation that the aforementioned abnormality appears larger on the SPACE T2 sequence and also the false image of superficial siderosis on the cervical spinal cord (black arrows in b)

Full size paradigm

Dynamic MRA

Clinical applications include investigation of vascular malformations such as dural fistulas (Fig. 4) and arteriovenous malformations and identification of the exact location of the artery of Adamkiewicz (AKA) for presurgical planning for tumours to facilitate endovascular treatment. In case of ischaemia, it is very difficult to visualise the thrombus in the vessel lumen, especially in a small artery such as the AKA. On the other hand, dynamic MRA tin can be very useful in showing a dissection or a partially thrombosed aneurysm of the aorta. However, it plays no role in the workup of cavernomas equally they are angiographically silent. CT is an excellent technique for imaging of large vessels, but information technology does not allow visualisation of spinal cord ischaemia.

Fig. 4

Sagittal T2WI (a) demonstrates multiple dilated vessels with corkscrew appearance surrounding the spinal cord (a); 3D MRA reformat nicely illustrates the arteriovenous shunt at the level of T6 on the right (pointer in b) confirmed past DSA (c)

Full size epitome

The main challenges of dynamic MRA are the pocket-sized size of vascular structures in the spine and the dynamic aspect of this sequence. These are besides the main reasons why high field strength is useful because of its higher SNR.

There are ii techniques for performing dynamic MRA: dynamic sequences with a temporal resolution of approximately one min (iii phases: arterial, venous and delayed, and an additional later acquisition at loftier spatial resolution) [7] and 4D imaging [eight].

The commencement relies on a 3D slope echo T1-weighted sequence with a field of view comprising the descending aorta equally well as the spine in the sagittal airplane. The angiography technique uses a noncontrast prototype that is afterward subtracted from the arterial stage image. An important attribute is the timing of the imaging. The arterial bolus remains in the arteries for a short period of fourth dimension; thus, imaging should exist done at a precise time to eliminate venous contagion. This timing depends on the injection charge per unit and also on the cardiovascular status of the patient.

The utilisation of claret puddle agents or doubly concentrated contrast media may nevertheless facilitate image acquisition and subsequent assay.

The other technique for MRA relies on a 4D sequence also known as time-resolved angiography with stochastic trajectories (TWIST) [ix] or 4D time-resolved MR angiography with a keyhole (4D-TRAK) with a spatial resolution of 1 mm and temporal resolution of approximately 1.3 s.

Diffusion and improvidence tensor imaging

Acute ischaemia is one of the principal clinical indications for DWI, is seen as high signal on trace images and decreased ADC without enhancement (Fig. five), which just appears in the subacute phase [ten]. The main causes in adults are atherosclerosis, cardiac surgery and minimally invasive procedures, pinch of the radicular artery past a disc [eleven] and minor trauma to the cervical spine in the setting of degenerative changes.

Fig. 5

A 14-year-old male who suffered minor trauma. Spine MR performed 24 h afterward shows increased signal intensity on T2WI (a,d) (arrows) and DWI (e) reflecting ischaemia. Note an acute wedge fracture of T12 (*)

Full size image

In children, minor trauma is a cause of ischaemia related to fibrocartilage emboli [12] (Fig. v) and too arterial spasm. Other causes include traction for scoliosis after orthopaedic surgery [13], complications of cardiac surgery, sickle cell anaemia and umbilical artery catheter in the neonate.

DWI is also used to differentiate between spondylodiscitis and inflammatory degenerative changes [14]. FA and ADC values may be used to predict gain of function in patients with cervical spondylotic myelopathy after decompressive surgery [15].

DTI tractography is used for pre-surgical planning of tumours [xvi] (Fig. six) as the generated cartography is the only method allowing the neurosurgeon to visualise the tracts in vivo [17].

Fig. 6

Patient with multiple myeloma and several vertebral fractures, treated past vertebroplasty. No enlargement or enhancement of the conus medullaris is visible (a). Spine MR performed approximately 7 months later shows hyperintensity and nodular enhancement of the conus medullaris (b,c,f,g). On tractography (d,e), destruction of the fibers of the conus medullaris can be seen; this translates into a secondary lesion with rapid growth

Full size epitome

Unlike in the brain, diffusion of water molecules in the spinal cord occurs mainly in the cranio-caudal direction [8, 18] because of the lower intracellular water content. This is the primary reason why b500 or b900 is used in spinal imaging and not b1000.

DWI and DTI are challenging techniques in spinal imaging for several reasons, including the small size of the string relative to the brain and respiratory and cardiac motion artefacts. Therefore, spine improvidence imaging requires high spatial resolution, which should be combined with distortion reduction techniques and homogeneous fatty saturation. These goals are difficult to reach with the broadly used single-shot spin repeat EPI diffusion sequence, especially when image conquering is in the sagittal plane, which is preferred for the evaluation of the spine. Specific aspects are (one) fat saturation, (2) imaging distortion and (3) b-values and directions.

1. (one)

   Conventional fat saturation with spectral selection of the fat summit based on CHESS (chemical shift selective) has the advantage of being fast but often delivers poor results in spine imaging. In dorsal areas, an inversion recovery technique, such as STIR (short tau inversion recovery), is more robust in eliminating the signal from fat and improving image quality. Withal, this causes a reduction in the point due to the inversion pulse. A compromise is to employ SPAIR (spectral attenuated inversion recovery) preparation, which shows relatively robust saturation provided the shim box is placed correctly in the area of interest avoiding the lungs.

A recently bachelor method to suppress the fat signal is the Dixon technique [nineteen]. It relies on the principle that water and fat practice not precess at the verbal aforementioned frequency and that they can be either in or out of phase later on the preselected time to echo. This technique provides very homogeneous fat-saturated images on large fields of view.

1. (two)

   Diffusion imaging uses a single-shot EPI sequence. Throughout the long echo train, phase errors will accumulate, resulting in spatial mismatch in the reconstructed image. The longer the echo railroad train and the higher the resolution, the more than pronounced the distortions will be. Distortions will also be enhanced considering of susceptibility differences between dissimilar spinal tissues (bone, intervertebral discs, cerebrospinal fluid, etc.).

Reducing the readout bandwidth minimises this baloney. To achieve this, parallel imaging can be used together with a rectangular field of view. Another choice is to cull a transverse orientation with an isotropic voxel resolution. Another alternative to this problem is sectionalization of the EPI readout in either the phase or readout management. A more than detailed explanation of distortion reduction in spine diffusion imaging can be found in: [20,21,22].

1. (3)

   b = 500 due south/mm^two is often chosen at ane.5 T since it produces a sufficient SNR to allow satisfactory interpretation of the images without being too low, and thus too sensitive, to perfusion effects [23]. This value can be increased at three T because of the college SNR.

For DTI, the optimal number of diffusion directions varies depending on the authors [24], a higher number being ofttimes preferred. While the minimum number of directions to generate DTI parameters such as FA or MD is six, a more reasonable value would be effectually twenty.

Dynamic contrast-enhanced T1-weighted perfusion

Dynamic dissimilarity enhancement (DCE) is a technique that allows dynamic visualisation of contrast behaviour in tissues. It is the technique of choice to assess microvascularisation, in item in the context of neoplasm growth, because it provides information about the tumour vasculature and the effects of treatment (Fig. 7). This technique is used in encephalon imaging for tumour characterisation and for distinguishing between radionecrosis and true tumour progression. In spine imaging, DCE is used to characterise tumours and to evaluate extradural spinal metastases and their vascularisation [25], which in turn helps in the selection of patients acquiescent to endovascular treatment.

Fig. 7

A patient with spinal cord glioblastoma. a Sagittal T1 mail service-gadolinium MR image shows an enhancing intramedullary mass. b Corrected Vp (volumetric plasma volume) parameter of T1 perfusion is increased in the mass. c and d Increased One thousand_trans and AUC (area under the curve) in the mass simply also in the posterior paraspinal soft tissues reflecting contrast extravasation due to postoperative changes. This example illustrates that T1 perfusion, especially corrected Vp, allows detection of truthful tumour hypervascularisation

Full size prototype

The goal of DCE is to quantify tissue permeability with the use of specific models such as the Tofts model or equivalent [26]. This two-compartment model provides physiologically relevant parameters such as the K_trans [volume transfer constant between blood plasma and extravascular extracellular space (EES)], K_ep (rate constant between EES and blood plasma) and V_e (volume of EES per unit book of tissue, i.east., the volume fraction of the EES).

To generate these parameters, imaging should be performed at relatively loftier temporal resolution (between 2 to 15 s) and over 5 to ten min mail service administration of dissimilarity media. Using a 3D-T1 spoiled gradient recalled repeat sequence to dynamically image the dissimilarity inflow and washout is recommended [27]. This sequence is very sensitive to T1 variations and is fast enough to produce a suitable temporal resolution while maintaining a sufficient SNR. For the modelling, it is necessary to convert the signal intensity curve into a Gd concentration bend, which tin can only exist washed with knowledge of the T1 values before contrast injection. Usually, the two flip bending method is called because it is fast and reliable. This technique has been more widely used in the brain just has also shown promising results in spine imaging, such as preclinical enquiry in spinal string injury cess [28, 29].

Susceptibility weighted imaging (SWI)

SWI is a sequence based on the magnetic susceptibility differences between tissues. Reconstructions of magnitude and stage images are possible. The conquering of this sequence does not need the administration of contrast medium.

SWI is principally used at the level of the brain to detect micro-haemorrhages, calcifications, fe and deoxy-Hb. Concerning the spine, few articles be apropos the use of this sequence at 1.v T. In our opinion, its apply is possible but has not been extended to daily clinical practice because of limitations in spatial resolution and multiple artefacts due to phase-encoding directions, os-tissue interfaces, flow and increased racket. This sequence is particularly sensitive to subtle changes of the local magnetic susceptibility variances, decreased signal-to-dissonance ratios, etc. [xxx].

The perhaps clinical indications are visualisation of normal venous anatomy [thirty], identification of bleeding, evaluation of the efficiency of treatment of spinal arteriovenous malformations and evaluation of changes in venous oxygenation [31] with SW stage imaging.

Spectroscopy

Spectroscopy shows the concentration of normal metabolites in a specific anatomic location and changes in those metabolites in case of pathology. Few works have shown the feasibility of spectroscopy in spinal cord imaging. Spectroscopy has, nevertheless, been used to characterise and differentiate tumours [32] from inflammatory pathologies, in amyotrophic lateral sclerosis or in the follow-up of cervical spondylotic myelopathy [33]. Furthermore, Holly et al. [33] showed that spectroscopy may exist of value in predicting neurological result in patients with cervical spondylotic myelopathy after surgery.

Spectroscopy of the spinal cord presents a real challenge considering of the minor dimensions of the string, catamenia artefacts, motion artefacts during the cardiac and respiratory cycles, the deep anatomical location [34] and B0 inhomogeneity, which is particularly deleterious to spectroscopy of the spine. For this reason, B0 shimming is essential. Saturation bands and pulse triggering [32] are used to reduce CSF flow artefacts.

The sequence used is PRESS (point-resolved spectroscopy), which produces better results with a long TE of around 135 or 280 ms than with short TE beneath 40 ms. Currently, this technique is used exclusively in research.

Functional imaging (fMRI)

fMRI provides information concerning spinal string motor function. The sequence used is essentially the aforementioned as that on the brain; withal, modifications are necessary because of the size of the spinal string. Spinal fMRI illustrates neuronal part indirectly by changes in blood menstruum and claret oxygen levels (potential clinical indication of fMRI) [35].

This tool is only used for research purposes.

The potential clinical applications are: to determine preserved motor function in patients with spinal injury, to programme treatment or to evaluate the treatment response of tumours to sympathise the physiopathology of cervical headaches and to monitor functional changes in diseases such as multiple sclerosis and amyotrophic lateral sclerosis [35].

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1. Sectionalisation of Neuroradiology, DISIM, Geneva University Hospitals and Kinesthesia of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva xiv, Switzerland

   M. I. Vargas, J. Boto & A. Fitsiori

2. Partitioning of Radiology, DISIM, Geneva University Hospitals, Geneva, Switzerland

   B. G. A. Delattre, J. Gariani & A. Dhouib

3. Division of Neuroradiology, Strasbourg University Hospitals, Strasbourg, France

   J. L. Dietemann

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Correspondence to G. I. Vargas.

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Vargas, M.I., Delattre, B.1000.A., Boto, J. et al. Advanced magnetic resonance imaging (MRI) techniques of the spine and spinal cord in children and adults. Insights Imaging 9, 549–557 (2018). https://doi.org/10.1007/s13244-018-0626-ane

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• Received: nineteen December 2017

• Revised: nineteen March 2018

• Accepted: 05 April 2018

• Published: 01 June 2018

• Issue Date: Baronial 2018

• DOI : https://doi.org/10.1007/s13244-018-0626-one

Keywords

• Spinal cord
• Perfusion
• Spectroscopy
• Magnetic resonance angiography
• Improvidence tensor imaging

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