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Kim, Kim, Park, Sung, and Cho: Triple Arterial Phase Hepatic MRI Using Four Dimensional T1-Weighted High Resolutions Imaging with Volume Excitation Keyhole Techniques: Feasibility and Initial Clinical Experience in Focal Liver Lesions
Abdominal Radiology

Journal of the Korean Society of Radiology 2013; 69(3): 223-234.

Published online: 11 September 2013

DOI: https://doi.org/10.3348/jksr.2013.69.3.223

Triple Arterial Phase Hepatic MRI Using Four Dimensional T1-Weighted High Resolutions Imaging with Volume Excitation Keyhole Techniques: Feasibility and Initial Clinical Experience in Focal Liver Lesions

Bo Kyu Kim, MD, Min Ju Kim, MD, Beom Jin Park, MD, Deuk Jae Sung, MD, Sung Bum Cho, MD

Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Corresponding author: Min Ju Kim, MD. Department of Radiology, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 136-705, Korea. Tel. 82-2-920-5567, Fax. 82-2-929-3796, dr.minjukim@gmail.com

Received 24 May 2013       Accepted 23 July 2013

Copyright © 2013 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate a new image acquisition method [four dimensional T1-weighted high resolution imaging with volume excitation (4D THRIVE)] which enables an accurate hepatic arterial phase definition. The feasibility and its potential for detection and characterizing focal liver lesions (FLLs) are being evaluated.

Materials and Methods

115 FLLs underwent liver MRI that included the 4D THRIVE-contrast enhanced timing robust acquisition order (CENTRA)-keyhole sequence. Triple arterial phase was obtained during a single breath-hold. Images were reviewed for image quality, lesion conspicuity, and lesion detection. Two radiologists independently assessed images from phase I, II, III and through the triple arterial phase, which were all reviewed separately and in random order. The image quality was scored by using the five-point scale, and then, one phase for lesion with greatest conspicuity was selected. The enhancement pattern for FLLs was analyzed.

Results

The detection rate was the highest on phase III. The image quality was greater than grade 3 with fair inter-observer agreements. The phase III showed greater conspicuity than phase I and II. Hepatocellular carcinomas (n = 38) showed variable enhancement pattern. Metastasis (n = 14) showed rim enhancement (n = 6), homogenous (n = 3) and no enhancement (n = 5). Most hemangiomas demonstrated homogenous enhancement (6/9, 67%).

Conclusion

Triple arterial MRI using the 4D THRIVE-CENTRA-keyhole technique is feasible in despite of the relatively low detection rate, and is thus, helpful for the characterization of focal liver lesions.

Keywords: Four Dimensional T1-Weighted High Resolution Imaging with Volume Excitation, Triple Arterial Phase Hepatic MRI, Focal Liver Lesion

Figures and Tables

Fig. 1
Schematic image of the keyhole technique (A) and the alternating viewsharing technique (B). The peripheral k-space data, called reference, is acquired only in last arterial phase and is shared with every phase. The central k-space data is determined by the keyhole percentage. In four dimensional T1-weighted high resolution imaging with volume excitation, the central ky-kz disc (keyhole) is subdivided in three regions, P+ (positive peripheral region), C (central region) and P- (negative peripheral region). The central region is acquired every arterial phase, but P+ and P- are shared with subsequent phase according to alternating viewsharing scheme as shown above. The view sharing percentage is determined by the rate of the area occupied by P+ (or P-) and C to the whole central disc.
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Fig. 2
A timing diagram shows the sequence of T1 weighted image acquisition. First, T1 weighted image without contrast injection is acquired within one breath hold. With short time of interval, contrast injection starts via peripheral venous route after delivering a message. 2D fluoroscopic real time imaging which is followed by contrast administration shows right atrium as we selected. When the contrast reaches right atrium, the MRI technologist manually presses the button to cessation of real-time display and to initiate breath-holding instructions. With one breath hold, three arterial phases are acquired with 4D THRIVE technique. According to alternating view sharing scheme as described, central disc of three phases are acquired first, and finally peripheral k-space date is acquired.
Note.-4D THRIVE = four dimensional T1-weighted high resolution imaging with volume excitation
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Fig. 3
Small HCCs in two different patients. From left to right, dynamic T1 weighted MRI images from three consecutive arterial phases, portal phase and delayed phase are shown.
A. Images from 49 years old male patient demonstrate a small hepatic nodule with gradual homogeneous arterial enhancement and delayed washout (white arrows).
B. In images from another 59 years old male patient with HCC show heterogeneous enhancement (black arrows).
Note.-Delay = 20 minutes delayed phase, HCC = hepatocellular carcinoma, PP = portal phase
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Fig. 4
Surgically confirmed hepatic metastasis from colon cancer in 57 years old patient. In arterial phase, the lesion shows peripheral rim enhancement. There is no definite difference of degree of contrast enhancement between each arterial phase.
Note.-Delay = 20 minutes delayed phase, PP = portal phase
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Fig. 5
Small hemangiomas in two different patients.
A. Dynamic T1 weighted contrast enhanced dynamic MRI shows typical peripheral nodular and centripetal enhancement of hemangioma.
B. Dynamic MRI images from another patient with small hemangioma show homogeneous enhancement. Note the degree of enhancement is same as that of adjacent hepatic arteries.
Note.-Delay = 20 minutes delayed phase, PP = portal phase
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Fig. 6
56 years old male patient with increased peripheral eosinophilic count. Portal phase CT (A) shows ill defined low density lesion (arrow). After 4 months, the lesion was disappeared on follow-up CT (B) and eosinophilic count was normalized. Dynamic MRI (C) shows subtle homogeneous enhancing lesion on arterial phase. And this lesion shows low signal intensity when compared with adjacent liver parenchyma on delayed phase (arrows).
Note.-Delay = 20 minutes delayed phase, PP = portal phase
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Fig. 7
Marked ringing artifact induced by respiratory motion. The artifact is shown on equally both phase I (A) and phase III (B), obscuring underlying focal liver lesion. A low signal intensity focal liver lesion is shown in delayed phase image (C) which is acquired during another breath hold.
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Table 1
Standards of Reference for Focal Liver Lesions
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Note.-*27 of 29 lesions were diagnosed by AASLD guideline. The two remaining lesions were not satisfied with AASLD guideline initially, but showed lipiodol uptake on TACE.

†2 lesions were increased in size on follow-up image, and the other lesions were diagnosed by concurrent serum AFP increase (> 200 ng/mL).

AASLD = American association for the study of liver diseases, AFP = alpha fetoprotein, DN = dysplastic nodule, F/U = follow up, FLL = focal liver lesion, HCC = hepatocellular carcinoma, RN = regenerative nodule, TACE = transarterial chemoembolization

Table 2
Liver Lesion Detection Rate for Each Arterial Phase
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Note.-*p-value based on McNemar test.

Table 3
Comparison of Image Quality and Conspicuity Scored by Two Observers
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Note.-*p-value is based on dependent t test results.

†p-values are based on χ2 test results.

Table 4
Image Features of Focal Hepatic Lesions on Triple Arterial Phase MRI
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Note.-DN = dysplastic nodule, FLL = focal liver lesion, HCC = hepatocellular carcinoma, RN = regenerative nodule

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