Journal List > J Korean Soc Radiol > v.78(3) > 1095515

Kim, Yi, Choi, Woo, and Cha: Does Multiphasic Contrast Enhanced Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Enhance the Detectability of Small Intracerebral Metastases?

Abstract

Purpose

To determine adequate timing of acquisition of contrast-enhanced fluid attenuated inversion recovery (FLAIR) by using multiphasic contrast-enhanced FLAIR magnetic resonance imaging (MRI) and to evaluate added value in detecting small intracerebral metastases 5 mm or less.

Materials and Methods

Twenty-nine patients, that underwent multiphasic contrast-enhanced FLAIR MRI and contrast-enhanced T1 weighted image (T1WI) were included and total number of small intracerebral metastases was 131. Sensitivity, specificity and accuracy of lesion detection were evaluated. Contrast ratio (CR) and enhancement ratio of each lesion were compared and analyzed among each imaging sequence.

Results

Sensitivity, specificity and accuracy of lesion detection were increased when contrast-enhanced FLAIR was added to contrast-enhanced T1WI. Area of under receiver operating characteristic curve significantly increased by addition of contrast-enhanced FLAIR than using contrast-enhanced T1WI alone (p < 0.05). CR was significantly higher in contrast-enhanced T1WI than FLAIR (p < 0.001). All of the above results were not different according to time of acquisition of contrast-enhanced FLAIR.

Conclusion

There was advantage of conducting contrast-enhanced FLAIR MRI, but multiphasic contrast-enhanced FLAIR did not provide additional information for detection of small intracerebral metastases compared with single-phase FLAIR MRI.

References

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Fig. 1.
53-year-old female with brain metastases from non-small cell lung cancer. On axial image of postcontrast T1 weighted image (A), there is a suspicious enhancing nodular lesion in left frontal area confused with cortical vessels (arrow). And axial image of precontrast fluid attenuated inversion recovery (B) shows perilesional edema around the lesion (arrow). Therefore the lesion was assessed as metastasis, not a cortical vessel.
jksr-78-179f1.tif
Fig. 2.
57-year-old male with brain metastases from non-small cell lung cancer. Axial image of postcontrast T1 weighted image (A) shows suspicious enhancing nodular lesion in left cerebellar hemisphere (arrow). But axial images of precontrast FLAIR (B), 1st postcontrast FLAIR (C), and 2nd postcontrast FLAIR (D) do not show abnormal enhancement at the same location. Therefore the lesion was assessed as pulsating artifact, not a metastasis. FLAIR = fluid attenuated inversion recovery
jksr-78-179f2.tif
Fig. 3.
78-year-old male with brain metastases from colon cancer. Axial image of postcontrast T1 weighted image (A) shows a subtle enhancing nodule in right frontal cortex (arrow). And axial images of 1st postcontrast FLAIR (B) and 2nd postcontrast FLAIR (C) also show strong rim-enhancing nodule at the same location (arrows). Therefore the lesion was assessed as metastasis. FLAIR = fluid attenuated inversion recovery
jksr-78-179f3.tif
Fig. 4.
ROC curves for detectability of small brain metastases of three readers. The area of under ROC curve is significantly greater in T1WI + pre/ postcontrast FLAIR as compared to that in pre/postcontrast T1WI or T1WI + precontrast FLAIR. FLAIR = fluid attenuated inversion recovery, ROC = receiver operating characteristic, T1WI = T1 weighted image
jksr-78-179f4.tif
Fig. 5.
Comparison of CRs and ERs on multiphase contrast enhanced FLAIR MRI. In 3-phase MRI (A, B), CRs of small brain metastases in post-contrast T1WI are significantly lower than those in postcontrast FLAIR (p < 0.001) and ERs in pre/postcontrast T1WI are significantly greater than those in pre/postcontrast FLAIR (p < 0.001). In 2-phase MRI (C, D), the result is not different from the above. And there is no significant difference between CRs and ERs with time delays in both 2-phase and 3-phase contrast enhanced FLAIR MRI. CR = contrast ratio, ER = enhancement ratio, FLAIR = fluid attenuated inversion recovery, MRI = magnetic resonance imaging, T1WI = T1 weighted image
jksr-78-179f5.tif
Fig. 6.
Comparison of CRs and ERs for contrast media on 2 phase contrast enhanced FLAIR magnetic resonance imaging. When gadobutrol is used (A, B), CRs of small brain metastases in postcontrast T1WI are significantly lower than those in postcontrast FLAIR (p < 0.001) and ERs in pre/postcontrast T1WI are significantly greater than those in pre/postcontrast FLAIR (p < 0.001). When gadoteridol is used (C, D), the result is not different from the above. When gadobutrol and gadoteridol are used, there is no difference in CRs and ERs according to time delays. CR = contrast ratio, ER = enhancement ratio, FLAIR = fluid attenuated inversion recovery, T1WI = T1 weighted image
jksr-78-179f6.tif
Table 1.
Sensitivity, Specificity, and Diagnostic Accuracy in Three Readers
  Pre/Post T1WI Pre/Post T1WI + Pre FLAIR Pre/Post T1WI + Pre/Post FLAIR
  Reader 1 Reader 2 Reader 3 Reader 1 Reader 2 Reader 3 Reader 1 Reader 2 Reader 3
Sensitivity (%) 92.4 89.3 90.1 94.7 93.1 93.1 97.7 95.4 95.4
Number of lesions 121/131 117/131 118/131 124/131 122/131 122/131 128/131 125/131 125/131
Specificity (%) 38.9 44.4 44.4 44.4 55.6 55.6 77.8 83.3 77.8
Number of lesions 7/18 8/18 8/18 8/18 10/18 10/18 14/18 15/18 14/18
Diagnostic accuracy (%) 85.9 83.9 84.6 88.6 88.6 88.6 95.3 94.0 93.3
Number of lesions 128/149 125/149 126/149 132/149 132/149 132/149 142/149 140/149 139/149

Because the results of 1st, 2nd, and 3rd postcontrast FLAIR are the same, the results of 2nd and 3rd postcontrast FLAIR are not mentioned in the table. Post FLAIR = 1st (or 2nd or 3rd) postcontrast fluid attenuated inversion recovery, Post T1WI = postcontrast T1 weighted image, Pre FLAIR = precontrast fluid attenuated inversion recovery, Pre T1WI = precontrast T1 weighted image

Table 2.
Area of Under Receiver Operating Characteristic Curve
  Reader 1 Reader 2 Reader 3
  AUC p-Value AUC p-Value AUC p-Value
Pre/post T1WI 0.656 0.032 0.669 0.02 0.673 0.018
Pre/post T1WI + pre FLAIR 0.696 0.007 0.743 0.001 0.743 0.001
pre/post T1WI + pre/post FLAIR 0.877 < 0.001 0.894 < 0.001 0.866 < 0.001
p-values between            
AUC1 vs. AUC2   0.717   0.488   0.512
AUC1 vs. AUC3   0.024   0.016   0.047
AUC2 vs. AUC3   0.064   0.097   0.194

AUC = area of under receiver operating characteristic curve, Post FLAIR = postcontrast fluid attenuated inversion recovery, Post T1WI = postcontrast T1 weighted image, Pre FLAIR = precontrast fluid attenuated inversion recovery, Pre T1WI = precontrast T1 weighted image

Table 3.
Effect of Time Delay after Contrast Injection on Multiphase CE-FLAIR
  3 Phase CE-FLAIR 2 Phase CE-FLAIR
CR ER CR ER
Combination of sequences (mean ± SD)
1 17.73 ± 10.86 101.25 ± 26.87 22.12 ± 15.08 101.50 ± 53.18
2 43.28 ± 24.40 10.93 ± 14.94 84.84 ± 44.14 12.78 ± 22.27
3 46.36 ± 26.81 11.85 ± 16.36 80.02 ± 38.39 11.11 ± 19.08
4 46.86 ± 25.16 14.14 ± 16.89
p-values between
1 vs. 2 < 0.001 < 0.001 < 0.001 < 0.001
1 vs. 3 < 0.001 < 0.001 < 0.001 < 0.001
1 vs. 4 < 0.001 < 0.001
2 vs. 3 0.927 0.996 0.598 0.948
2 vs. 4 0.892 0.876
3 vs. 4 1.000 0.951

CE-FLAIR = contrast enhanced fluid attenuated inversion recovery, CR = contrast ratio, ER = enhancement ratio, SD = standard deviation, T1WI = T1 weighted image, 1 = precontrast T1WI + postcontrast T1WI, 2 = precontrast FLAIR + 1st postcontrast FLAIR, 3 = precontrast FLAIR + 2nd postcontrast FLAIR, 4 = precontrast FLAIR + 3rd postcontrast FLAIR

Table 4.
Effect of Time Delay after Gadobutrol or Gadoteridol Injection on 2 Phase Contrast Enhanced FLAIR
  Gadobutrol Gadoteridol
CR ER CR ER
Combination of sequences (mean ± SD)
1 29.37 ± 17.36 104.99 ± 40.22 18.96 ± 12.55 99.98 ± 60.73
2 97.73 ± 47.41 18.09 ± 28.19 79.23 ± 36.62 10.47 ± 16.98
3 91.23 ± 34.94 12.45 ± 22.96 75.14 ± 38.13 10.52 ± 17.99
p-values between
1 vs. 2 < 0.001 < 0.001 < 0.001 < 0.001
1 vs. 3 < 0.001 < 0.001 < 0.001 < 0.001
2 vs. 3 0.779 0.786 0.749 1.000

CR = contrast ratio, ER = enhancement ratio, FLAIR = fluid attenuated inversion recovery, SD = standard deviation, T1WI = T1 weighted image, 1 = pre-contrast T1WI + postcontrast T1WI, 2 = precontrast FLAIR + 1st postcontrast FLAIR, 3 = precontrast FLAIR + 2nd postcontrast FLAIR

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