Does Multiphasic Contrast Enhanced Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Enhance the Detectability of Small Intracerebral Metastases?

Jung Hwan Kim; Kyung Sik Yi; Chi-Hoon Choi; Seung Tae Woo; Sang-Hoon Cha

doi:10.3348/jksr.2018.78.3.179

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

Original Article

J Korean Soc Radiol 2018;78(3):179-189.

Published online: 20 January 2018

DOI: https://doi.org/10.3348/jksr.2018.78.3.179

Does Multiphasic Contrast Enhanced Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Enhance the Detectability of Small Intracerebral Metastases?

Jung Hwan Kim, MD^1,², Kyung Sik Yi, MD^1,², Chi-Hoon Choi, MD^1,², Seung Tae Woo, PhD³, Sang-Hoon Cha, MD^1,^2,^4,^∗

¹Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea

²Translational Brain Disease Research Lab, Clinical Research Institute, Chungbuk National University Hospital, Cheongju, Korea

³Radiology, Bayer Healthcare Medical Care, Seoul, Korea

⁴Department of Radiology, College of Medicine, Chungbuk National University, Cheongju, Korea

^∗Corresponding author: Sang-Hoon Cha, MD Department of Radiology, Chungbuk National University Hospital, 776 1sunhwan-ro, Seowon-gu, Cheongju, Korea. Tel. 82-43-269-6473 Fax. 82-43-269-6479 E-mail: shcha@chungbuk.ac.kr

Received 6 July 2017 Revised 14 August 2017 Accepted 7 September 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Index terms Brain Metastasis Magnetic Resonance Imaging Image Enhancement Contrast Media

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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.

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

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

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

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

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

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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