title: MR-guided sclerotherapy of low-flow vascular malformations using T2 -weighted interrupted bSSFP (T2 W-iSSFP): comparison of pulse sequences for visualization and needle guidance.
abstract: OBJECTIVE
  Image-guided treatment of low-flow vascular (venous or lymphatic) malformations presents a challenging visualization problem, regardless of the imaging modality being used for guidance. The purpose of this study was to employ a new magnetic resonance imaging (MRI) sequence, T2 -weighted interrupted balanced steady-state free precession (T2 W-iSSFP), for real-time image guidance of needle insertion.
  
  
  METHODS
  T2 W-iSSFP uses variable flip angle balanced steady-state free precession (bSSFP, a.k.a. SSFP) to establish T2 -weighting and fat suppression. Swine (n = 3) and patients (n = 4, three female, all with venous malformations) were enrolled in the assessment. T2 -weighted turbo spin echo (T2 -TSE) with spectral adiabatic inversion recovery (SPAIR), SPAIR-T2 -TSE or T2 -TSE for short, was used as the reference. T2 -weighted half Fourier acquired single shot turbo spin echo (T2 -HASTE) with SPAIR (SPAIR-T2 -HASTE, T2 -HASTE for short), fat saturated bSSFP (FS-SSFP), and T2 W-iSSFP were imaged. Numeric metrics, namely, contrast-to-noise ratio (CNR) efficiency (CNR divided by the square root of acquisition time) and local sharpness (the reciprocal of edge width), were used to assess image quality. MR-guided sclerotherapy was performed on the same patients using real-time T2 W-iSSFP to guide needle insertion.
  
  
  RESULTS
  Comparing the visualization of needles in the images of swine, the local sharpness (mm(-1) ) was: 0.21 ± 0.06 (T2 -HASTE), 0.48 ± 0.02 (FS-SSFP), and 0.49 ± 0.03 (T2 W-iSSFP). T2 W-iSSFP is higher than T2 -HASTE (P < 0.001). For the patient images, their CNR efficiencies were: 797 ± 66 (T2 -HASTE), 281 ± 44 (FS-SSFP), and 860 ± 29 (T2 W-iSSFP). T2 W-iSSFP is higher than FS-SSFP (P < 0.02). The frame rate of T2 W-iSSFP was 2.5-3.5 frames per second. All MR-guided sclerotherapy procedures were successful, with all needles (six punctures) placed in the targets.
  
  
  CONCLUSIONS
  T2 W-iSSFP provides effective lesion identification and needle visualization. This new pulse sequence can be used for MR-guided sclerotherapy of low-flow vascular malformations. It may have potential use in other MR-guided procedures where heavily T2 -weighted real-time images are needed.
authors.affiliation: Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Di
authors.initials: D
authors.lastname: Xu
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Herzka
authors.forename: Wesley D
authors.initials: WD
authors.lastname: Gilson
authors.forename: Elliot R
authors.initials: ER
authors.lastname: McVeigh
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Lewin
authors.forename: Clifford R
authors.initials: CR
authors.lastname: Weiss
mesh_terms: D000328:Adult; D000818:Animals; D003287:Contrast Media; D005260:Female; D006801:Humans; D053783:Magnetic Resonance Imaging, Interventional / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009339:Needles; D015911:Sclerotherapy / Q000379:methods*; D013552:Swine; D054079:Vascular Malformations / Q000628:therapy*
chemical_list: D003287:Contrast Media
keywords: MR-guided sclerotherapy; T2-weighted fat suppressed magnetic resonance imaging; low-flow vascular malformations; real-time MR imaging; real-time guidance of needle placement