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Fat-saturated post gadolinium T1 imaging of the brain in multiple sclerosis

Osama Al-Saeed, Mohammed Ismail, Reji Athyal and Mehraj Sheikh Acta Radiol 2011 52: 570 DOI: 10.1258/ar.2011.100396 The online version of this article can be found at: http://acr.sagepub.com/content/52/5/570

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Original article

Fat-saturated post gadolinium T1 imaging of the brain in multiple sclerosis

Osama Al-Saeed1, Mohammed Ismail2, Reji Athyal3 and Mehraj Sheikh1
Department of Radiology, Kuwait University; 2Ibn Sina Hospital, Kuwait; 3Amiri Hospital, Kuwait Correspondence to: Osama Al-Saeed. Email: osamas@hsc.edu.kw
1

Abstract
Background: Magnetic resonance imaging (MRI) is of vital importance in the diagnosis and follow-up of patients with multiple sclerosis (MS). Imaging sequences better demonstrating enhancing lesions can help in detecting active MS plaques. Purpose: To evaluate the role of fat-saturated gadolinium-enhanced T1-weighted (T1W) images of the brain in MS and to assess the benet of performing this additional sequence in the detection of enhancing lesions. Material and Methods: In a prospective study over a six-month period, 70 consecutive patients with clinically diagnosed MS were enrolled. These constituted 14 male and 56 female patients between the ages of 21 and 44 years. All the patients underwent brain MRIs on a 1.5 Tesla Magnet. Gadolinium-enhanced T1 images with and without fat saturation were compared and results were recorded and analyzed using a conspicuity score and McNemar test. Results: There were a total of 157 lesions detected in 70 patients on post-contrast T1W fat-saturated images compared with 139 lesions seen on the post-contrast T1W fast spin-echo (FSE) images. This was because 18 of the lesions (11.5%) were only seen on the fat-saturated images. In addition, 15 lesions were more conspicuous on the fat saturation sequence (9.5%). The total conspicuity score obtained, including all the lesions, was 2.24 /20.60 (SD). Using the two-tailed McNemar test for quantitative analysis, the P value obtained was , 0.0001. Conclusion: T1W fat-saturated gadolinium-enhanced images show better lesion enhancement than T1W images without fat saturation.

Keywords: Multiple sclerosis, magnetic resonance imaging, fat saturation, gadolinium, brain
Submitted September 19, 2010; accepted for publication February 19, 2011

Multiple sclerosis is a chronic debilitating disease most likely of autoimmune etiology, involving the white matter in the central nervous system. MR imaging, especially after intravenous administration of gadolinium chelates, helps to demonstrate the inammatory nature of the disease and hence plays a major role in the diagnosis and follow-up of these patients (1). Enhancing lesions on brain MRI are more reliable in the diagnosis of MS indicating dissemination in time and space and are also useful in grading the severity of the disease, assessing treatment response, and documenting relapse (2). The use of the fat saturation sequence in neurological disease has been limited thus far; mainly being used for depiction of fat content in CNS tumors (35), optic neuritis (6), vertebral abnormalities (7), and in lipomatous lesions within the spinal canal and skull base (8). This imaging sequence is the preferred technique on higher eld strength
Acta Radiologica 2011; 52: 570 574. DOI: 10.1258/ar.2011.100396

magnets as against the alternative techniques of inversion recovery imaging and opposed phase imaging which are particularly useful in low eld strength magnets for lesions containing small amounts of fat (9). The literature on the use of fat saturation imaging sequence in MS patients is scant. To our knowledge there is only one study on the use of fatsaturated T1-weighted sequence with intravenous gadolinium on a 1.0 Tesla magnet with documented benets (2). The aim of this study was to compare fat-saturated T1W gadolinium-enhanced images to T1W images without fat saturation in the detection of enhancing lesions in MS patients in 1.5T.

Material and Methods

In a prospective six-month study, 70 consecutive patients with clinically diagnosed MS were enrolled. These

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constituted 14 male and 56 female patients between the ages of 21 and 44 years. The imaging session in all the patients was part of the regular follow-up of cases diagnosed with MS. The study was approved by university ethics committee, and patient consent was obtained for additional sequences. All the patients underwent brain MRIs on a 1.5 Tesla machine (GE Signa 1.5T Echospeed, GE Healthcare, Milwaukee, WI, USA) using an 8-channel head coil. The pre-contrast imaging included the axial T1W FSE, axial T2W FSE, T2W Flair, and sagittal Flair sequences. Three minutes after IV contrast by a manual injection of 0.1 mmol/kg body weight of gadodiamide (Omniscan, GE Health care, Cork, Ireland) over 30 s, axial T1W FSE and axial T1W fat-saturated sequences were performed. The T1W FSE sequence (TR 600, TE min, Echotrain 2, FOV 24, NEX 2, Freq 384, phase 256, thickness 5) took an average of 2 min and 30 s to perform and the T1W fat-saturated sequence (TR 600, TE min, Echotrain 2, FOV 24, NEX 2, Freq 384, phase 256, thickness 5) took an average of 5 min and 12 s. These two sequences were alternatively performed rst to avoid bias related to timing of the scans. The resultant sequences were analyzed by two experienced MR radiologists (OS and MI) each with over 15 years of experience in MR imaging. The analysis was performed on a consensual basis. Using a full screen, 21-inch monitor with 2K resolution (Barco, Mfgd 3420, Brussels, Belgium), enhancing lesions were counted one image at a time on both T1W FSE images and T1W fat-saturated images. A simultaneous comparison between the two sequences was performed. The two radiologists assigned a conspicuity score for each enhancing lesion on both T1W sequences by direct visual comparison between the two corresponding images. A scoring system was used wherein the highest score of three was assigned if the lesion was only

seen or better visualized on T1W fat-saturated images compared to T1W FSE images, the lowest score of one was assigned if the lesion was relatively more difcult to see or not seen on T1W fat-saturated images compared to T1W FSE, and a score of 2 was assigned if the lesion was equally well-seen on both sequences. Statistical analysis of the ndings was performed using McNemar test for quantitative evaluation of the number of lesions.

Results
There were a total of 1069 lesions seen on T2W and Flair images. Out of those, 139 lesions were seen on the postcontrast T1W FSE images in the 70 patients; whereas on post-contrast T1W fat-saturated sequences, 157 lesions were detected, indicating that 18 additional lesions (11.5%) were only seen on the fat-saturated images (Figs. 1 and 2) (Table 1). Additionally there were 15 lesions (9.5 %) that were better seen on the fat saturation sequence (Fig. 3) (Table 2). All the lesions detected on either of the two T1W sequences (157 in total) including the 18 only seen on T1W fat-saturated sequences were evident as hyperintense foci on T2W and Flair images. In scoring the 157 lesions detected, 18 of the lesions were only detected on fatsaturated images (score 3). Four lesions were better seen on T1W FSE images (score 1), and 15 better seen on fatsaturated images (score 3). The remaining 120 lesions were equally well-seen on both the sequences (score 2). By statistical analysis the conspicuity score obtained for all the lesions was 2.24 /20.60 (SD) with P value , 0.0001 by the twotailed McNemar test. In all the patients where a lesion was better seen in one of the two post-contrast sequences (four on T1W FSE and 15 on fat saturated), it was noted that this particular sequence was performed second. Likewise, the 18 lesions detected on fat-saturated images were all seen in patients in whom the

Fig. 1 29-year-old woman with recently diagnosed multiple sclerosis. (a) Axial T1WI demonstrates no denite enhancement. (b) However, the lesion is well visualized on the fat saturation scan adjacent to the posterior part of the left lateral ventricle

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Fig. 2 39-year-old man with known multiple sclerosis for follow-up scan. (a) Gadolinium-enhanced axial T1WI shows no abnormal enhancement. (b) Fat saturation scan reveals clear focal left inferior cerebellar enhancement

fat-saturated sequence was performed after the T1W FSE sequence.

Discussion
In this study, there were 18 (11.5%) lesions of a total of 157 enhancing lesions that were only seen on gadoliniumenhanced fat-saturated T1W images, and 15 (9.5%) additional lesions were better seen on the fat-saturated images compared with regular post-contrast T1W images. The contribution of MR imaging in the diagnosis of MS is well established. The ndings detected on cranial MRI in a clinically suspected case constitute part of the algorithm for initial diagnosis and follow-up (10). Enhancing white matter foci that are indicative of inammatory activity of demyelinating lesions alter the grade and stage of disease (1). They are considered to reect the disruption of the blood brain barrier with a consequent shortening of T1 relaxation time and hyperintensity on the T1-weighted sequence obtained after administration of gadolinium chelates (2, 11). Any technique wherein enhancing lesions are better demonstrated would hence play an important contributory role in the diagnosis and in grading the severity of the disease. There are several techniques that have been studied to improve the visualization of enhancing plaques in multiple sclerosis. These include triple-dose administration of gadolinium (12 16), thin (3 mm) post-contrast sections without spacing (17), magnetization transfer (18 21) and delayed post-contrast imaging (22, 23). Triple-dose contrast administration and the alternate improved technique of three subsequent single doses have been reported to pick up many more lesions but are expensive and may possibly show enhancement that might not be clinically signicant (24). Furthermore, post-contrast non-spaced sections are time consuming. Magnetization transfer images suffer from

pseudo-enhancement (25 27) and would require precontrast MT images to be performed which signicantly increases the time for scanning. Delaying acquisition of images after contrast injection is reported to signicantly increase the visualization of images (22) and could be achieved by performing T2W and air imaging between contrast injection and post-contrast T1W scans. A recent multicenter study in 113 patients (28) with brain lesions concluded that MR imaging with Gadobenate dimeglumine provides signicantly greater diagnostic information and better lesion enhancement compared to Gadodiamide at an equivalent dose. Fat saturation has been attempted before using a 1T magnet and imaging after contrast. Fat saturation is the preferred means of fat suppression when using higher eld magnets (9). The increased detection and conspicuity of lesions on fat-saturated post-contrast images has been attributed to the reduction in signal from lipids in the relatively intact myelin, a MT effect, and the improved overall image contrast due to signal loss of subcutaneous and marrow fat (2). We found signicantly improved detection of lesions in the fat-saturated post-contrast T1W image (33 or 21% of all enhancing lesions are either only seen or more conspicuous) compared with regular post-contrast images. There were 18 lesions that were not identiable on the regular post-contrast images but were seen only on the fat-saturated images. Although our gure (21%) with the 1.5 T scanner is lower, our ndings are in agreement with the results obtained by Sardanelli et al. (2) who reported a 30% increase in the number of lesions on fat-saturated images and improved conspicuity on a 1T MRI magnet. In our study we scheduled the sequences so that each of the two post-contrast sequences were alternately performed rst in our subjects to avoid the potential bias due to the

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Table 1. Enhancing lesions seen on T1W sequences Seen on both T1W FSE and T1W FS 139 Seen only on T1W FS 18 Seen only on T1W FSE 0

Table 2. Conspicuity of lesions on T1W sequences (total number 157) Lesion better seen on T1W FSE than T1W FS 4 Lesion visualization same on TW1 FSE as on T1W FS (score 2) 120 Lesion better (or only) seen on T1W FS than T1W FSE sequence (score 3) 33 (15 18)

T1W FSE T1-weighted fast spin-echo, T1W FS T1-weighted fatsaturated sequence

variable timing of imaging after contrast injection. There was no signicant difference noted in regards to the order of performing the two sequences in the 120 lesions that were equally well seen. However, all the 37 lesions better or only seen on any one of the two sequences (33 better or only seen on fat-saturated images and four better seen on T1W FSE images) were detected on images where the respective sequence was performed second. It should be mentioned that when performed second, the fat-saturated sequence was performed at approximately 5 min and 30 s after contrast (3 min plus 2 min and 30 s for the rst postcontrast sequence) and the T1W FSE was performed at approximately 8 min and 12 s after contrast (3 min plus 5 min and 12 s for the rst post-contrast sequence). The improved detection cannot thus be attributed only to the delayed time of scanning, for then there should have been many more lesions detected on T1W FSE considering that this sequence was performed even later when done second. The delay in scanning does however help and a minimum delay of 5 min after IV contrast as recommended in the current imaging guidelines should be adequate to maximize lesion detection. These ndings correlate with the previously reported nding (22) of better visualization on more delayed imaging. The consortium of MS centers consensus guidelines on MR imaging in multiple sclerosis has also taken note of the fact that delayed imaging does increase lesion conspicuity and number. For this reason they have recommended that the gadolinium-enhanced axial T1W scans be taken 5 min after contrast administration (29).

T1W FSE T1-weighted fast spin-echo, T1W FS T1-weighted fat-saturated sequence

The use of 1.5T magnet in our study is also important as fat saturation is better on higher eld strength as a consequence of decreased artifacts related to magnetic eld in homogeneities when the strength of the magnet is increased while keeping other parameters constant (30). The time for imaging is increased; in our case it was increased from 2 min and 30 s to 5 min and 12 s, which, although signicant, would be less than other approaches like MT imaging and delayed post-contrast scanning. A limitation of the study was that an even more delayed post-contrast scanning was not utilized. We sought to ensure that the second performed post-contrast sequence was taken at least 5 min after IV contrast according to the guidelines of the consortium of MS centers (29). However, several centers currently perform the T2W and air imaging sequence between the contrast injection and postcontrast T1W scans thereby further delaying the time of scanning to approximately 9 10 minutes. This would potentially have increased the yield of enhancing lesions in our study while permitting the total examination time to remain constant. In conclusion, our study revealed that the use of gadolinium-enhanced fat saturation T1W sequence in patients scanned at least 5 min after contrast administration improved the detection and conspicuity of the lesions in patients with MS. T1W fat-saturated post-contrast imaging could constitute an alternative sequence and replace the

Fig. 3 38-year-old woman with remitting-relapsing multiple sclerosis. (a) Gadolinium-enhanced axial T1WI shows very faint small focal enhancement in the right occipital lobe. (b) The lesion is more conspicuous on the gadolinium-enhanced fat-saturated T1WI

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regular post-contrast T1W imaging for better demonstration of lesions and hence could play an important role in the initial diagnosis and follow-up in patients with MS. Conict of interest: None.
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