Diffusion abdominal MRI: comparison between free-

breathing and respiratory-triggered echo planar imaging

sequences

Poster No.: C-2026

Congress: ECR 2015
Type: Scientific Exhibit
Authors: 1 1 1 1
G. Cappello , S. Palmucci , R. O. A. Siverino , G. Attinà , F.
1 1 2 1 1
Roccasalva , M. Piccoli , M. L. Giunta , G. Petrillo ; Catania/IT,
2
Tremestieri Etneo/IT
Keywords: Abdomen, Liver, MR-Diffusion/Perfusion, Comparative studies,
Diagnostic procedure, Technical aspects, Quality assurance
DOI: 10.1594/ecr2015/C-2026

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Page 1 of 18
Aims and objectives

Diffusion weighted sequences are now routine in MR imaging [1]. In fact several studies
have emphasized its role in the detection and characterization of abdominal parenchymal
organ lesions [2-4], in the assessment of hepatic fibrosis [5-7], and in the evaluation of
response to therapy in oncological patients [8, 9].

DW acquisition is influenced by susceptibility and motion artifacts, the latter caused

by breathing and cardiac pulsations (Fig. 1 on page 2) [10]. In order to reduce
these artifacts, DWI could be acquired using different technical approaches. Namely,
four different motion compensation methods are usually employed: breath-hold, free-
breathing, respiratory-triggered and navigator-triggered DW imaging.

In clinical practice most patients are not able to hold their breath for up to 20 seconds,
so that the triggered sequences or free-breathing sequences are mostly used.

Different studies have pointed out that ADC values have different repeatability and
reproducibility. Therefore, several methods have been proposed in order to standardize
the technique of measurement especially in the evaluation of hepatic disease [11].

In view of these considerations, the goal of this study is:

• to compare Apparent Diffusion Coefficient (ADC) measurements obtained

by free-breathing and respiratory-triggered techniques, evaluating their
reproducibility in abdominal parenchymal organs;
• to evaluate overall visual/image quality of mentioned DWI sequences.

Images for this section:

Page 2 of 18
Fig. 1: Axial diffusion-weighted single-shot echo-planar images with parallel imaging and
fat saturation illustrating possible artifacts in DW imaging. In figure a, respiratory artifact is
demonstrated by double-edged liver and spleen (arrows), due to misregistration. In figure
1b, cardiac pulsation artifact is showed, with consequent left liver signal loss (arrows)
and cardiac ghost outside the abdomen (arrowheads).

Page 3 of 18
Methods and materials

This study was approved by our internal institutional committee. From April to August
2014, twenty-seven patients (15 men and 12 women; mean age 59 years; range 21-82
years) were enrolled for abdominal MR examination. Written informed consent was
obtained from all patients.

13 patients were studied for chronic liver disease or hepatocellular carcinoma (HCC), 10
patients underwent MRI to characterize focal liver lesions, one patient was analyzed to
stage renal cancer, 3 patients were scanned for metastatic cancer staging.

Patients were examined with a 1.5 Tesla (T) MR scanner (Signa HDxt; GE Healthcare,
Milwaukee), with an eight channel dedicated phased-array coil.

Study protocol

DW triggered sequences were acquired during end-expiration phase using a respiratory

trigger belt, fixed to the hypocondral region. Single-shot echo planar (SS-EP) imaging
was performed with ASSET (array spatial sensivity encoding technique) imaging, with
active diffusion gradient in every plane direction. DWI sequences were acquired with b-
values of 0-500 and 0-800.

For respiratory-triggered diffusion sequences, acquisition parameters (Fig. 2 on page

5) were: TR=1R-R, TE=70-77 ms (respectively for b=500 e b=800), EPI factor=80,
slice thickness 5 mm, gap 1 mm, flip angle=90, acceleration factor = 2, FOV 32-44
cm, NSA=2, half scan-factor=2, bandwidth=250KHz, scan percentage=100%, acquisition
voxel=N/A, reconstruction voxel=N/A, acquisition matrix 160x160, reconstruction matrix=
256x256, spatial fat saturation= Yes -Water Excitation, isotropic motion gradient= SI, RL
and AP with Stejskal-Tanner Diffusion scheme.

For free-breathing diffusion sequences, acquisition parameters diverge from triggered

only for TR (=3000 ms) and NSA (=4).

Imaging analysis and statistical technique

Quantitative ADC maps were derived automatically on a voxel-by-voxel basis using

Advantage workstation VolumeShare 5 GE Healthcare.

Images were retrospectively evaluated for ADC assessment in both sequences. Namely,
ADC values were obtained placing ROI of 1 cm in the following anatomical regions (Fig.
3 on page 6): left liver lobe, right liver lobe, spleen and right kidney.

Page 4 of 18
Wilcoxon matched pairs signed rank test was performed to compare ADC measurements
obtained with both techniques. Pearson ADC correlation was also assessed.

A qualitative analysis was performed by two independent observers, in order to

compare image quality obtained by the two different diffusion modalities. The quality of
visualization was evaluated according to the following 4-point scale:

1-poor quality: several artifacts with severe image quality degradation.

2-fair quality: substantial artifacts in one of studied abdominal organ.

3-good quality: few artifacts.

4-excellent quality: no artifacts at all.

A Student's t-test was performed to compare qualitative score between respiratory

triggered and free breathing images at b-500 and b-800 for both observers.

A Cohen's kappa coefficient was calculated to measure inter-observer agreement.

Images for this section:

Page 5 of 18
Fig. 2: The table illustrates parameters used in b500 and b800 diffusion-weighted single-
shot echo-planar sequences acquired with triggered and free-breathing techniques.

Page 6 of 18
Fig. 3: ADC maps obtained from diffusion-weighted single-shot echo-planar images.
Figures show examples of ROI (Region of Interest) placed in left liver (II-III segment on
figure a and IV segment on figure b), in right liver (c), in anterior (d) and posterior (e)
portions of spleen and in right kidney (f).

Page 7 of 18
Results

One patient was excluded for motion artifacts.

For statistical analysis, a p-value of 0.05 or less was defined as significant.

Using Wilcoxon test, no statistically significant difference (p= 0.76) was reported between
free breathing and respiratory triggered techniques, in diffusion MR sequences acquired
with b=0-500 (Fig. 4 on page 8).

Also for diffusion MR sequences acquired with b=0-800, no statistically significant

difference (p= 0.79) was observed between the two modalities (Fig. 5 on page 9).

High Pearson correlations (Fig. 6 on page 10; Fig. 7 on page 11) between
sequences in both modalities were also found (0.76 for b-500 values and 0.90 for b-800
values).

For the qualitative assessment (Fig. 8 on page 12), a statistically significant better
performance was found for free-breathing images (p<0.05) for both b=500 and b=800,
using Student's t-test.

High interobserver agreement (k>0.85) was found adopting Cohen's kappa coefficient.

Images for this section:

Page 8 of 18
Fig. 4: Graphic representation of Wilcoxon for b=500 DW sequences. Wilcoxon test
reported no statistically significant difference (p= 0.76) for ADC measurements between
free breathing and respiratory-triggered techniques.

Page 9 of 18
Fig. 5: Graphic representation of Wilcoxon test for b=800 DW sequences. The test
reported no statistically significant difference (p= 0.79) for ADC measurements between
free breathing and respiratory-triggered techniques.

Page 10 of 18
Fig. 6: Scatter plot of ADC values obtained with b=500 DW sequences. Graphic shows
high correlation between ADC values obtained through the two techniques.

Page 11 of 18
Fig. 7: Scatter plot of ADC values in b=800 DW sequences. Graphic indicates high
correlation between ADC values obtained through the two techniques.

Page 12 of 18
Fig. 8: Qualitative assessment of the two techniques analyzed by two separated
operators (first operator in a and b; second operator in c and d). Both operators found
a statistically significant better performance for free-breathing images for both b=500 (a,
c) and b=800 (b, d) DW sequences.

Page 13 of 18
Conclusion

Although breath-hold DW sequences are more rapid than triggered or free-breathing

sequences, the latter are currently more frequently performed in order to improve image
quality because patients are often uncooperative (obesity, old age, hearing defects,
respiratory or cardiac problems) [12].

Respiratory-triggered sequences allow for high-quality images in patients with low-

compliance for the exam [13, 14], but patients need regular breathing in order to
synchronize images acquisition with respiratory trigger.

Free-breathing echo-planar sequences do not have this limit and can also be used in
patients with irregular breathing, using some expedients that permit improved image
quality. High signal averages or number of excitations are generally able to increase
the signal-to-noise ratio and reduce motion artifacts on images [15]. In addition, an
incremented number of excitations (NEX) increase the possibility of data acquisition
during diastole, reducing pulsation artifacts using only respiratory trigger [16].

Comparison of triggered and free-breathing sequences has been already discussed

in different studies with controversial opinions: Nasu et al. found a higher ADC
measurement accuracy with respiratory trigger than in free-breathing modality [16].
However, ADC measurements were not statistically different using both acquisition
modalities; Kwee et al. found statistically significative higher ADC values for respiratory
triggered acquisitions than breath-hold and free breathing modalities [17]. Furthermore
Chen et al. found better reproducibility and briefer acquisition time for free-breathing
technique [12].

In our study, quantitative analysis of ADC values did not show any significant difference
between acquisition techniques. Free breathing technique reported high image quality
score and therefore could be used in patients with irregular respiratory gating.

Results of our study agree with the experience reported by Choi et al [18], although
they used 3T scanner for their study. No statistical difference was reported between
the different techniques for ADC measurements, even though our qualitative analysis
significantly favors free-breathing sequences.

Unfortunately, number of enrolled patients in our study is quite low. Therefore further
patients are needed in order to obtain a more reliable statistical analysis.

Personal information

Giuseppina Cappello, MD

Page 14 of 18
giuseppina.cappello@gmail.com

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

Stefano Palmucci, MD

spalmucci@sirm.org

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

Rita Olivia Anna Siverino, MD

ritasi84@hotmail.it

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico-Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

Giancarlo Attinà, MD

gianco82t@hotmail.it

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

Federica Roccasalva, MD

f.roccasalva@gmail.com

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Page 15 of 18
Via Santa Sofia 78 - 95123, Catania - Italy

Marina Piccoli, MD

p.mari4@hotmail.it

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

Maria Luisa Giunta, MD

marialuisagiunta@gmail.com

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

Giuseppe Petrillo, Professor

pucciopetrillo@hotmail.com

Radiodiagnostic and Radiotherapy Unit

University Hospital "Policlinico- Vittorio Emanuele"

Via Santa Sofia 78 - 95123, Catania - Italy

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