Multimodality Imaging Evaluation Research Articles

The Role of Cardiac Magnetic Resonance Imaging in the Evaluation of Congenital Pericardial Defects

Pericardial defects are rare congenital anomalies that result from failure of the pericardium to form properly during embryogenesis. In this article, we present a case of a patient with persistent atrial fibrillation who underwent a multimodality imaging evaluation that included cardiac magnetic resonance imaging. Our patient demonstrated secondary signs of a partial defect that was not directly visualized on imaging and was ultimately diagnosed during open surgical intervention. This case illustrates that a high level of suspicion should be maintained for patients who demonstrate secondary imaging findings that suggest the presence of an underlying pericardial defect. Magnetic resonance imaging is the preferred modality for evaluating the pericardium, because of its ability to image the heart in any plane, improved soft tissue contrast compared with computed tomography, and lack of radiation exposure to the patient. However, direct visualization may be limited by patient-specific factors, such as paucity of pericardial fat and the size and location of the defect. In such cases, surgical evaluation may be necessary.

Multimodality imaging evaluation of esophageal cancer: staging, therapy assessment, and complications

Esophageal cancer is among the leading causes of cancer-related deaths worldwide. The management of patients with esophageal cancer is determined to a large extent by patient performance status, location of the primary cancer, and stage of disease at presentation. Multimodality regimens combining neoadjuvant chemotherapy and/or radiotherapy followed by surgery have been increasingly used in suitable candidates with locally advanced cancer. There is substantial morbidity and mortality associated with this treatment strategy, which makes appropriate patient selection important. Endoscopic esophageal ultrasound is the optimal modality to evaluate the local extent of the primary tumor and diagnose locoregional nodal metastasis. Computed tomography is more useful in detecting distant nodal and systemic metastasis. Positron emission tomography/CT is increasingly being used in patient management and improves the accuracy of staging, particularly in the detection of distant nodal and systemic metastatic disease. In this article, we review the role of imaging in the staging, assessment of therapeutic response, and detection of recurrent disease, as well as the evaluation of therapeutic complications in patients with esophageal cancer.

Evaluation of multimodal imaging in carriers of X-linked retinitis pigmentosa

The aim of this study was to investigate visualization of the tapetal-like reflex using current imaging modalities and evaluate SD-OCT changes in known carriers of X-linked retinitis pigmentosa (XLRP); the objective being the development of an optimal protocol for clinicians to identify carriers. Ten XLRP carriers (19 eyes) were examined using color fundus photography, 488 nm reflectance (488-R), near-infrared reflectance (NIR-R), autofluorescence (AF) and spectral domain optical coherence tomography (SD-OCT) imaging (Spectralis SLO-OCT, Heidelberg). Horizontal line scans through the fovea were acquired in all subjects and in a group of 10 age-similar controls. Peripheral SD-OCT scans (extending to 27.5° eccentricity) were also acquired in both eyes of 7 carriers. MP-1 microperimetery (10-2 pattern; Nidek) was performed in one eye of each carrier. For the XLRP carriers, a tapetal reflex was observed with all imaging modalities in 8 of 19 eyes. It had the same retinal location on color fundus, 488-R and NIR-R imaging but a different location on AF. The tapetal reflex was most easily detected in 488-R images. The horizontal foveal SD-OCT scans were qualitatively normal, but measurements showed significant outer retinal layer thinning in all eyes. Additionally, the 14 eyes with peripheral SD-OCTs demonstrated patchy loss of the inner segment ellipsoid band. Microperimetry exhibited patchy visual sensitivity loss in 9 eyes. Full field ERGs were variable, ranging from normal to severely abnormal rod and cone responses. Our findings suggest that an optimal protocol for identifying carriers of XLRP should include 488-R imaging in a multimodal approach. Peripheral SD-OCT imaging and central retinal layer quantification revealed significant structural abnormalities.

Multimodality Imaging Evaluation of Functional and Clinical Benefits of Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion Lesion

Aims: To determine the effects of percutaneous coronary intervention (PCI) on cardiac perfusion, cardiac function, and quality of life in patients with chronic total occlusion (CTO) lesion in left anterior descending (LAD) coronary artery.Methods and Results: Patients (n=99) with CTO lesion in the LAD coronary artery who had successfully undergone PCI were divided into three groups based on the SPECT/CTCA fusion imaging: (a) no severe cardiac perfusion defects (n=9); (b) reversible cardiac perfusion defects (n=40); or (c) fixed cardiac perfusion defects (n=50). No statistical difference of perfusion abnormality was observed at 6 months and 1 year after PCI in group (a). In group (b), SPECT/CTCA fusion imaging demonstrated that cardiac perfusion abnormality was significantly decreased 6 month and 1 year after PCI. Left ventricular ejection fraction (LVEF) increased significantly at 6 months and 1 year follow up. Quality of life improved at 6 months and 1 year after PCI procedure. Moreover, patients in group (c) also benefited from PCI therapy: a decrease in cardiac perfusion abnormality, an increase in LVEF, and an improvement in quality of life. PCI of coronary arteries in addition to LAD did not significantly affect cardiac function and quality of life improvement in each group.Conclusions: PCI exerts functional and clinical benefits in patients with CTO lesion in LAD coronary artery, particularly in patients with reversible cardiac perfusion defects. SPECT/CTCA fusion imaging may serve as a useful tool to evaluate the outcomes of patients with CTO lesion in LAD coronary artery.

E0469 Multimodality imaging evaluation of functional and clinical benefits of percutaneous coronary intervension on patients with chronic total occlusion lesion

AimsTo determine the effects of percutaneous coronary intervension (PCI) on cardiac perfusion, cardiac function and quality of life in patients with chronic total occlusion (CTO) lesion in left anterior descending...

Imaging and atrial fibrillation: the role of multimodality imaging in patient evaluation and management of atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and is associated with an increased risk of cardiac morbidity and mortality. In this review, the role of multimodality imaging in the evaluation and treatment of AF is discussed in two main parts. First, an overview of the initial assessment of an AF patient is provided, including the role of different imaging techniques. Conditions that are associated with AF (coronary artery disease, heart failure, valvular heart disease, and left ventricular hypertrophy), and the assessment with various imaging modalities, will be reviewed. Furthermore, left atrial size assessment and the screening for thrombus formation are addressed. Secondly, the role of imaging in the invasive treatment of AF with catheter ablation is reviewed. Issues that should be considered before the procedure including contra-indications and pulmonary vein and left atrial anatomy will be discussed. Furthermore, the integration of different imaging modalities during catheter ablation is explored. Finally, an overview of the role of imaging in the follow-up of patients treated with catheter ablation will be provided.

Gallbladder Carcinoma Update: Multimodality Imaging Evaluation, Staging, and Treatment Options

The purpose of this article is to review the epidemiology, multimodality imaging findings, differential diagnosis, pathologic staging, and current treatment options of gallbladder carcinoma. Understanding the characteristic appearances of primary gallbladder carcinoma at multiple imaging modalities can facilitate diagnosis and enable more accurate staging for triage to extended resection or an alternate therapy.

Superficial Siderosis

Superficial siderosis of the central nervous system results from hemosiderin deposition in the subpial layers of the brain and spinal cord. A clinical history of subarachnoid hemorrhage is often absent. Patients present with slowly progressive gait ataxia and sensorineural hearing impairment. A history of prior intradural surgery or trauma is common. With widespread use of magnetic resonance imaging, presymptomatic cases are being diagnosed and it is difficult to be certain about the true incidence of this disorder. Despite extensive investigations, the cause of bleeding is often not apparent. An intraspinal fluid-filled collection is a common accompaniment and may be the likely bleeding source. An early diagnosis and prompt intervention directed at removal of the bleeding source may prevent progression. This review discusses the role of multimodality imaging in evaluation of superficial siderosis and the therapeutic implications of identified associations.

TU‐C‐330D‐02: Digital Breast Tomosynthesis

Both film‐screen and digital mammography are subject to a number of fundamental limitations related to the projection process, whereby 2D images are produced of the 3D breast anatomy. Mammography can produce artifactual densities from the superposition of normal tissues that are separated in space; although only visible in a single view, these often appear sufficiently suspicious to necessitate a biopsy, leading to a loss in specificity. Furthermore, true lesions in mammograms can be masked by superimposed normal tissue and thereby rendered undetectable; this reduces the sensitivity of mammography.Numerous tomographic methods have been proposed to overcome these limitations, including digital breast tomosynthesis (DBT). DBT is a tomographic imaging technique in which a set of tomographic images can be reconstructed from a limited number of x‐ray projection images. DBT has the potential to mitigate against both the superposition of non‐adjacent tissue (false positive densities) and the masking of real lesions (false negatives) observed in projection mammography, while also providing a simple means of localizing lesions in 3D. A preliminary retrospective study of breast tomosynthesis by Rafferty et al. has demonstrated a 16% increase in sensitivity and 85% decrease in false positives as compared to digital mammography. Our own experience at the University of Pennsylvania with 51 patients has provided supported anecdotal evidence.DBT also offers the potential for functional imaging. Breast tumor growth and metastasis are accompanied by the development of new blood vessels. We have used a modified GE 2000D under IRB approval, to gain initial experience in contrast‐enhanced DBT (CE‐DBT). To date we have acquired 13 CE‐DBT clinical cases. Suspicious enhancing lesions were demonstrated with CE‐DBT in 10 of 11 cases of pathology‐proven breast cancer. The cases illustrated that CE‐DBT could provide information in concordance with multimodality imaging evaluation. The pre‐contrast tomosynthesis images demonstrated lesion morphology and border characteristics in greater detail than the digital mammography images, and the CE‐DBT data sets demonstrated vascular characteristics of the breast lesions of interest that were consistent with the vascular information provided by MR. In addition, quantitative evaluation of contrast uptake is anticipated to be more easily standardized with CE‐DBT due to the linear relationship between attenuation and contrast concentration compared to MRI.In this presentation, the following education objectives will be addressed:1. Review the development and design of digital breast tomosynthesis systems.2. Evaluate the results of the existing DBT clinical trials.3. Examine advanced applications of DBT including contrast‐enhanced DBT and CAD.4. Compare DBT to other x‐ray tomographic imaging modalities.

Multimodality Imaging Evaluation of the Pediatric Neck: Techniques and Spectrum of Findings

Neck masses are a common finding in children and can present a difficult diagnostic challenge. These masses may represent a variety of conditions having a congenital, acquired inflammatory, neoplastic, or vascular origin. The fascial spaces and compartments of the neck provide an approach to differential diagnosis, and extensive knowledge of the anatomy and contents of each cervical compartment is mandatory in the diagnosis of pediatric neck lesions. Several imaging techniques, including radiography, gray-scale and Doppler ultrasonography, conventional and three-dimensional computed tomography, magnetic resonance (MR) imaging, and MR angiography, have been proposed for the evaluation of such lesions, and each has its own advantages and limitations. The imaging findings in 120 children who had been referred or treated for cervical lesions were retrospectively reviewed, and a systematic multimodality imaging approach to pediatric neck lesions based on the involvement of anatomic compartments of the cervical region was developed to increase diagnostic efficiency. Careful attention to clinical history and physical examination findings, along with knowledge of the embryologic features and anatomy of the cervical region and a multimodality imaging approach, is very helpful in the diagnosis and management of pediatric neck lesions.

A study of multi-modality imaging for three-dimensional radiotherapy treatment planning of brain tumors

Integration of information from multiple imaging modalities like CT/MRI/SPECT/PET helps in management of cancer, from tumor detection to assessment of treatment efficacy since each imaging modality provides unique information about the tumor and normal structures. This Ph.D. study has been aimed at evaluation of multi-modality imaging in target localization and radiation treatment planning in patients with malignant glioma undergoing radiotherapy. Variations of gross tumor and the edema volumes delineated by a radiologist on CT and MRI scans were addressed. These scans were registered and transferred to the treatment planning system (TPS) using Windows based automatic image registrationsoftware developed in house using AIR routines (Roger Woods, UCLA). QA tests were designed and tested for the 3D automatic target expansion algorithm of the treatment planning system. The influences of variation of target volumes in CT and MRIimages on cumulative dose distribution were also analyzed.Software for quantitative analysis of DVHs has been developed (for Isis-3D TPS) and results showed the importance of incorporation of targets from multiple imaging modalities. A novel approach to study the radiation-induced changes in normal appearing white matter (NAWM) using T2 and magnetization transfer ratio (MTR) maps was developed. The study demonstrated dose-dependent changes of the MTR values and reversal of MTR values seen for doses Gy . However, the T2 maps did not show any dose depended changes within the time period studied. The following in-house software tools were developed to accomplish various tasks of the thesis work: (a) Windows based automatic image registration (AIR) of multi-modality images suitable for radiotherapy planning, (b) to preprocess “bitmap” images from film scanner suitable for AIR software, (c) to transfer registered “tiff” images into the Isis-3D planning system, (d) quantitative analysis of DVH curves generated by the Isis-3D system, and (e) quantitative analysis of sequential MRI scans to generate and analyze T2, MTR, and ADC maps. These software tools, along with source codes, can be freely supplied upon request to the author.