Dynamic susceptibility weighted contrast enhanced perfusion imaging

see also Relative cerebral blood volume from Dynamic susceptibility weighted contrast enhanced perfusion imaging.

Dynamic-susceptibility contrast (DSC) MRI, also known as bolus-tracking MRI, is a perfusion MRI method to measure perfusion and other related hemodynamic parameters.

It is shown that DSC-MRI is a very powerful technique that provides important information regarding cerebral hemodynamics.

Dynamic susceptibility weighted contrast enhanced perfusion imaging (DSC MRP) has been used to assess changes in cerebral perfusion attributable to vascular stenosis or occlusion that may predict stroke risk.

It is one of the most frequently used techniques for MRI perfusion, and relies on the susceptibility induced signal loss on T2* weighted sequences which results from a bolus of gadolinium-based contrast passing through a capillary bed. The most commonly calculated parameters are rCBV, rCBF and MTT.

The relatively high contrast-to-noise ratio, fast acquisition, and wealth of information available have made DSC-MRI the most commonly used MRI technique for the rapid assessment of the brain hemodynamics in clinical investigations. While very important advances have been achieved in the last 2 decades, there are still some remaining limitations that users should be aware of to avoid misinterpretation of the findings and to make the most of the invaluable information provided by perfusion MRI 1).

Hilario et al retrospectively analyzed DSC perfusion MRI in 24 Glioblastoma recurrences treated with bevacizumab as second line chemotherapy. Leakage at baseline and changes in maximum leakage between baseline and the first follow-up after treatment were selected for quantitative analysis. Survival univariate analysis was made constructing survival curves using Kaplan-Meier method and comparing subgroups by log rank probability test.

Leakage reduction at 8 weeks after initiation of bevacizumab treatment had a significant influence on overall survival (OS) and progression-free survival (PFS). Median OS and PFS were 2.4 and 2.8 months longer for patients with leakage reduction at the first follow-up. Higher leakage at baseline was associated with leakage reduction after treatment. Odds ratio of treatment response was 9 for patients with maximum leakage at baseline >5.

Leakage decrease may predict OS and PFS in Glioblastoma recurrences treated with bevacizumab. Leakage reduction postulates as a potential biomarker for treatment response evaluation. Leakage at baseline seems to predict response to treatment, but was not independently associated with survival 2).

CNS toxoplasmosis and lymphoma are often indistinguishable by conventional contrast-enhanced MRI. There is limited literature on the diagnostic efficacy of dynamic susceptibility weighted contrast enhanced perfusion imaging for differentiating these entities. A study assesses the clinical utility of relative cerebral blood volume (rCBV) for making a diagnosis and determines rCBV thresholds for differentiation using contemporary DSC-MRI.

Thirteen patients with 25 lesions (13 toxoplasmosis and 12 lymphoma) and pre-treatment DSC-MRI were identified retrospectively. Volumetric regions of interest of segmented enhancement were used to extract mean rCBV normalized to normal-appearing white matter for each lesion.

They compared average mean rCBV between all toxoplasmosis and lymphoma lesions using a general mixed model. Three models were also compared for evaluating rCBV-based disease status in each patient: 1) mean rCBV of each lesion using a generalized estimating equation, 2) volume-weighted mean rCBV, and 3) maximum mean rCBV of all lesions using logistic regression.

The average mean rCBV for all toxoplasmosis lesions was 0.98 (95% CI 0.55-1.41) compared to 2.07 (95% CI 1.71-2.43) for all lymphoma lesions, a significant difference (1.09, 95% CI 0.53-1.65, p=0.0013). For the three models used to evaluate rCBV-based disease status in each patient, a significant relationship was observed, with an optimal rCBV threshold of approximately 1.5 for distinguishing lymphoma from toxoplasmosis in each model.

RCBV derived from contemporary DSC-MRI is helpful for distinguishing between cerebral toxoplasmosis and cerebral lymphoma on an individual patient basis and may facilitate more timely initiation of appropriate directed therapy 3).

Calamante F. Perfusion MRI using dynamic-susceptibility contrast MRI: quantification issues in patient studies. Top Magn Reson Imaging. 2010 Apr;21(2):75-85. doi: 10.1097/RMR.0b013e31821e53f5. Review. PubMed PMID: 21613873.
Hilario A, Sepulveda JM, Hernandez-Lain A, Salvador E, Koren L, Manneh R, Ruano Y, Perez-Nuñez A, Lagares A, Ramos A. Leakage decrease detected by dynamic susceptibility-weighted contrast-enhanced perfusion MRI predicts survival in Glioblastoma recurrence treated with bevacizumab. Clin Transl Oncol. 2016 Mar 30. [Epub ahead of print] PubMed PMID: 27026567.
Dibble EH, Boxerman JL, Baird GL, Donahue JE, Rogg JM. Toxoplasmosis versus lymphoma: Cerebral lesion characterization using DSC-MRI revisited. Clin Neurol Neurosurg. 2016 Dec 2;152:84-89. doi: 10.1016/j.clineuro.2016.11.023. [Epub ahead of print] PubMed PMID: 27940418.
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