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An echo-planar imaging sequence is superior to a steady-state free precession sequence for visual as well as quantitative assessment of cardiac magnetic resonance stress perfusion
Department of Radiology, Ryhov County Hospital, Jönköping.
Department of Radiology, Ryhov County Hospital, Jönköping / Department of Clinical Physiology, Karolinska University Hospital, Stockholm.
Department of Clinical Physiology, Kalmar County Hospital, Kalmar.
Department of Natural Science and Biomedicine, School of Health Sciences, Jönköping University / Department of Oncology, Hospital Physics, Ryhov County Hospital, Jönköping.
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2015 (English)In: Clinical Physiology and Functional Imaging, ISSN 1475-0961, E-ISSN 1475-097XArticle in journal (Refereed) Epub ahead of printText
Abstract [en]

Background To assess myocardial perfusion, steady-state free precession cardiac magnetic resonance (SSFP, CMR) was compared with gradient-echo–echo-planar imaging (GRE-EPI) using myocardial perfusion scintigraphy (MPS) as reference. Methods Cardiac magnetic resonance perfusion was recorded in 30 patients with SSFP and in another 30 patients with GRE-EPI. Timing and extent of inflow delay to the myocardium was visually assessed. Signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were calculated. Myocardial scar was visualized with a phase-sensitive inversion recovery sequence (PSIR). All scar positive segments were considered pathologic. In MPS, stress and rest images were used as in clinical reporting. The CMR contrast wash-in slope was calculated and compared with the stress score from the MPS examination. CMR scar, CMR perfusion and MPS were assessed separately by one expert for each method who was blinded to other aspects of the study. Results Visual assessment of CMR had a sensitivity for the detection of an abnormal MPS at 78% (SSFP) versus 91% (GRE-EPI) and a specificity of 58% (SSFP) versus 84% (GRE-EPI). Kappa statistics for SSFP and MPS was 0·29, for GRE-EPI and MPS 0·72. The ANOVA of CMR perfusion slopes for all segments versus MPS score (four levels based on MPS) had correlation r = 0·64 (SSFP) and r = 0·96 (GRE-EPI). SNR was for normal segments 35·63 ± 11·80 (SSFP) and 17·98 ± 8·31 (GRE-EPI), while CNR was 28·79 ± 10·43 (SSFP) and 13·06 ± 7·61 (GRE-EPI). Conclusion GRE-EPI displayed higher agreement with the MPS results than SSFP despite significantly lower signal intensity, SNR and CNR.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015.
Keyword [en]
cardiac imaging techniques, coronary heart disease, Magnetic Resonance Imaging, nuclear medicine, perfusion
National Category
Radiology, Nuclear Medicine and Medical Imaging Medical Laboratory and Measurements Technologies Medical Image Processing Clinical Medicine
URN: urn:nbn:se:liu:diva-130795DOI: 10.1111/cpf.12267PubMedID: 26147785OAI: diva2:955017
Available from: 2016-08-24 Created: 2016-08-24 Last updated: 2016-09-01Bibliographically approved
In thesis
1. Magnetic Resonance Imaging of the Heart: Image quality, measurement accuracy and patient experience
Open this publication in new window or tab >>Magnetic Resonance Imaging of the Heart: Image quality, measurement accuracy and patient experience
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Non-invasive diagnostic imaging of atherosclerotic coronary artery disease (CAD) is frequently carried out with cardiovascular magnetic resonance imaging (CMR) or myocardial perfusion single photon emission computed tomography (MPS). CMR is the gold standard for the evaluation of scar after myocardial infarction and MPS the clinical gold standard for ischemia. Magnetic Resonance Imaging (MRI) is at times difficult for patients and may induce anxiety while patient experience of MPS is largely unknown.

Aims: To evaluate image quality in CMR with respect to the sequences employed, the influence of atrial fibrillation, myocardial perfusion and the impact of patient information. Further, to study patient experience in relation to MRI with the goal of improving the care of these patients.

Method: Four study designs have been used. In paper I, experimental cross-over, paper (II) experimental controlled clinical trial, paper (III) psychometric crosssectional study and paper (IV) prospective intervention study. A total of 475 patients ≥ 18 years with primarily cardiac problems (I-IV) except for those referred for MRI of the spine (III) were included in the four studies.

Result: In patients (n=20) with atrial fibrillation, a single shot steady state free precession (SS-SSFP) sequence showed significantly better image quality than the standard segmented inversion recovery fast gradient echo (IR-FGRE) sequence (I). In first-pass perfusion imaging the gradient echo-echo planar imaging sequence (GREEPI) (n=30) had lower signal-to-noise and contrast–to-noise ratios than the steady state free precession sequence (SSFP) (n=30) but displayed a higher correlation with the MPS results, evaluated both qualitatively and quantitatively (II). The MRIAnxiety Questionnaire (MRI-AQ) was validated on patients, referred for MRI of either the spine (n=193) or the heart (n=54). The final instrument had 15 items divided in two factors regarding Anxiety and Relaxation. The instrument was found to have satisfactory psychometric properties (III). Patients who prior CMR viewed an information video scored significantly (lower) better in the factor Relaxation, than those who received standard information. Patients who underwent MPS scored lower on both factors, Anxiety and Relaxation. The extra video information had no effect on CMR image quality (IV).

Conclusion: Single shot imaging in atrial fibrillation produced images with less artefact than a segmented sequence. In first-pass perfusion imaging, the sequence GRE-EPI was superior to SSFP. A questionnaire depicting anxiety during MRI showed that video information prior to imaging helped patients relax but did not result in an improvement in image quality.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016. 74 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1524
National Category
Radiology, Nuclear Medicine and Medical Imaging Medical Image Processing Cardiac and Cardiovascular Systems Medical Laboratory and Measurements Technologies Family Medicine
urn:nbn:se:liu:diva-130796 (URN)10.3384/diss.diva-130796 (DOI)9789176857427 (Print) (ISBN)
Public defence
2016-09-30, Originalet, Qulturum, Hus B4, Länssjukhuset Ryhov, Jönköping, 09:00 (Swedish)
Available from: 2016-08-24 Created: 2016-08-24 Last updated: 2016-08-29Bibliographically approved

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Ahlander, Britt-MarieMaret, EvaEngvall, Jan
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Division of Cardiovascular MedicineCenter for Medical Image Science and Visualization (CMIV)Faculty of Medicine and Health SciencesDepartment of Clinical Physiology in Linköping
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Clinical Physiology and Functional Imaging
Radiology, Nuclear Medicine and Medical ImagingMedical Laboratory and Measurements TechnologiesMedical Image ProcessingClinical Medicine

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