Clinically applicable objective diagnosis of Ménière's disease by MR: How "to do" it

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1 Clinically applicable objective diagnosis of Ménière's disease by MR: How "to do" it Poster No.: C-0488 Congress: ECR 2013 Type: Authors: Keywords: DOI: Educational Exhibit S. Naganawa, M. Yamazaki, H. Kawai, T. Nakashima; Nagoya/JP Image registration, Drugs / Reactions, Diagnostic procedure, MR, Neuroradiology brain, Head and neck, Ear / Nose / Throat /ecr2013/C-0488 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Learning objectives To illustrate the easy and clinically appreciable MR method for the objective diagnosis of Ménière's disease. To outline pulse sequence tips, image processing techniques, image interpretation guideline. To review this e-poster, viewers can begin the objective diagnosis of Ménière's disease at their hospitals. Background Ménière's disease is an abnormality of the inner ear causing vertigo attacks, fluctuating hearing loss, tinnitus, and ear fullness. Prevalence: 35-48/100,000 Average age of onset: 50 years old Conventional diagnosis of Ménière's disease: a detailed medical history interview, a physical examination, hearing and balance tests. Pathology of Ménière's disease is endolymphatic hydrops. There has been no objective diagnostic tool for Ménière's disease. Diagnosis by MRI begun with intratympanic Gd-DTPA injection in Perilymph is preferentially enhanced after IV-Gd. In human, labyrinthine fluid is enhanced most intensely at 4 hours after single dose IV-Gd (Naganawa S, et al. Eur Radiol Mar;16(3): )(Fig. 1) The methods were developed as shown below; Intratympanic Gd injection+3d-flair, Laryngoscope 2007 # Intratympanic Gd injection+3d-real IR, European Radiology 2008 # Page 2 of 12

3 Double dose IV-Gd+3D-FLAIR, Acta Oto, 2010 # Single dose IV-Gd+heavily T2w-3D-FLAIR, MRMS, 2012 # HYDROPS image processing, MRMS, 2012 Images for this section: Fig. 1: A 48-year-old man with right Ménière's disease. After single-dose intravenous (iv) Gd-DTPA injection, perilymph signal gradually increases. After 3.5 or 4 hours of iv-gd, EH (endolymphatic hydrops) can be recognized. VIII, eighth nerve Right lower corner image is heavily T2-weighted MR cisternography. Page 3 of 12

4 Imaging findings OR Procedure details MR scan protocol parameters at 3T using 32ch head coil are as follows (Fig. 2); -(1) Heavily (h) T2-weighted 3D-FLAIR using SPACE (positive perilymph image; PPI); axial slab, TR9000/eTE544/TI2250, SPACE with constant flip angle of 120, ETL 173x3, GRAPPA x2, fat sat, 0.47x0.47x1.0mm, 14.3min scan time. -(2) Positive perilymph image (PEI); identical as (1) except TI. TI of 2050ms is applied to suppress the Gd containing perilymph. -(3) MR cisternography by heavily T2-weighted SPACE (T2) for anatomical reference of total lymph space; Same slab and resolution as (1), TR4400/eTE544, restore pulse, 3min scan time. Total scan time is less than 40 min. All images are obtained 4 hours after single dose iv-gd-dtpa injection. Image processing techniques for the generation of HYDROPS image are shown on Fig. 3 and Fig. 4. HYDROPS= PPI-PEI (Fig. 5) HYDROPS image allows the clear separation of endolymph and bone, however those are siminalr zero signal on PPI. Grading scale on MRI is shown on Fig. 6 and Fig. 7. Images for this section: Page 4 of 12

5 Fig. 2: Scan parameters and corresponding image examples. (1) ht2w-3d-flair (positive perilymph image, PPI) (2) PEI (positive endolymph image) (3) heavily T2- weighted MR cisternography (T2) Page 5 of 12

6 Fig. 3: This image illustrate how to process the images to generate HYDROPS image. Subtraction of PEI from PPI produces HYDROPS image. Page 6 of 12

7 Fig. 4: Lower image is an example of HYDROPS image. On HYDROPS image, border between bone and endolymph is clear. On PPI, both bone and endolymph show zero signal. Page 7 of 12

8 Fig. 5: A 75-year-old woman with the suspect of left side Ménière's disease. Images were obtained 4 hours after iv-single dose Gd-DTPA injection. HYDROPS image clearly shows the severely enlarged endolymphatic space in cochlea and vestibule as black area. Page 8 of 12

9 Fig. 6: MR imaging Grading criteria of endolymphatic hydrops. Page 9 of 12

10 Fig. 7: Example images for the grading of endolymphatic hydrops. Page 10 of 12

11 Conclusion Objective diagnosis of Ménière's disease(eh; endolymphatic hydrops) is now feasible with clinically and easily applicable MR method This technique will rapidly spread in the clinical field for the evaluation of the patients with vertigo attacks, fluctuating hearing loss and ear fullness. Viewers of this educational exhibit will be able to start this procedure at their work place. After more than 600 cases experience, we noticed that all Ménière's disease patients have EH, however all patients with EH do not have the symptoms of Ménière's disease. Mechanism of vertigo attack should be clarified in the future. References 1: Naganawa S, Yamazaki M, Kawai H, Bokura K, Sone M, Nakashima T. Imaging of Ménière's Disease by Subtraction of MR Cisternography from Positive Perilymph Image. Magn Reson Med Sci. 2012;11(4): : Naganawa S, Yamazaki M, Kawai H, Bokura K, Sone M, Nakashima T. Imaging of Ménière's disease after intravenous administration of single-dose gadodiamide: utility of subtraction images with different inversion time. Magn Reson Med Sci. 2012;11(3): : Naganawa S, Yamazaki M, Kawai H, Bokura K, Sone M, Nakashima T. Imaging of endolymphatic and perilymphatic fluid after intravenous administration of single-dose gadodiamide. Magn Reson Med Sci. 2012;11(2): : Naganawa S, Yamazaki M, Kawai H, Bokura K, Sone M, Nakashima T. Visualization of endolymphatic hydrops in Ménière's disease after single-dose intravenous gadoliniumbased contrast medium: timing of optimal enhancement. Magn Reson Med Sci. 2012;11(1): : Yamazaki M, Naganawa S, Tagaya M, Kawai H, Ikeda M, Sone M, Teranishi M, Suzuki H, Nakashima T. Comparison of contrast effect on the cochlear perilymph after intratympanic and intravenous gadolinium injection. AJNR Am J Neuroradiol Apr;33(4): Page 11 of 12

12 6: Naganawa S, Yamazaki M, Kawai H, Bokura K, Sone M, Nakashima T. Visualization of endolymphatic hydrops in Ménière's disease with single-dose intravenous gadoliniumbased contrast media using heavily T(2)-weighted 3D-FLAIR. Magn Reson Med Sci. 2010;9(4): : Naganawa S, Kawai H, Sone M, Nakashima T. Increased sensitivity to low concentration gadolinium contrast by optimized heavily T2-weighted 3D-FLAIR to visualize endolymphatic space. Magn Reson Med Sci. 2010;9(2): : Nakashima T, Naganawa S, Teranishi M, Tagaya M, Nakata S, Sone M, Otake H, Kato K, Iwata T, Nishio N. Endolymphatic hydrops revealed by intravenous gadolinium injection in patients with Ménière's disease. Acta Otolaryngol Mar;130(3): : Nakashima T, Naganawa S, Pyykko I, Gibson WP, Sone M, Nakata S, Teranishi M. Grading of endolymphatic hydrops using magnetic resonance imaging. Acta Otolaryngol Suppl Feb;(560):5-8. Personal Information Shinji Naganawa, M.D., Ph.D. Department of Radiology, Nagoya University Graduate School of Medicine 65 Tsurumai-cho, Shouwa-ku, Nagoya, Japan Page 12 of 12

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