MR imaging of endolymphatic hydrops in 10 minutes: A new strategy for dramatic scan time reduction

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1 MR imaging of endolymphatic hydrops in 10 minutes: A new strategy for dramatic scan time reduction Poster No.: C-0020 Congress: ECR 2014 Type: Scientific Exhibit Authors: S. Naganawa, K. Bokura, H. Kawai, T. Nakashima; Nagoya/JP Keywords: Ear / Nose / Throat, MR, Contrast agent-intravenous, Edema DOI: /ecr2014/C-0020 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 15

2 Aims and objectives Ménière's disease is an inner ear disorder characterized by spontaneous attacks of vertigo, fluctuating low-frequency hearing loss, aural fullness, and tinnitus. Endolymphatic hydrops has long been held to be the pathologic basis for Ménière's disease. Endolymphatic hydrops is a pathologic anatomical finding in which the structures bounding the endolymphatic space are distended by an enlargement of endolymphatic fluid volume. Before the development of MR evaluation method for endolymphatic hydrops, there has not been the direct objective diagnositic method for endolympahtic hydrops. MR visualization of endolymphatic hydrops in Ménière's disease patients was firstly enabled by 3D-FLAIR and intratympanic Gd administration. 1 Recently, it was enabled by heavily T2-weighted 3D-FLAIR (ht2w-3d-flair) and intravenous singledose Gd administration (IV-SD-GD). 2 For easier image interpretation and semiquantification of endolymphatic size, generation of a HYDROPS-Mi2 (HYbriD of Reversed image Of Positive endolymph signal and native image of positive perilymph Signal-Multiplied by T2) image has been proposed. 3 For the generation of the HYDROPS-Mi2, we need 31 min of scan time in total: ht2w-3d-flair or positive perilymph image (PPI, 14 min), positive endolymph image (PEI, 14 min) and heavily T2-weighted MR cisternography (MRC, 3 min). 3 By the multiplication of MRC, contrast-to-noise ratio (CNR) in HYDROPS-Mi2 images increases more than 200-folds compared to original HYDROPS images. 4 HYDROPS2-Mi2 (HYbriD of Reversed image Of MR cisternography and positive Perilymph Signal by heavily T2-weighted 3D-FLAIR-Multiplied by T2), which is the multiplication of MRC with the subtracted image of MRC from PPI, has been reported to provide similar image contrast and endolymph size as HYDROPS-Mi2. 5 This HYDROPS2-Mi2 was generated from the total scan time of 17 min. To shorten the total scan time further, we propose a shorter version of HYDROPS2-Mi2 image, which is generated from PPI with a reduced number of excitations (7 min) and MRC (3 min). We hypothesized that the reduced CNR by the reduction of the number of excitation can be compensated by the multiplication of MRC. The purpose of this study was to compare the endolymphatic size on HYDROPS-Mi2 (Image A, 31 min) and that on HYDROPS2-Mi2 (Image B, 10 min) in patients with clinically suspected endolymphatic hydrops and to test the feasibility of a newly proposed 10 min protocol (HYDROPS2-Mi2). Page 2 of 15

3 Methods and materials Fifteen patients (M:F=4:11; Age, years old, median 46) with clinically suspected endolymphatic hydrops underwent MR imaging 4 hours after IV-SD-GD (Omniscan, gadodiamide) at 3T using a 32-channel array head coil. PPI (14 min), PEI (14 min), MRC (3 min) and PPI with reduced number of excitations (7 min) were obtained according to the MR protocol of our hospital. Detailed MR imaging parameters are shown on Table 1. Image A and B was generated as follows: HYDROPS-Mi2 (Image A) = (PPI 14min -PEI 14min ) x MRC 3min HYDROPS2-Mi2 (Image B) = (PPI 7min -0.04xMRC 3min ) x MRC 3min Previously, (PPI 14min -PEI 14min ) has been reported as HYDROPS image, and (PPI 7min -0.04xMRC 3min ) has been reported as HYDROPS2 image. 6,7 Schematic diagrams for the image processing of HYDROPS-Mi2 and HYDROPS2-Mi2 are shown in Fig. 1 and 2. The purpose for the multiplication of MRC is to boost the contrast-to-noise ratio between endo- and perilymph while suppressing and stabilizing the background signal of bone and air. 4 Pixels with negative value were estimated as endolymph. In 30 ears, the area percentage of endolymph in total lymph space (%EL) was semiquantitatively measured for the cochlea and vestibule on Image A and B according to the previously reported thresholdbased method. 5 The measured %EL was compared between Image A and B. Image analysis method is shown in Fig. 3. Image processing and analysis was performed with free software OsiriX (downloadable at on imac. One neuroradiologist (experience of 25 years) evaluated the images if there is significant patients' motion or not, then drew the ROIs on MRC for the %EL measurement. Observer dependent part of this measurement is only the ROI drawing on MRC. Inter-observer variability of this evaluation method has been reported to be small. 5 Page 3 of 15

4 For statistical analysis, paired student's t-test was used with the significance level of 5%. Linear regression analysis between %EL on Image A and B was also performed. This retrospective study has been approved by the medical ethics committee of our institution with the waiver of informed consent. Images for this section: Table 1: Table 1 MR sequence parameters Page 4 of 15

5 Fig. 1: Fig. 1 Schematic diagram for the image processing of HYDROPS-Mi2 (Image A) HYDROPS image is generated by the subtraction of PEI from PPI. PPI, positive perilymph image PEI, positive endolymph image HYDROPS-Mi2 is generated by the multiplication of MRC and HYDROPS. By the multiplication of MRC, background noise is suppressed, making the segmentation of perilymph and endolymph easier. Necessary scan time for the generation of HYDROPS-Mi2 is 31 minutes. Page 5 of 15

6 Fig. 2: Fig. 2 Schematic diagram for the image processing of HYDROPS2-Mi2 (Image B) In this study, HYDROPS2 image is generated by the subtraction of MRC from PPI with reduced NEX. HYDROPS2-Mi2 is obtained by the multiplication of MRC and HYDROPS2. Again, background noise is suppressed on HYDROPS2-Mi2. Necessary scan time for the generation of HYDROPS2-Mi2 is 10 minutes. Page 6 of 15

7 Fig. 3: Fig. 3 An example of manually drawn ROI on MRC for cochlea and vestibule. These ROIs are then copied onto processed images (Image A and B). When drawing the ROI, the observer drew them according to the instructions shown below. 1) ROI for cochlea; mid-modiolar slice (size of modiolus is maximum. If the seize of modiolus is comparable on 2 slices, select the slice with larger modiolar height, ROI was drawn excluding modiolus. 2) ROI for vestibule; choose the lowest slice with more than 240 degree of LSCC is visualized. ROI was drawn excluding ampulla and SCC. Pixels with positive value was estimated as perilymph and those with negative values was estimated as endolymph. The area percentage of endolymph in total lymph space (%EL) was measured for the cochlea and vestibule on Image A and B using OsiriX software. MRC shows total lymph space anatomy. Back area represents endolymphatic space on Image A and B. Page 7 of 15

8 Results All patients underwent the MR scan without significant motion. MRC shows the total lymph space anatomy. In all patients, Image A and B allowed separate visualization of endo- and perilymph (Fig. 4, 5). The mean %EL of the cochlea was 26.7+/-22.9 % in Image A and /-17.5% (p=0.65). That of the vestibule was /-31.8% in Image A and /- 27.4% in Image B (p=0.91). No significant difference was observed between Image A and B. (Table 2) The correlation coefficient between Image A and B was 0.66 for the cochlea and 0.91 for the vestibule. (Fig. 6, 7) Evaluation of the degree for endolymphatic hydrops had been performed by subjective grading scale. 8 To decrease observer dependency, semi-quantitative method has been proposed. 5 However, necessary total scan time for this method is 31-minutes. To shorten total scan time dramatically, we propose 10-minutes protocol in the present study. Although both of mean %EL in cochlea and vestibule did not show significant difference between Image A and B, the correlation coefficient between Image A and B was smaller in the cochlea than in the vestibule. This might be due to the smaller size of endolymph in cochlea, which is more susceptible to partial volume effect than vestibular endolymph. In other words, measured %ELvalues for cochlea should tend to have more fluctuation than those for vestibule. The linear regression lines intersect the vertical axis at positive values of %EL of Image B, where several data points of Image A show 0% of EL% in cochlea and vestibule (Fig. 6, 7). In the previously reported MRI study obtained after IT of GBCM, normal value of %EL was 8-26% in cochlea and 20-41% in vestibule. 9 In the previous histological study, %EL in control subjects was 9-12% in cochlea and 22-26% in vestibule. 10 These results suggest that there should be some non-zero %EL values even in healthy condition. Therefore, we can speculate that Image A tends to underestimate the values of %EL. This is probably due to the blurring effect of small endolymph on PEI. 3 Limitations of the present study are; (1) Lack of gold standard: It is virtually impossible to know the true %EL in living human, therefore we cannot firmly conclude which of %EL value by Image A or that by Image B is closer to the truth. (2) Only one observer drew ROIs on MRC, although the evaluation method used in the present study has been reported to be less observer dependent. Page 8 of 15

9 Images for this section: Fig. 4: Fig. 4 A 25-year-old woman with significant endolymphatic hydrops both in cochlea and vestibule MRC shows total lymph space anatomy. Back area represents endolymphatic space on Image A and B. Note that even on 10 minutes protocol (Image B), we can appreciate significant endolymphatic hydrops both in cochlea and vestibule similar to 31 minutes protocol(image A). Page 9 of 15

10 Fig. 5: Fig. 5 A 62-year-old man without significant endolymphatic hydrops both in cochlea and vestibule MRC shows total lymph space anatomy. Back area represents endolymphatic space on Image A and B. Note that even on 10 minutes protocol (Image B), we can appreciate endolymphatic space. In this particular patient, shape of endolymphatic space in cochlea is slightly different between Image A and B, however that in vestibule is similar. Page 10 of 15

11 Fig. 6: Fig. 6 Linear regression analysis of %EL values on Image A and B for cochlea. Note that the linear regression line intersects the vertical axis at positive values of %EL of Image B, where several data points of Image A show 0% of %EL in cochlea. Even in healthy subjects, there should be some %EL. Page 11 of 15

12 Fig. 7: Fig. 7 Linear regression analysis of %EL values on Image A and B for vestibule. Note that the linear regression line intersects the vertical axis at positive values of %EL of Image B, where a few data points of Image A show 0% of %EL in vestibule. Even in healthy subjects, there should be some %EL. Correlation coefficient value is larger for vestibule than for cochlea. This is probably due to the larger size of endolymph in vestibule than in cochlea. Page 12 of 15

13 Table 2: Table 2 Mean %EL in coclea and vestibule by Image A and B Page 13 of 15

14 Conclusion The newly proposed 10-minute protocol (Image B, HYDROPS2-Mi2) might be feasible as a substitute of 31-minute protocol (Image A, HYDROPS-Mi2) for the measurement of endolymphatic size after IV-SD-GD. This will promote more widespread use of the MR imaging evaluation of endolymphatic hydrops by clinicians. Personal information Shinji Naganawa, M.D., Ph.D. Professor and Chairman Department of Radiology, Nagoya University Graduate School of Medicine 65 Tsurumai-cho, Shouwa-ku, Nagoya, Japan naganawa@med.nagoya-u.ac.jp Kiminori Bokura, R.T. Department of Radiology, Nagoya University Graduate School of Medicine 65 Tsurumai-cho, Shouwa-ku, Nagoya, Japan Hisashi Kawai, M.D., Ph.D. Associate Professor Department of Radiology, Nagoya University Graduate School of Medicine 65 Tsurumai-cho, Shouwa-ku, Nagoya, Japan Tsutomu, Nakashima, M.D., Ph.D. Professor and Chairman Department of Otorhynolaryngology, Nagoya University Graduate School of Medicine 65 Tsurumai-cho, Shouwa-ku, Nagoya, Japan References [1] Nakashima T, Naganawa S, Sugiura M, et al. Visualization of endolymphatic hydrops in patients with Meniere's disease. Laryngoscope 117(3): , 2007 Page 14 of 15

15 [2] Naganawa S, Yamazaki M, Kawai H, et al. Visualization of endolymphatic hydrops in Ménière's disease with single-dose intravenous gadolinium-based contrast media using heavily T(2)-weighted 3D-FLAIR. Magn Reson Med Sci 9(4): , 2010 [3] Naganawa S, Yamazaki M, Kawai H, et al. Imaging of endolymphatic and perilymphatic fluid after intravenous administration of single-dose gadodiamide. Magn Reson Med Sci 11(2): , 2012 [4] Naganawa S, Yamazaki M, Kawai H, et al. Imaging of Ménière's disease after intravenous administration of single-dose gadodiamide: utility of multiplication of MR cisternography and HYDROPS image. Magn Reson Med Sci;12(1):63-68, 2013 [5] Naganawa S, Suzuki K, Nakamichi R, et al. Semi-quantification of endolymphatic size on MR imaging after single-dose intravenous injection of gadodiamide: Comparison between two types of processing strategies. Magn Reson Med Sci, in press [6] Naganawa S, Yamazaki M, Kawai H, et al. Imaging of Ménière's disease after intravenous administration of single-dose gadodiamide:utility of subtraction images with different inversion time. Magn Reson Med Sci;11(3):213-9, 2012 [7] Naganawa S, Yamazaki M, Kawai H, et al. Imaging of Ménière's disease by subtraction of MR cisternography from positive perilymph image. Magn Reson Med Sci;11(4):303-9, 2012 [8] Nakashima T, Naganawa S, Pyykko I, et al. Grading of endolymphatic hydrops using magnetic resonance imaging. Acta Otolaryngol Suppl; Feb(560):5-8, 2009 [9] Liu F, Huang W, Meng X, et al. Comparison of noninvasive evaluation of endolymphatic hydrops in Meniere's disease and endolymphatic space in healthy volunteers using magnetic resonance imaging. Acta Otolaryngol;132: , 2012 [10] Teranishi M, Yoshida T, Katayama N, et al. 3D computerized model of endolymphatic hydrops from specimens of temporal bone. Acta Otolaryngol;560:43-47, 2009 Page 15 of 15

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