3D-Black-Blood 3T-MRI for the Diagnosis of thoracic large Vessel Vasculitis: A Feasibility Study

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1 3D-Black-Blood 3T-MRI for the Diagnosis of thoracic large Vessel Vasculitis: A Feasibility Study Tobias Saam 1, MD; Karla M. Treitl 1, MD; Stefan Maurus 1 ; Nora N. Kammer 1, MD; Hendrik Kooijman 2 ; PhD; Marcus Treitl1, MD; Maximilian F. Reiser 1, MD, FACR, FRCR; Eva Coppenrath 1, MD 1 Institute of Clinical Radiology, Ludwig-Maximilian-University Hospital, Munich, Germany 2 Philips Healthcare, Hamburg, Germany

2 RSNA 2014 Clinical Background The diagnosis of large vessel vasculitis is challenging due to unspecific clinical symptoms and lab results 1 Temporal artery biopsy is invasive, results are false-negative in 15-70% in patients with giant cell-arteritis 2 Imaging methods are needed to diagnose the disease and to monitor disease activity/ response to treatment 3 Newer anti-inflammatory drugs, such as IL-6 receptor antibodies (Tocilizumab) have shown promising results but suppress serological markers of inflammation (e.g. CRP) 4 1) Arend WP et al. The American College of Rheumatology ) Nesher G et al. Journal of autoimmunity ) de Souza AW et al. Journal of autoimmunity ) Tombetti E et al. J Rheumatol. 2013

3 RSNA 2014 Imaging Background PET/CT gold standard for vasculitis of aorta and large arteries - - Ionizing radiation Difficulties to differentiate between atherosclerosis and mild vasculitis Possible solution: 3D Black-blood sequence with PPU triggering and navigator Ultrasound excellent for diagnosis of temporal and subclavian arteritis - - Aorta and intra-thoracic vessels not visible on ultrasound No definite information about vessel inflammation Black-blood MRI can visualize vessel wall thickening and contrast enhancement in small, medium and large arteries - - Conventional 2D black-blood sequences are time consuming Thoracic vessels challenging due to breathing and motion artefacts

4 RSNA 2014 Purpose To evaluate a commercially not available isotropic 3D black-blood T1w-TSE sequence with variable flip angles for the diagnosis of thoracic large vessel vasculitis.

5 3D-T1-Black-Blood-VISTA

6 RSNA 2014 Material & Methods 14 patients with suspected large vessel vasculitis and 14 controls were imaged at 3.0 T (Philips Ingenia) MR Protocol: fat suppressed 3D-T1-black-blood-VISTA (Volumetric Isotropic TSE Acquisition), pre- and post- contrast with navigator and peripheral pulse unit triggering (net scan time: 3:12 minutes; effective scan time = 5-6 minutes) 2 readers blinded to the clinical diagnosis (consensus) Presence / Absence of concentric wall thickening and contrast enhancement (4-point scale) in Aortic arch, ascending and descending aorta Left and right subclavian arteries Pulmonary arteries

7 MR parameters: 3D- VISTA RSNA 2014 Sequence 3D-TSE TR (ms) 1000 TE (ms) 35 Fat Suppression SPIR SENSE factor (RL) / (AP) 3 x 2 TSE / TFE factor 50 Flip Angle ( ) variable NSA 2 Scan FOV (mm 3 ) 365 x 365 x 170 Recon matrix 576 Number of Slices 170 Voxel size (mm 3 ) 1.20 x 1.30 x 1.00 Recon voxel size (mm 3 ) 0.63 x 0.63 x 1.00 Scan time per sequence (min) 3:12 Effective Scan Time (min) 5-6 3D: tree-dimensional; VISTA: Volumetric Isotropic TSE Acquisition; TSE: turbo-spin echo; TR: repetition time; TE: echo time; SPIR: Spectral Presaturation with Inversion Recovery; SENSE: sensitivity encoding; RL: right-left; AP: anterior-posterior; TFE: turbo field echo; NSA: number of signal averages; FOV: field-of-view

8 MR Imaging findings in Vasculitis 76 year old Patient with Giant Cell Arteritis 55 year old Patient (Control Group) Criteria for active vasculitis: concentric and long segment contrast enhancement and wall thickening

9 RSNA 2014 Black-blood MRI for thoracic Vasculi<s * % of vessel segments * Vasculi:s Control Group Contrast enhancement Wall thickening * P<0.001 Acceptable image quality was achieved in 27 out of 28 exams (96.4%)

10 Case 1: Female, 77y, histologically confirmed giant-cell arteritis 3D-BB T1 VISTA 3D-BB T1 VISTA CE PPU-gating + Navigator; Scan Time: 5~6 min

11 Case 1: Female, 77y, histologically confirmed giant-cell arteritis 3D-BB T1 VISTA 3D-BB T1 VISTA CE

12 Case 2: Female, 27y with Takayasu Arteritis 3D-BB T1 VISTA 3D-BB T1 VISTA CE 18F-FDG PET/CT

13 Case 2: Follow-up after 4 weeks of intensive immunosuppressive therapy (Tocilizumab & high dose steroids) Before high-dose therapy 3D-BB T1 T1 CE 3D-BB After high-dose therapy CE 3D-BB T1

14 Case 3: 36y, female with Takayasu-Aortitis 3D-BB T1 VISTA CE 3D-BB T1 VISTA

15 RSNA 2014 Conclusion Navigated, PPU-triggered T1w-3D VISTA black-blood MRI of the thoracic vessels is feasible in 5 to 6 minutes scan time Image quality is good to excellent in >95% of exams T1w-3D VISTA allows to visualize concentric wall thickening and contrast enhancement in patients with vasculitis Future studies are necessary to evaluate T1w-3D VISTA for monitoring of anti-inflammatory therapies and for a direct comparison with PET/CT and ultrasound Black-Blood MRI could be particularly useful in young patients (e.g. Takayasu arteritis) in which ionizing radiation should be used with caution

16 Plaque Imaging Group Institut für Klinische Radiologie Prof. Dr. med. Dr. h.c. M. Reiser PD Dr. med. T. Saam PD Dr. med. C. Cyran Dr. med. F. Schwarz PD Dr. med. A. Helck Dr. med. H. Hetterich Dr. med. F. Strobl Dr. rer. nat. O. Dietrich Dr. rer. nat. M. Ingrisch Cand. med. S. Fill Cand. med. C. Habbel Cand. med. S. Hörterer Cand. med. T. Obenhuber Cand. med. S. Maurus Cand. med. N. Webber Prof. Dr. med. Dr. h.c. D. Clevert Dr. med. E. Coppenrath Dr. med. K. M. Treitl Dr. med. N. Kammer Interdisziplinäres Zentrum für Schlaganfall- und Demenzforschung Prof. Dr. M. Dichgans (Co-PI CAPIAS) Dr. med. A. Beyer-Karpinska Neurologische Klinik und Poliklinik Prof. Dr. M. Dieterich Neuroradiologie Prof. Dr. H. Brückmann Dr. med. N. Lummel Klinik und Poliklinik für Nuklearmedizin Prof. Dr. P. Bartenstein PD Dr. med. A. Rominger Vascular Imaging Lab, Seattle, USA Prof. Dr. rer. nat. C. Yuan Prof. Dr. med. T. Hatsukami Angiologie Prof. Dr. med. U. Hoffmann Dr. med. M. Czihal Technische Universität München (Physik E17) Prof. Dr. rer. nat. F. Pfeiffer Dr. rer. nat. J. Herzen Marian Willner Marco Stockmar Klinikum Rechts der Isar (Neurologie) PD Dr. med. H. Poppert Dr. med. D. Sepp Klinikum Rechts der Isar (Neuroradiologie) Dr. med. T. Boeck-Behrens Universitätsklinikum Freiburg (Neurlogie) PD Dr. med. A. Harloff Support - MAP Dr. rer. nat. S. Auweter Dr. rer. nat. T. Hendel Visiting Fellows: Dr. med. M. de Trelles