Techniques
3D Techniques
3D acquisition techniques refer to the acquisition of a volume data set with near
isotropic resolution instead of individual slices. While in conventional 2 D multislice
imaging, slices are excited individually and the slice thickness is typically much
larger than the edge length of the pixels in the slice plane, a thick slab is excited
during 3D imaging, which is resolved into individual slices by a second phase encoding.
This allows much higher spatial resolution in this third spatial direction; likewise
isotropic voxels are possible [8]. 3D methods are suitable when lesions are to be measured reproducibly during their
progression, when their positional relationship to neighboring structures is to be
precisely determined and when the distribution pattern of multiple lesions is to be
characterized. They are thus a prerequisite for a structured follow-up of lesions
independent of primary slice angulation and allow the employment of advanced image
analysis techniques including image registration and artificial intelligence. In addition,
they are used for intraoperative navigation, for example. They offer the advantage
of multiplane reconstructions for visual diagnosis.
3D Turbo Spin Echo (TSE)
The acquisition of a large volume with higher resolution is usually unrealistic when
using “conventional” 3D TSE techniques due to a long measurement time and a high specific
absorption rate (SAR). The reason for this in conventional TSE techniques [9] is the numerous 180° refocusing pulses. New modified 3D TSE techniques [8] address these problems by designing long echo trains (high turbo factor) with variable
lower refocusing angles. The sequence of refocusing angles is chosen in such a way
that the resulting image contrast is similar to that when using multiple 180° pulses.
Contrast here is mainly based on stimulated echoes [8]. It is important to observe the contrast-related “effective” echo time when changing
the sequence parameters [8]. In addition, these sequences use short, spatially non-selective high frequency
pulses which allow a short echo interval, and thus enable the long echo trains required
for the acquisition of a large volume in clinically acceptable measurement time [8]. In addition, these methods employ acceleration techniques such as optimized parallel
imaging [8] or compressed sensing (CS, see Part 2). Manufacturer designations[3] of such techniques include CUBE, VIEW/VISTA and SPACE. Improvements in homogeneity
and measurement time have increasingly established these modified 3D TSE techniques
as routine clinical procedures, e. g., 3D Fluid Attenuated Inversion Recovery (FLAIR).
Further reading: [8]
T2 FLAIR 3D
Technical background and potential advantages
FLAIR is the primary examination technique for the detection and follow-up of cerebral
lesions, e. g., in multiple sclerosis [1]
[2]
[3]. The higher resolution and reformatting capability are the main advantages of 3D
FLAIR over 2 D FLAIR for this application. The basic principle of the underlying 3D
TSE sequences with variable refocusing angles is described in the previous section.
Since 3D FLAIR techniques with low refocusing angle lead to pronounced flow-related
signal cancellations (flow voids) [8] while at the same time are hardly affected by hyperintense flow artefacts [10]
[11], they can also be used more widely outside the brain parenchyma than 2 D FLAIR,
partly even for the assessment of venous vessels ([Fig. 1]). 3D FLAIR sequences appear to be relatively less susceptible to motion artefacts
compared to conventional 2D Cartesian TSE sequences. In this case, moderate motion
effects do not lead to multiple contours or ghost images in phase encoding direction,
but rather to a relatively small increase in overall image blur.
Fig. 1 3D FLAIR in two different patients with venous sinus thrombosis: a superior sagittal sinus, subacute stage; b sigmoid sinus, acute stage. The thrombus leads to a lack of typical flow void in the
corresponding sinus (arrows). 3D FLAIR, compared with c 2D FLAIR, is less susceptible to hyperintense flow related artefacts (open arrow).
However, such artefacts should be considered in narrow vessel segments. Final assessment
should take all available sequences into account since a thrombus can be totally T2
hypointense in rare cases.
Combined with fat suppression, 3D FLAIR could achieve possible additional diagnostic
information about extracranial or bony lesions in primary cerebral examination protocols
without increasing measurement time. Thus, 3D FLAIR is suitable as a cross-indication
replacement for 2 D FLAIR sequences in most cases, and contributes to the reduction
of the number of indication-specific brain MRI examination protocols due to its independence
from slice orientation. Further reading: [12]
Possible limitations
Limitations of 3D FLAIR compared to 2 D FLAIR have only been described in a few indications
(e. g., detection of the so-called “ivy sign” in moyamoya disease [13]). Despite overall low susceptibility, motion artefacts can sometimes appear as signal
fluctuations ([Fig. 2]), mimicking cortical lesions, for example. In 3 T, significant signal inhomogeneities
may occur in older scanners due to B1 inhomogeneities [7], through which, for example, the temporal lobes appear differently bright. For example,
this may affect the assessability of autoimmune encephalitis. To the best of our knowledge,
there are no direct possibilities for the user to influence this by selecting measurement
parameters. The respective implementation of the sequence can have an influence and,
if necessary, a 2 D FLAIR is preferable to a 3D sequence.
Fig. 2 3D FLAIR (accelerated by compressed sensing) in a patient with moderate movement
artefacts. Movement can lead to small-scale signal fluctuations in this technique.
This might imitate cortical lesions (examples highlighted by arrows) if the reader
is not aware of this artefact.
Practical notes on application
[Fig. 3] summarizes geometric aspects that can contribute to the avoidance of artefacts and
the more efficient use of 3D FLAIR in practical routine use. The sequences provided
by the manufacturers have a good contrast-to-noise ratio (CNR) for many lesion types.
Originally, the signal-to-noise ratio (SNR) was often the determining factor for the
presets. For example, while a sequence with a longer repetition time (TR) typically
leads to a reduction in SNR due to the resulting further setting adjustments required,
the CNR for lesions initially increases within a certain range [14]
[15]. Therefore, for example, protocol recommendations for gliomas [4] call for a TR of 6000 to 10 000 ms. This is sometimes not compatible with acceptable
measurement time in older implementations. When combined with newer acceleration techniques,
these recommendations can be fully implemented. A suitable combination of repetition
time (TR), (effective) echo time (TE) and inversion time (TI) is required to achieve
complete suppression of the CSF signal [12]. Since no good heuristic exists for determining their appropriate ratio, it is recommended
here to select these parameters based on different presets or published combinations
(e. g., considering the field strength [14]
[16]) instead of freely varying them. Since the subjective image impression of 3D FLAIR
differs from that of 2 D FLAIR sequences, a familiarization phase is useful for reliable
diagnosis.
Fig. 3 Geometric aspects of using whole brain 3D sequences (e. g. 3D FLAIR). a A sagittal primary slice orientation is often more efficient and helps to avoid fold-over
artefacts due to the lower number of necessary phase-encode steps. b Some manufacturers’ presets adopt slightly anisotropic voxel dimensions (three different
edge lengths, especially higher slice thickness, ST) in order to reduce acquisition
time by fewer phase encode steps. Most of these images will, however, be viewed as
transverse and coronal reconstructions. Thus, fully or near-isotropic voxels (equal
edge lengths) are favourable. A few adjustments of acquisition geometry by the user
are thus recommended to achieve isotropic voxels. Additionally, slight c tilting and d size adjustments of the field of view (FOV) and potentially adjustment of standard
head positioning may be necessary in order to both avoid fold-over artefacts and be
time efficient. Such artefacts might result in pseudo-lesions, for example caused
by a fold-over of the external ears into the brainstem when using parallel imaging
techniques in image space (e. g. SENSE). It is recommended to carry out such adjustments
as a systematic optimisation instead of adjustments for individual patients. This
can help leverage the benefits of such 3D sequences for comparability and automated
image analyses. e A standardised approach for creating multiplanar reconstructions (MPR) is favourable.
Examples of further 3D TSE techniques
The high flow void susceptibility of 3D TSE sequences can be used in a targeted manner
with a reduced refocusing angle, and thus capture certain flow phenomena with T2-weighted
sequences [17]. However, T2-weighted 3D TSE sequences without CSF suppression have not yet been
accepted as a full-fledged substitute for 2 D T2 sequences of the brain. They exhibit
altered parenchymal contrast due to the long echo trains and magnetization transfer
effects of the refocusing pulses [8]. They are also susceptible to truncation artefacts [18]. T2 TSE sequences are commonly used for visual classification of anatomical details
and assessment of lesion morphology for which a high in-plane resolution can be advantageous,
as primarily offered by 2 D sequences.
T1-weighted fat-suppressed TSE 3D sequences have recently become the standard for
vessel wall imaging [19]
[20] and have increasingly replaced 2 D “black blood” techniques. This is based on the
pronounced flow void of these sequences [8]. Although initially described at 7.0 T and 3.0 T [19], based on the authors' experience image quality can also be achieved with current
1.5 T devices which exceed the informative capability of comparable 2 D techniques
(for example parameters see Online Table 1). Our experience shows that basic settings do not always meet diagnostic requirements.
Special attention should be paid to a resolution in the sub-millimeter range (if necessary
with the aid of compressed sensing) [21]
[22]
[23]
[24] and sufficient suppression of flowing blood (if necessary with additional techniques
such as a prepulse [25] and/or lowering of the refocusing angle [8]
[19]). Further reading: [19] These T1-weighted sequences have a good contrast-to-noise ratio for barrier-disrupted
lesions when imaging the brain parenchyma. Nevertheless, these sequences can also
provide good co-assessment of extracranial structures [26]. However, artefacts sometimes occur due to slow flow in superficial veins [19] and field strength-dependent differences in image impression.
3D Gradient Echo
3D gradient echo techniques have been in routine clinical use for some time and will
therefore not be discussed in depth here. Examples include T1-weighted sequences with
inversion prepulse (e. g. MPRAGE [27]) and susceptibility-weighted imaging (SWI) [28]
[29]. Due to higher sensitivity and specificity, SWI has largely replaced T2*-weighted
2 D sequences for brain imaging for appropriate indications. In this case, we recommend
reconstruction of phase images [29] for a more specific assessment. Further references for SWI: [29]. Innovations in 3D gradient-echo sequences have arisen most recently from the combination
possibilities with Dixon [30] and newer acceleration techniques [31]
[32].
Artefact Reduction Techniques
Radial Sampling Techniques
Technical background and potential advantages
Techniques to reduce motion artefacts in 2 D sequences are widely used clinically
under names such as PROPELLER [33], MultiVANE, JET, RADAR, and BLADE [34]
[35]
[36]
[37]
[38]
[39]. They are based on the acquisition of Cartesian-acquired segments of k-space with
only a few phase encoding steps where the segments are arranged like spokes of a wheel
(radial-Cartesian trajectory hybrids). The center of the k-space is captured by each
spoke. Analysis of the difference between the averaged signals and the individual
signals of each spoke in the center enables correction of movements in the slice plane,
including both translation and rotation, and to a certain extent also movements in
the slice direction [33]. Artefacts in sequences with radial scanning, e. g., due to residual aliasing, often
appear in the form of radially arranged stripes. This image impression is also caused
by “gridding”, i. e. the projection of the radially recorded points in k-space onto
the points of a Cartesian matrix, which is then Fourier-transformed to obtain the
image. Such artefacts [39]
[40] are usually perceived as less disturbing for the findings than motion artefacts
with purely Cartesian sampling. Recently, motion corrections have been improved by
newer iterative methods [41]. The basic principle of combining partial radial sequences with motion correction
has now been applied to T1-weighted 3D gradient echo sequences. Examples include techniques
such as StarVIBE [42]
[43]
[44]
[45] and radial eTHRIVE [46]. In our experience, robust and low-artefact image quality can be achieved with these
sequences over many patients. Further reading: [39]
Possible limitations
With respect to comparable purely Cartesian techniques, the spatial resolution achievable
in realistic measurement time is lower. T1-weighted radial Cartesian sequences exhibit
somewhat lower contrast than comparable purely Cartesian acquisition techniques when
assessed visually, especially for gadolinium-enhancing structures.
Practical notes on application
The number of spokes in the k-space is an important factor influencing image quality.
If too few are chosen, the artefacts mentioned above increase significantly. By varying
the number of spokes, it is possible to moderately influence the measurement time
and SNR in the sense of non-integer averaging, so that for these sequences primarily
the number of spokes should be modified instead of the number of averages. Artefacts
also arise from signal contributions from outside the field of view (FOV). Coil elements
predominantly located outside the FOV should therefore be deactivated [47]. Transverse slice orientation offers potential advantages.
Reduction of metal and other susceptibility artefacts
Technical background and potential advantages
Metallic implants result in pronounced local magnetic field inhomogeneities. As a
consequence – among other effects – the linear relationship between precession frequency
and spatial position as the basis of location encoding is disturbed. In addition to
full signal cancellations, this results in spatial distortions as well as related
signal loss and signal accumulation, i. e. dark areas with bright edges. These distortions
occur both within the slice in the readout direction and perpendicular to the slice
plane [48]
[49]. Well-established metal artefact reduction methods (see [Fig. 4]) include the use of a high receiver bandwidth (corresponding to a low water fat
shift, depending on the manufacturer); high resolution (including thin slices), preference
for TSE sequences with short echo spacing and parallel imaging; if possible, lower
field strength, use of less susceptible fat saturation techniques such as Short Tau
Inversion Recovery (STIR) and Dixon if necessary, and possibly rotation of the FOV
and phase encoding direction to influence the direction of maximum artefact expansion
[48]
[50]
[51]. These principles were first extended to include specific sequences that reduce
susceptibility artefacts within the slice by view angle tilting (VAT, e. g., O-MAR
or to some extent in the context of WARP). In this case, an additional gradient is
switched in the slice selection direction during the readout. This compensates for
distortions that have occurred during slice selection [48]
[52]. Furthermore, in recent years, multispectral techniques have been established for
clinical application, which additionally reduce artefacts from slice to slice [48]
[49]
[50]
[51]. In slice-encoding for metal artefact correction (SEMAC) ([Fig. 5]), usually combined with VAT, additional location coding is performed in the direction
of the slice stack by using phase encoding. Consequently spatial errors due to the
distorted slice profile can be corrected during image reconstruction [48]
[53]. During multiacquisition with variable resonance image combination (MAVRIC), multiple
three-dimensional TSE data sets are acquired with discrete shifts in transmit and
receive frequencies, from which a complete image is assembled in the course of reconstruction
[54]. It should also be mentioned that multi-shot techniques (e. g., RESOLVE) can reduce
susceptibility artefacts in diffusion-weighted imaging [55]. However, unlike the previously mentioned techniques, the reduced susceptibility
of multi-shot DWI is based only on shortened echo trains compared to single-shot techniques
and not on actual correction or suppression of susceptibility artefacts. This offers
a selection of well-implemented sequences for most body regions. Further reading:
[48]
[49]
Fig. 4 Effect of metal artefact reduction on cervical spine imaging in presence of dental
braces and material from spinal fusion (outside the image plane): a standard T2 TSE with near-total signal loss in the spinal canal at the level of the
lesion, b T2 TSE with a combination of conventional metal artefact reduction techniques with
nearly complete visibility of the spinal cord lesion.
Fig. 5 2 D T2 STIR sequence using SEMAC for metal artefact reduction. In this example this
technique facilitates assessment of the sciatic nerve (arrow) running immediately
dorsal to a hip endoprosthesis.
Possible limitations
Metal artefact reduction sequences exhibit significantly increased measurement time,
decreased SNR [48], and increased specific absorption rate (SAR) [49]. It should be noted that the increased SAR for critical implants increases the risk
of excessive heating of the implant. However, the prolongation of measurement time
can be compensated with modern acceleration techniques, e. g., CS for SEMAC [56] and MAVRIC [57] and simultaneous multislice imaging for RESOLVE DWI [58]. VAT creates a blur in the readout direction [48]. Blurring with specific metal artefact reduction has been cited as an argument to
use predominantly only conventional artefact reduction modifications for high-resolution
peripheral MR neurography [59] if this can sufficiently reduce the extent of the artefacts.
Practical notes on application
Due to the limitations mentioned above, these sequences should not be used across
the board for metallic implants in the study area. Rather, individual sequences of
these types can be used selectively to assess details in the immediate area of influence
of the artefacts.
Dixon Techniques
Technical background and potential advantages
In particular, Dixon techniques (e. g., Dixon, mDixon, IDEAL, Flex, or WFOP) offer
relatively homogeneous fat suppression and acquisition of fat-saturated and non-fat-saturated
images in a single acquisition. They can be combined with different sequence types
(e. g. TSE or gradient echo, 2 D and 3D) and weightings (e. g., T1, T2, PD) and thus
used for different targets [30].
Although Dixon techniques were developed as early as the 1980 s and 1990 s [60] and have been refined several times [61]
[62]
[63], they have only found their way into clinical use with newer hardware and software.
They use the property that fat and water protons precess at a slightly different frequency
[30]
[63], so that in-phase and opposed-phase conditions exist depending on the TE. In Dixon
techniques, two (or more) partial measurements are made with different echo times.
During image reconstruction, pure fat (“F”) and water (“W”) images can be calculated
from this in addition to the in-phase and opposed-phase images. Thus, fat suppression
here does not occur as a primary saturation, but by post-processing [30]. Further reading: [30]
Possible limitations
The expected artefacts differ from other fat suppression techniques. A so-called “fat-water
swap” is typical: during the computational separation of water and fat signals, it
can happen that instead of the water image in image sections or the entire image,
the fat signals are actually displayed and vice versa [30]
[64]. A partial swap may follow anatomical structures and may then be relatively difficult
to detect, most likely with the aid of all calculated image series ([Fig. 6]). Dixon techniques in their pure form are highly susceptible to inhomogeneities
of the main magnetic field. However, further developments that determine the present
properties of Dixon techniques make them in the end just less susceptible to such
magnetic field inhomogeneities [63]. Compared with conventional TSE sequences, Dixon TSE techniques take slightly longer
or have slightly worse SNR [30], but can be a very good compromise.
Fig. 6 Swap artefact in a T2 TSE sequence with Dixon technique. This example shows a misassignment
of tissues in parts of the images during image reconstruction. Bone marrow signal
of the humerus (indeed fatty) wrongly appears hyperintense in the actual water image
a, yet hypointense in the actual fat image b. The artefact can be suspected because tissue immediately lateral to the humerus
features altered signal characteristics as well with an unexpectedly sharp border.
An additional T2 STIR sequence c unambiguously identifies this as an artefact. This example shows that swap artefacts
can follow anatomical boundaries in rare cases. More frequently, however, they affect
the entire image or punched out image areas near susceptibility artefacts.
Practical notes on application
Since the individual images to be calculated are typically selected prior to the measurement,
it may be useful to calculate all conceivable images from the data, but to maintain
clarity, only use the images in the PACS that are primarily relevant for the findings
(e. g., in-phase and water image). The Dixon technique can be combined with different
sequences and weightings. Consequently image contrast varies greatly with Dixon techniques.
Also, artefacts that occur are usually more due to the base sequence than to the Dixon
module.
Dixon techniques are most suitable for anatomic transition areas (e. g., neck/thorax
[65]
[66]
[67]) and regions adjacent to air-containing spaces (e. g., orbit [26]). They are also relatively robust around metallic implants, although STIR remains
superior here [30]. However, STIR fat suppression is based on the short T1 time of fat and therefore
can also suppress fat-free lesions after contrast uptake [68], in contrast, fat suppression using the DIXON technique has the advantage that it
is based on the frequency difference between water and fat and is independent of T1.
T2-weighted Dixon techniques with 2 D TSE sequences can replace STIR in many cases
while exhibiting better SNR [30].