Yonsei Med J.  2014 Sep;55(5):1231-1237. 10.3349/ymj.2014.55.5.1231.

The Added Value of Double Dose Gadolinium Enhanced 3D T2 Fluid-Attenuated Inversion Recovery for Evaluating Small Brain Metastases

• Ahn SJ
• Chung TS
• Chang JH
• Lee SK

• KMID: 1799485
• DOI: http://doi.org/10.3349/ymj.2014.55.5.1231

Abstract

PURPOSE
Single dose gadolinium (Gd) enhanced fluid-attenuated inversion recovery (FLAIR) is helpful for visualizing superficial parenchymal metastases. However, the usefulness of FLAIR with a higher dose of Gd is uncertain. The aim of our study was two-folds: first, to prove that the signal to noise ratio (SNR) of small brain metastases is higher than large brain metastases on double-dose (DD) enhanced FLAIR and, second, to explore the added value of DD Gd enhanced FLAIR in relation to T1 GRE for evaluating small brain metastases.
MATERIALS AND METHODS
For the first purpose, 50 pairs of small (2 mm5 mm) were included. The difference in the SNR and contrast ratio (CR) between small and large metastases on DD Gd-enhanced 3D T2 FLAIR was compared by Wilcoxon signed-rank tests. For the second purpose, a total of 404 small metastases were included. The diagnostic sensitivities between 3D T1 gradient echo (GRE) alone and combined results of 3D T1 GRE and 3D T2 FLAIR were compared with McNemar test.
RESULTS
The SNR and CR of small brain metastases were significantly higher than those of large brain metastases (p<0.001). In qualitative analysis, the diagnostic sensitivities for small brain metastases were significantly higher for 3D T1 GRE plus 3D T2 FLAIR than 3D T1 GRE alone regardless of scan time (p<0.001).
CONCLUSION
Small brain metastases showed higher signal intensity than large brain metastases on the DD Gd enhanced 3D T2 FLAIR images. DD Gd enhanced 3D T2 FLAIR imaging may have a complementary role to 3D T1 GRE for evaluating small brain metastases.

Keyword

CNS; MR-imaging; metastases

MeSH Terms

Adult
Aged
Brain Neoplasms/*pathology
Contrast Media/administration & dosage/*diagnostic use
Female
Gadolinium/administration & dosage/*diagnostic use
Humans
Imaging, Three-Dimensional
Magnetic Resonance Imaging/*methods
Male
Middle Aged
Retrospective Studies
Signal-To-Noise Ratio
Contrast Media
Gadolinium

Figure

• 

  Fig. 1 Comparison of SNR and CR between small metastasis (2 mm5 mm) on DD Gd enhanced 3D T2 FLAIR. (A) SNRs of small and large brain metastases (32.82±13.03 vs. 19.38±11.73). (B) CRs of small and large brain metastases (2.14±0.57 vs. 1.29±0.63). SNR, signal-to-noise ratio; DD, double dose; Gd, gadolinium; FLAIR, fluid-attenuated inversion recovery; CR, contrast ratio.

• 

  Fig. 2 A 45-year-old patient with renal cell cancer. (A) A larger brain metastasis (8 mm) with dark signal intensity and peri-lesional edema in the left frontal lobe on DD Gd-enhanced 3D T2 FLAIR (SNR: 9.61). (B) The same lesion with strong enhancement on post DD gadolinium enhanced 3D T1 GRE. (C) Another small brain metastasis (4.2 mm) in the left frontal lobe with high signal intensity on DD Gd-enhanced 3D T2 FLAIR (SNR: 21.63). (D) The same lesion with enhancement on DD Gd-enhanced 3D T1 GRE. SNR, signal-to-noise ratio; DD, double dose; Gd, gadolinium; FLAIR, fluid-attenuated inversion recovery; GRE, gradient echo.

• 

  Fig. 3 68-year-old female patient with lung cancer. (A) In first review, both reviewers missed the left frontal small brain metastases on early phase DD Gd enhanced 3D T1 GRE, because they regarded them as enhancement of the cortical vein. (B) On late phase DD Gd enhanced 3D T2 FLAIR, the same lesion with high signal intensity was more prominent and distinct from the surrounding normal parenchyma. Both reviewers retrospectively detected the left frontal lesion on 3D T1 GRE after reviewing the 3D T2 FLAIR. DD, double dose; Gd, gadolinium; FLAIR, fluid-attenuated inversion recovery; GRE, gradient echo.

• 

  Fig. 4 A 49-year-old male patient with renal cell cancer. (A) On early DD Gd-enhanced 3D T1 GRE, brain metastasis is not detected. (B) On late phase DD Gd enhanced 3D T2 FLAIR, small enhancing metastasis is clearly demonstrated in the right frontal lobe (arrow). (C) Two month follow up 3D T1 GRE reveals the small brain metastases in the right frontal lobe (dashed arrow). DD, double dose; Gd, gadolinium; FLAIR, fluid-attenuated inversion recovery; GRE, gradient echo.

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