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Differentiation Between Neoplastic and Non- Neoplastic Intracranial Lesions Using Diffusion Tensor Imaging and Arterial Spin Labelling Technique. Sunil Kumar, Neetu Soni , Karthika S, Rajesh Kumar , Jayantee Kalita , U K Misra , Sanjay Behari

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  1. Differentiation Between Neoplastic and Non-Neoplastic Intracranial Lesions Using Diffusion Tensor Imaging and Arterial Spin Labelling Technique Sunil Kumar, NeetuSoni, KarthikaS, Rajesh Kumar, JayanteeKalita, U K Misra, Sanjay Behari Sanjay Gandhi Postgraduate Institute of Medical Sciences, RadiodiagnosisLucknow-India ASNR 54th 2016 Annual Meeting Presentation #: eP- 74 Abstract Control Number - 1627

  2. Disclosure The authors have no disclosures to report

  3. Background • Standard MR imaging may not be able to differentiate intracranial lesions correctly. • Diffusion Tensor Imaging (DTI) and Perfusion MRI (DSC, DCE and ASL) techniques have been used to further characterize the brain lesion (Arterial spin labeling). • Based on these techniques, some differentiation has been reported in the literature between high grade gliomas, metastases and non-neoplastic lesions • Particularly, emphasis has been on the wall of the lesion and also perilesional edema. The perilesional edema can represent vasogenic edema or vasogenic edema with infiltrating tumour cells (Lee et al 2007).

  4. Background contd… • Chatterjee et al, 2009 retrospectively studied 11 patients of tuberculoma and metastasis and found high Regional cerebral blood volume (rCBV) from the walls of the metastases (5.06 ± 2.13ml/100gm) than tuberculous lesions (0.90 ± 0.49 ml / 100gm) with no difference in the ADC value. • Chatterjee et al, 2010 found inferior mean rCBV ratio between lesion and normal white matter in tubercular lesions than metastasis. • Floriano et al, 2013 found higher rCBV values in solid part of neoplastic lesions (4.28±2.11) than infectious lesions (0.63±0.49) (p<0.001) using DSC. 

  5. ASL (Arterial spin labeling). • ASL is a non-ionizing and non-invasive MRI technique for measuring tissueperfusion (blood flow), which uses magnetically labeled arterial blood water protons as an endogenous tracer. • Weber et al, 2010 found higher CBF in peritumoral non enhancing T2-hyperintense regions of glioblastomas compared with metastases. • Bai et al, 2013 found significantly higher values of CBF in the peritumoral regions of glioblastomas than metastases (P < 0.05) and no significant difference between CBF of solid parts of cerebral glioblastomas and solitary brain metastases.

  6. Diffusion Tensor Imaging • Lu S et al, 2002 found significant increases in MD (P < .005) and decreases in FA (P < .005) in the peritumoral region of both gliomas and metastatic tumors in comparison with normal white matter. • Wang et al, 2009 studied DTI in 49 patients (30 GBM, 19 metastases) and found significantly lower FA in gross tumor (P < .001) and peritumoral margin (P < .001), in GBM compared with metastases. • Toh et al, 2011 studied 56 patients of abscess, metastases and glioblastoma and reported that FA of the rim was significantly higher in glioblastoma and metastasis compared with abscesses.

  7. Purpose • To use DTI technique to map the various diffusion parameters in the wall/lesion and perilesional edema of intracranial lesions- Fractional Anisotropy (FA), Mean Diffusivity (MD), Radial Diffusivity, Apparent Diffusion coefficient and Axial diffusivity (AD). • To use ASL technique to map cerebral blood flow (CBF) in perilesional edema and wall/lesion of intracranial lesions. • To compare DTI and ASL data from perilesional edema and enhancing wall/lesion in differentiation of etiology of intracranial lesions.

  8. Materials and Methods Inclusion criteria: • Single or Multiple enhancing intracranial lesion with perilesional white matter edema. Exclusion criteria: • The patients with history of stroke, cardiac arrhythmia or congestive heart failure were excluded. • HIPPA compliant and granted permission by Research Ethics Board review. • In a prospective study of 22 patientswith intracranial lesions underwent MRI including DTI and ASL.

  9. Materials and Methods • For analysis these patients (22) were divided into 2 groups (neoplastic (11) and non-neoplastic (11) based on histopathological, clinical, biochemical and imaging evaluation. • Neoplastic group - metastasis=7, gliomas=3 and choroid plexus carcinoma=1. • Non-neoplastic group - Tuberculomas=6 and Neurocysticercosis=5. • The DTI and CBF parameters from the enhancing wall/lesion and peri-lesional edema were compared between the two groups using independent t-test. Statistical analysis was done using SPSS 16 version software and the variable having a P value <0.05 was considered significant.

  10. MRI Protocol • All patients underwent MR imaging on a 3T MR scanner (Signa Hdxt, General Electric, Milwaukee, USA), using a 12 channel head coil. Following MR sequences done: • Axial T2 imaging , T1/T2 FLAIR, DWI including ASL and DTI. • ASL parameters -Frequency =512, Phase=8, NEX= 3, no. of slice=46, FOV=24, slice thickness=6 mm, Band width=62.50. • DTI parameters - frequency- 128,phase- 128,phase FOV-1.00,TR-12400,Tmin-86.4,slice thickness-3.0mm,spacing-0, FOV-24, axial plane, estimated SAR-0.48, no. of direction- 30.

  11. Image Processing and Data Analysis • ASL and DTI raw data transferred to the off-cart workstation with following software MATLAB, Diffusion toolkit and Mricron for analysis. • After generating Nifti files from the MATLAB the CBF maps were created using Perfusion SPM 8. CBF was calculated by placing Region of Interest (ROI) on the enhancing wall/lesion and perilesional white matter (average of atleast 3 measurements). • Similarly, using Diffusion Tool Kit FA, MD, AD, ADC and RD values were measured from the same areas. • In case of multiple lesions with visible perilesional edema, then the lesion with maximum perilesional edema was targeted for measurements.

  12. Results: • Paired t-test was done to check the significant difference in neoplastic and non-neoplastic lesions. • In neoplastic group FA of perilesional edema (0.220±0.07) was significantly (P<0.001) higher than enhancing wall/lesion (0.112±0.05). • In non-neoplastic group no significant difference was found.

  13. Results contd… Independent sample t test was done to check any significant difference in the various DTI parameters and CBF in neoplastic versus non-neoplastc lesions. No significant differences were found in the other DTI derived parameters between neo and non-neoplastic group of the enhancing wall/lesion and perilesional edema.

  14. T1 T2 DWI FLAIR T1+C ASL Choroid plexus carcinoma right lateral ventricle with extensive perilesional edema and mass effect. ASL shows increase intralesional flow (arrow).

  15. A B C Choroid plexus carcinoma right lateral ventricle. Perfusion (A,B) and FA (C) maps generated using MATLAB and diffusion tool kit, ROI placed within the lesion and perilesional edema to measure the diffusion parameters and CBF.

  16. T2 FLAIR T1 T1+C ASL DWI Neurocysticercosis right thalamic region with perilesional edema. ASL shows increase intralesional flow (arrow).

  17. A B Neurocysticercosis right thalamic region. Perfusion (A) and FA (B) maps generated using MATLAB and diffusion tool kit, ROI placed within the lesion and perilesional edema to measure the diffusion parameters and CBF.

  18. Results contd… • CBF measured in the enhancing wall/lesion (enhancing) was significantly higher in the neoplastic group as compared to non-neoplastic group (69.32+42; 0. 26.21+19;; p=0.002). • No significant difference was found in DTI derived parameters and CBF of peri-lesional edema of the two groups.

  19. Results contd… • Neoplastic lesion ---Bivariate correlation between FA and CBF of enahancing wall/lesion was 0.767 (p value 0.006). • No significant correlation between FA and CBF of perilesional edema. • Non-neoplastic lesion---no significant correlation between FA and CBF

  20. Summary Enhancing wall/lesion • DTI - FA measured in the enhancing wall/lesion was significantly higher in the non-neoplastic group as compared to neoplastic group.No significant differences in the other DTI derived parameters were found. • ASL- Significant high CBF of enhancing wall/lesion of neoplastic as compared to non neoplastic group (p= 0.002). Perilesional Edema- • No significant difference was found in DTI derived parameters and CBF of peri-lesional edema of the two groups.

  21. Conclusion • Neoplastic and non-neoplastic intracranial lesions can be differentiated using DTI derived FA and ASL derived CBF measured in the wall/lesion.

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