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Is True FISP Imaging Reliable in the Evaluation of Venous Thrombosis?

¹ Department of Radiology, Harvard Medical School and Beth Israel Deaconess Medical Center, One Deaconess Rd., Boston, MA 02215.
² Department of Radiology, Hospital de Basurto, Bilbao 48013, Spain.
³ Averion Inc., 4 California Ave., Framingham, MA 01701.

View larger version (158K): [in a new window]   Fig. 1A —46-year-old woman with breast carcinoma and facial swelling. Axial true fast imaging with steady-state precession image (TR/TE, 4.8/2.3; flip angle, 70°; matrix, 134 x 256; slice thickness, 5 mm) at level of mid chest shows low-signal-intensity filling defect in superior vena cava (SVC) (arrow). Small area of high signal intensity in medial aspect of SVC (arrowhead) is consistent with patent lumen.

View larger version (138K): [in a new window]   Fig. 1B —46-year-old woman with breast carcinoma and facial swelling. Coronal 3D fat-saturated T1-weighted gradient-echo image (4.2/1.7; flip angle, 25°; matrix, 160 x 256; slice thickness, 2 mm after interpolation) obtained 40 sec after arterial peak of biphasic injection of double dose of gadolinium (0.1 mL/kg body weight at 2 mL/sec followed by 0.1 mL/kg body weight at 0.8 mL/sec) confirms presence of thrombus within SVC (arrow) and patent lumen in its medial aspect (arrowhead).

View larger version (169K): [in a new window]   Fig. 2A —37-year-old man at follow-up examination after left hepatic lobectomy for resection of hepatocellular carcinoma; patient reported bilateral lower extremity swelling 10 days before MR examinations. Axial true fast imaging with steady-state precession image (TR/TE, 4.8/2.3; flip angle, 70°; matrix, 134 x 256; slice thickness, 5 mm) at level of superior abdomen shows slight heterogeneous appearance of inferior vena cava (IVC) (arrow) with minimal decrease in signal intensity compared with that of portal vein (arrowhead). Both reviewers interpreted this finding as no evidence for thrombus.

View larger version (154K): [in a new window]   Fig. 2B —37-year-old man at follow-up examination after left hepatic lobectomy for resection of hepatocellular carcinoma; patient reported bilateral lower extremity swelling 10 days before MR examinations. Coronal 3D fat-saturated T1-weighted gradient-echo image (4.2/1.7; flip angle, 25°; matrix, 160 x 256; slice thickness, 2 mm after interpolation) obtained 40 sec after arterial peak of biphasic injection of double dose of gadolinium (0.1 mL/kg body weight at 2 mL/sec followed by 0.1 mL/kg body weight at 0.8 mL/sec) shows large hypointense filling defect in IVC (arrowheads) consistent with thrombus. Right hepatic vein and suprahepatic IVC (arrows) are patent. This was confirmed by Doppler sonography and contrast-enhanced CT (not shown). Low-signal-intensity areas within liver (asterisks) are consistent with infarcts.

View larger version (143K): [in a new window]   Fig. 3A —43-year-old man with pulmonary embolism. Axial true fast imaging with steady-state precession (FISP) image (TR/TE, 4.8/2.3; flip angle, 70°; matrix, 134 x 256; slice thickness, 5 mm) at level of femoral heads shows bilateral low-signal-intensity filling defects in both common femoral veins (arrows). Both reviewers interpreted these findings as suspicious for venous thrombus.

View larger version (86K): [in a new window]   Fig. 3B —43-year-old man with pulmonary embolism. Coronal curved reconstructions from coronal 3D fat-saturated T1-weighted gradient-echo acquisition (4.2/1.7; flip angle, 25°; matrix, 160 x 256; slice thickness, 2 mm after interpolation) obtained 40 sec after arterial peak of biphasic injection of double dose of gadolinium (0.1 mL/kg body weight at 2 mL/sec followed by 0.1 mL/kg body weight at 0.8 mL/sec) shows normal enhancement of both right (B) and left (C) external iliac and common femoral veins (arrowheads). Nonocclusive thrombus is seen in left common iliac vein (arrow, C). Filling defects shown on true FISP image (A) are likely related to turbulent flow, pulsation artifact, or both. Doppler sonography examination (not shown) depicted no thrombus in common femoral veins. Follow-up MR examination (not shown) showed resolution of nonocclusive thrombus in left iliac vein after anticoagulation therapy.

View larger version (89K): [in a new window]   Fig. 3C —43-year-old man with pulmonary embolism. Coronal curved reconstructions from coronal 3D fat-saturated T1-weighted gradient-echo acquisition (4.2/1.7; flip angle, 25°; matrix, 160 x 256; slice thickness, 2 mm after interpolation) obtained 40 sec after arterial peak of biphasic injection of double dose of gadolinium (0.1 mL/kg body weight at 2 mL/sec followed by 0.1 mL/kg body weight at 0.8 mL/sec) shows normal enhancement of both right (B) and left (C) external iliac and common femoral veins (arrowheads). Nonocclusive thrombus is seen in left common iliac vein (arrow, C). Filling defects shown on true FISP image (A) are likely related to turbulent flow, pulsation artifact, or both. Doppler sonography examination (not shown) depicted no thrombus in common femoral veins. Follow-up MR examination (not shown) showed resolution of nonocclusive thrombus in left iliac vein after anticoagulation therapy.

View larger version (135K): [in a new window]   Fig. 4A —53-year-old man with right upper extremity thrombosis secondary to lipoma. Sagittal true fast imaging with steady-state precession image (TR/TE, 4.8/2.3; flip angle, 70°; matrix, 134 x 256; slice thickness, 5 mm) in right hemithorax at level of mid clavicle shows large hyperintense mass (asterisk) inferior in relation to subclavian vessels. Right subclavian vein (white arrowhead) shows slightly heterogeneous high signal intensity, which is similar to other veins (black arrowhead) in the same image. However, its signal intensity is mildly decreased compared with that of right subclavian artery (arrow). Both reviewers interpreted these findings as flow artifacts with patent subclavian vein.

View larger version (116K): [in a new window]   Fig. 4B —53-year-old man with right upper extremity thrombosis secondary to lipoma. Sagittal true fast imaging with steady-state precession image (4.8/2.3; flip angle, 70°; matrix, 134 x 256; slice thickness, 5 mm) in left hemithorax at level of mid clavicle shows left subclavian vein (arrowhead) has homogeneous hyperintense signal intensity, similar to that of subclavian artery (arrow).

View larger version (137K): [in a new window]   Fig. 4C —53-year-old man with right upper extremity thrombosis secondary to lipoma. Maximum intensity projection reconstruction of subtracted (venous minus arterial) coronal 3D fat-saturated T1-weighted gradient-echo image (4.2/1.7; flip angle, 25°; matrix, 160 x 256; slice thickness, 2 mm after interpolation) obtained 40 sec after arterial peak of biphasic injection of double dose of gadolinium (0.1 mL/kg body weight at 2 mL/sec followed by 0.1 mL/kg body weight at 0.8 mL/sec) shows occlusion of right subclavian vein (arrowhead), including at level of A; extensive venous collaterals in right shoulder area are also seen. Note normal left subclavian artery (arrow). These findings were confirmed by Doppler sonography examination (not shown).

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