DOI:10.2214/AJR.07.2114
AJR 2007; 189:1443-1448
© American Roentgen Ray Society
Assessment of Low Signal Adjacent to the Falciform Ligament on Contrast-Enhanced MRI
Michael Macari1,
Rita Yeretsian1 and
James Babb1
1 All authors: Department of Radiology, Abdominal Imaging, New York University
School of Medicine, Tisch Hospital, 560 First Ave., Ste. HW 202, New York, NY
10016.
Received February 22, 2007;
accepted after revision June 10, 2007.
Address correspondence to M. Macari
(michael.macari{at}nyumc.org).
Abstract
OBJECTIVE. Geographic low signal in the medial segment of the liver
seen on contrast-enhanced MRI has been attributed to focal fatty infiltration.
Using in- and opposed-phase gradient-recalled echo (GRE) T1-weighted MRI, we
attempted to determine if this finding represents focal fatty
infiltration.
MATERIALS AND METHODS. From a radiology information system, we
identified 174 consecutive patients who underwent contrast-enhanced abdominal
MRI. Subjects with diffuse liver disease were excluded. The presence of
geographic low signal adjacent to the falciform ligament in the anterior
medial aspect of the medial segment of the liver during dynamic
gadolinium-enhanced imaging was assessed during the arterial, portal venous,
and equilibrium phases of enhancement. If this finding was present on any
contrast-enhanced sequence, in- and opposed-phase images were qualitatively
evaluated to determine if signal loss occurred on opposed-phase imaging.
RESULTS. Fifty-three patients were excluded because of diffuse liver
disease. Twenty-one (17.4%) of the remaining 121 patients showed focal low
signal during gadolinium-enhanced MRI. This finding was present in all 21
patients during the portal venous phase and in seven and five during the
arterial and equilibrium phases of enhancement, respectively. Of the 21
patients, three showed signal loss on opposed-phase imaging and 18 (85.7%) did
not.
CONCLUSION. Although low attenuation or signal adjacent to the
falciform ligament may represent focal fat, it usually does not and is likely
related to anomalous venous drainage into the liver.
Keywords: focal fat • in- and opposed-phase imaging • liver • MRI
Introduction
Fatty deposition in the liver is common and has many imaging
manifestations. It may be diffuse and is often related to alcohol, diabetes,
certain drugs and medications, or obesity
[1–6].
Occasionally, there may be diffuse fatty infiltration in the liver with focal
areas of sparing or focal areas of fatty deposition in an otherwise normal
liver
[4–6].
At imaging, fatty deposition is seen as increased echogenicity on sonography,
decreased attenuation on CT, or areas of signal loss on T1-weighted
gradient-echo opposed-phase imaging relative to images acquired in phase
[1].
In cases of diffuse fatty liver, common locations for fatty sparing occur
around the gallbladder, in the posterior medial segment, and around tumors
such as hemangiomas. The cause is likely related to a lack of direct portal
venous inflow into these areas of the liver
[4–6].
It has been suggested that for fatty liver to occur, superior mesenteric
venous inflow to the liver parenchyma is required. If superior mesenteric
venous inflow is lacking or reduced, fatty sparing may occur. The typical
areas of fatty sparing seen in the posterior medial segment and around the
gallbladder are explained by aberrant right gastric and direct cholecystic
venous drainage directly into these regions of the liver, respectively
[6]. Similarly, around tumors,
the portal venous supply may be reduced because of direct venous compression
or because of increased arterial flow resulting in focal fatty sparing
[4].
The cause of focal fatty deposition in the liver is not so easy to explain
and has many imaging manifestations. It has been described as being round and
occasionally multifocal and in these cases may mimic tumors
[7,
8]. Rarely, focal fatty
infiltration may be perivascular and mimic hepatic inflammation
[3]. Although focal
abnormalities in the posterior aspect of the medial segment of the liver are
usually due to focal sparing as previously described, a case of focal fatty
deposition has been described in this location
[9].
A common location for focal fatty infiltration in the liver has been
described as occurring in the medial segment of the left lobe, usually
anteriorly, and adjacent to the falciform ligament
[1,
9,
10]. This is usually seen as a
geographic area of decreased attenuation relative to the background liver
parenchyma at contrast-enhanced CT
[10,
11]. The exact cause for the
development of focal fatty infiltration in this region of the liver is poorly
understood but thought to be due to aberration in blood flow with direct blood
flow into the liver from anterior abdominal wall veins (the inferior vein of
Sappey) somehow causing disturbances in the metabolic activity of the liver
with resultant fatty change
[12,
13].
We have observed areas of decreased signal intensity in this area at
contrast-enhanced MRI that did not show signal loss on opposed-phase
T1-weighted gradient-echo sequences. Therefore, using imaging data obtained at
in- and opposed-phase gradient-echo T1-weighted sequences as a surrogate for
fatty deposition, we performed this retrospective study to determine how often
geographic decreased signal at contrast-enhanced MRI in the anterior medial
segment of the left lobe of the liver actually represented focal fatty
deposition.
Materials and Methods
Subjects
Our institutional review board approved the protocol, which was exempt from
full review, and the study was HIPAA compliant. The requirement for informed
patient consent was waived. From May 1 until July 14, 2006, 174 patients were
identified from our radiology information system who underwent
contrast-enhanced abdominal MRI. The patients included 70 men and 104 women;
mean age, 57.2 years; age range, 18–81 years. The indications for
abdominal MRI included abdominal pain; liver, pancreatic, or renal lesion
characterization; pancreatitis; and biliary evaluation.
MRI Technique
All 174 patients underwent abdominal MRI at 1.5 T using either a Vento or
Symphony magnet (Siemens Medical Solutions) and a torso phased-array coil. A
22-gauge IV catheter was inserted into an arm vein. All patients underwent a
breath-hold spoiled gradient-echo T1-weighted sequence using a dual-echo for
in-phase (TR/TE, 180/4.7) and opposed-phase (TR/first- and second-echo TEs,
180/1.9, 2.3) imaging with 80° flip angle and 6- to 8-mm-thick sections
with a 1.6-mm gap.
All patients underwent breath-hold T2-weighted imaging with a HASTE
sequence with parameters TR/TEeff, 900/88; 150° flip angle; 5-mm-thick
sections; and no gap. In addition, heavily T2-weighted sequences were obtained
using either a STIR sequence with parameters TR/TE, 4,350/85; inversion time,
180 milliseconds; 144° flip angle; 8-mm-thick sections;1.6-mm gap
(n = 16) or a fat-suppressed fast spin-echo technique with parameters
3,570/101, 180° flip angle, 8-mm-thick sections, 1.6-mm gap (n =
9).
Contrast-enhanced imaging was performed using a volumetrically acquired 3D
fat-suppressed gradient-recalled echo (GRE) sequence with parameters 3.3/1.3;
12° flip angle; and slice thickness, 2.4 mm. This sequence was run before
and during a dual arterial phase acquisition, and at approximately 60 (venous
phase) and 180 (equilibrium phase) seconds after the IV administration of 20
mL of gadopentetate dimeglumine (Magnevist, Berlex Laboratories).
The arterial phase acquisition was determined after a test bolus of 1 mL of
gadolinium was injected followed by a 20-mL saline flush using serially
acquired T1-weighted images. The parameters were 500/1.66 with 10-mm-thick
sections. The time-to-peak was calculated on the basis of visual observation
and was used as the time to initiate the first arterial phase acquisition. The
second arterial phase was obtained 5 seconds after the completion of the first
arterial phase. All data were sent to a PACS workstation.
Data Interpretation
All MR data were retrospectively evaluated by two reviewers in consensus on
a PACS workstation in the following manner. Patients with diffuse hepatic
disease (cirrhosis, diffuse fatty infiltration or diffuse iron deposition,
prior liver transplantation, or multiple metastases or hepatocellular
carcinoma [HCC]) were excluded from the analysis. Exclusion was based on
consensus review of MRI data. Exclusion was based solely on the MRI
appearance. Laboratory data were not used as criteria for exclusion.
Fifty-three (30.5%) of the 174 patients were excluded due to the presence of
cirrhosis (n = 37), diffuse fatty infiltration (n = 5),
multiple liver metastases or HCC (n = 7), liver transplant
(n = 3), and hemochromatosis (n = 1).
In patients without diffuse liver disease, the multiphase volumetrically
acquired 3D fat-suppressed GRE T1-weighted sequences acquired during the
arterial, portal venous, and equilibrium phases of contrast enhancement were
reviewed for the presence of geographic low signal intensity adjacent to the
falciform ligament in the anterior medial aspect of the medial segment of the
left lobe of the liver. The contrast-enhanced data were evaluated to determine
if the low signal was present on either of the two arterial, venous, or
equilibrium phases of enhancement. When present, the size of the area was
measured in millimeters. The greatest transverse diameter of the decreased
enhancement was measured by a single reviewer using electronic calipers on the
PACS. Measurements were made on axial images during the contrast-enhanced
sequence that showed the focal area as being most visually conspicuous.
If this finding was present on any of these contrast-enhanced sequences,
the in- and opposed-phase images and the axial T2-weighted sequences were
reviewed and qualitatively assessed to evaluate for signal loss on
opposed-phase imaging when compared with the in-phase images, which served as
surrogate markers for focal fatty deposition. The T2-weighted images were
qualitatively evaluated for focal areas of high or low signal in the area. If
an abnormality was seen on the opposed-phase or the T2-weighted sequence it
was measured in millimeters as previously described. The exact z-axis
position was used from data on the images to correlate the gradient-echo
T1-weighted and T2-weighted sequences to the contrast-enhanced images.
Statistical Analysis
The prevalence of decreased signal on the contrast-enhanced sequences and
of signal loss on opposed-phase imaging when decreased signal was observed
were expressed as percentages. The Blyth-Still-Casella procedure was used to
derive exact CIs for these percentages. All statistical computations were
performed using StatXact, version 6.2.0 (Cytel Software).
Results
Twenty-one (17.4%) of the 121 patients without diffuse liver disease showed
focal low signal intensity in the anteromedial aspect of the medial segment of
the liver on the contrast-enhanced acquisition
(Table 1). The mean size was 15
mm with a range of 9–25 mm. During contrast-enhanced imaging, this
finding was seen during at least one of the arterial phase acquisitions in
seven of 21 patients (33.3%; 95% CI, 14.6–55.1%), on the venous phase in
21 of 21 patients (100%; 95% CI, 85.4–100%), and on the equilibrium
phase in five of 21 patients (23.8%; 95% CI, 8.5–40.6%).
When correlating the decreased signal on the contrast-enhanced sequences
with the T2-weighted sequences, no focal abnormality in T2 signal was seen in
any of the patients. When correlating the decreased signal on the
contrast-enhanced sequences, three patients showed signal loss on
opposed-phase imaging when compared with the in-phase sequences at the same
z-axis level. Eighteen (85.7%) of 21 did not show signal loss on
opposed-phase imaging (Figs.
1A,
1B,
1C,
1D,
1E,
2A,
2B,
2C,
2D,
2E,
3A,
3B,
3C, and
3D). All 21 patients showed no
focal signal abnormality on the in-phase images.
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Fig. 1A —26-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on arterial and venous phases (patient 21 in
Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during arterial
phase shows focal geographic low signal in liver (arrows).
|
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Fig. 1B —26-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on arterial and venous phases (patient 21 in
Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during venous
phase shows focal geographic low signal (arrows).
|
|
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Fig. 1C —26-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on arterial and venous phases (patient 21 in
Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during
equilibrium phase shows no focal geographic low signal (arrows).
|
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Fig. 1D —26-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on arterial and venous phases (patient 21 in
Table 1). Axial gradient-echo
T1-weighted in-phase MR image shows no focal geographic low signal
(arrow).
|
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Fig. 1E —26-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on arterial and venous phases (patient 21 in
Table 1). Axial gradient-echo
T1-weighted opposed-phase MR image shows no focal geographic low signal
(arrow).
|
|
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Fig. 2A —18-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase of aortic enhancement
(patient 18 in Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during arterial
phase shows no focal geographic low signal in liver (arrow).
|
|
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Fig. 2B —18-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase of aortic enhancement
(patient 18 in Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during venous
phase shows focal geographic low signal (arrows).
|
|
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[as a PowerPoint slide]
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Fig. 2C —18-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase of aortic enhancement
(patient 18 in Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during
equilibrium phase shows no focal geographic low signal (arrow).
|
|
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[in this window]
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[as a PowerPoint slide]
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Fig. 2D —18-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase of aortic enhancement
(patient 18 in Table 1). Axial
gradient-echo T1-weighted in-phase MR image shows no focal geographic low
signal (arrow).
|
|
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[in this window]
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[as a PowerPoint slide]
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Fig. 2E —18-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase of aortic enhancement
(patient 18 in Table 1). Axial
gradient-echo T1-weighted opposed-phase MR image shows no focal geographic low
signal (arrow).
|
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Fig. 3A —59-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase (patient 7 in
Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during arterial
phase shows no focal geographic low signal in liver. Note small central vessel
within region (arrow). Asterisk indicates pancreatic pseudocyst.
|
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Fig. 3B —59-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase (patient 7 in
Table 1). Axial
contrast-enhanced gradient-echo T1-weighted MR image obtained during venous
phase shows focal geographic low signal (arrows). Asterisk indicates
pancreatic pseudocyst.
|
|
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[in this window]
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[as a PowerPoint slide]
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Fig. 3C —59-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase (patient 7 in
Table 1). Axial gradient-echo
T1-weighted in-phase MR image shows no focal geographic low signal
(arrows). Asterisk indicates pancreatic pseudocyst.
|
|
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
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Fig. 3D —59-year-old woman with focal low signal in anterior medial
aspect of medial segment of liver on venous phase (patient 7 in
Table 1). Axial gradient-echo
T1-weighted opposed-phase MR image shows focal geographic low signal
consistent with fatty deposition (arrows). Asterisk indicates
pancreatic pseudocyst.
|
|
On the basis of these results, there is 99% confidence that fewer than
26.4% of patients can be expected to manifest focal decreased enhancement in
the anterior medial aspect of the medial segment of the liver during dynamic
gadolinium-enhanced MRI. More important, our results show that there is 99%
confidence that low signal in the anterior medial aspect of the medial segment
of the liver on gadolinium-enhanced MRI will be associated with signal loss on
opposed-phase imaging in < 40% of cases.
Discussion
The presence of focal low attenuation or signal adjacent to the falciform
ligament in the anterior medial aspect of the medial segment of the left lobe
of the liver is often seen during contrast-enhanced CT or MRI, respectively.
This imaging finding usually has geometric morphology or well-circumscribed
borders and has been attributed to focal fatty deposition or to perfusion
abnormalities related to aberrant venous drainage with poor portal venous
inflow [1,
9,
10–13].
In our study, this finding was present in 17.4% of patients on
contrast-enhanced MRI during the venous phase of hepatic enhancement.
The process may be confused for a primary hepatic neoplasm or more commonly
as a metastasis in a patient with a known extrahepatic neoplasm. There are a
number of imaging findings that suggest its benign nature including the
typical location, presence of geometric borders, and visualization of the
hepatic vasculature traversing the region without distortion or interruption.
On unenhanced CT, nonspecific low attenuation may be seen in this region. At
MRI, the diagnosis of focal fatty deposition can be made by exploiting in- and
opposed-phase gradient-echo T1-weighted sequences
[14,
15].
In- and opposed-phase imaging takes advantage of the fact that MR voxels
that contain similar amounts of fat and water will lose signal on
opposed-phase imaging when compared with in-phase images. This is because
during gradient-echo sequences, the protons in fat and water resonate in phase
and out of phase depending on the TE and field strength of the magnet. At 1.5
T, protons are in phase at approximately 4.4 milliseconds and out of phase at
2.2 milliseconds [15]. Current
data acquisition techniques allow both of these echoes to be obtained in the
same sequence during a single short breath-hold. The in- and opposed-phase
images can then be interleaved. By viewing the in- and opposed-phase sequences
interleaved, subtle changes of fatty infiltration (which appear dark on
opposed-phase images relative to in-phase images) or T2*
susceptibility effects such as iron deposition (which appear dark on in-phase
images when compared with opposed-phase images) may be detected.
It is unclear why geographic fatty infiltration should affect the anterior
medial aspect of the medial segment of the liver. It has been hypothesized
that fatty infiltration and focal areas of fatty sparing in the liver are
likely related to local disturbances in hepatic blood flow that cause
alterations in metabolism [1,
4–10].
Several studies using combined CT hepatic arteriography and CT
arterioportography have shown aberrant vascular supply and drainage
corresponding to these geometric regions of decreased enhancement
[12,
13]. Another angiographic
study found that a draining abdominal wall vein, the vein of Sappey, drained
directly into the anterior medial aspect of the medial segment of the liver
[10]. In this patient, fatty
deposition was present in the region based on low attenuation on unenhanced
CT. Moreover, in patients who have superior vena cava obstruction, increased
venous collateral flow into the medial segment of the left lobe of the liver
may be present on early phase imaging in exactly the same location as
typically seen with focal fatty deposition
[16]. The early
hyperenhancement seen in this area of the liver in superior vena cava
obstruction usually becomes isoenhanced to adjacent hepatic parenchyma on
delayed phase imaging. This observation has been shown to be due to aberrant
non–portal venous drainage into the left lobe of the liver
[16].
We have observed that the geographic low signal in the medial segment seen
on contrast-enhanced imaging does not always correlate with loss of signal on
opposed-phase imaging. In the current study, we attempted to determine how
often this finding was present on contrast-enhanced MRI and how often it
reflected underlying focal fatty infiltration. We found that in the majority
of cases in which this finding was present on contrast-enhanced imaging, it
was not seen as signal loss on opposed-phase imaging. In fact, in 18 (85.7%)
of the 21 patients in whom the finding was present during the portal venous
phase of hepatic enhancement, signal loss on opposed-phase imaging was not
shown.
Our findings are similar to a previous study evaluating geometric
low-signal perfusion abnormalities in the liver at contrast-enhanced MRI
[11]. In that study,
low-signal perfusion abnormalities were seen in 15 (13%) of 103 patients
[11]. Twelve were in segment
IV, and all were seen during the venous phase of enhancement with variable
visualization during the arterial and equilibrium phases. Moreover, in only
one of the 15 cases was signal loss shown on opposed-phase imaging. Our study,
in contrast to the prior study, used a breath-hold dual-echo in- and
opposed-phase acquisition. On the PACS, these images can be interleaved, which
allows improved z-axis location evaluation of the in- and
opposed-phase imaging data. This theoretically should allow better evaluation
of subtle changes in signal intensity differences between in- and
opposed-phase data.
As has been previously shown, and as we have shown, focal decreased signal
seen on contrast-enhanced MRI in the anterior medial aspect of segment IV is
common. These areas are likely related to different venous inflows and
drainages and not focal fatty deposition
[11–13].
Indeed, during the arterial and equilibrium phases of hepatic enhancement, the
focal area of decreased signal was not present in 14 and 16, respectively, of
the 21 patients with decreased signal on the venous phase. This observation,
coupled with the fact that in the majority of cases no signal loss was seen on
opposed-phase imaging, suggests that the process is usually due to variations
in hepatic blood flow without focal fatty deposition.
There are several limitations to this study. First, histologic proof was
not present. However, MRI using in- and opposed-phase dual-echo acquisition
has become the imaging standard for diagnosing fatty deposition and is used
not only in the liver but in the adrenal gland to diagnose lipid-rich adenomas
and in the kidney to diagnose angiomyolipomas
[1,
3,
14,
15]. Moreover, the T1-weighted
in-phase images and the T2-weighted imaging sequences showed no focal
abnormality in the region. On none of the contrast-enhanced acquisitions was a
capsule or pseudocapsule present to suggest neoplasm. Second, confirmation
that the cause of the low signal at venous phase imaging was due to accessory
venous drainage was not established. However, to confirm this angiographically
would be invasive, and accessory venous drainage into this region of the liver
has been previously established
[12,
13]. In addition, the lack of
signal loss on opposed-phase imaging and the change in appearance during
different phases of contrast enhancement strongly support a perfusion
abnormality as the cause.
In conclusion, our study showed that focal decreased signal in the anterior
medial aspect of the medial segment of the liver is not rare and is seen in up
to 16.5% of cases during the venous phase of hepatic enhancement at
gadolinium-enhanced MRI. We noted fatty deposition in only 14% of cases. In
most cases, signal loss on opposed-phase imaging was not present at the same
z-axis position as the decreased signal on the venous phase of
enhancement. Our results suggest that there is 99% confidence that low signal
at gadolinium-enhanced MRI in this location will be associated with signal
loss on opposed-phase imaging in less than 40% of cases.
Thus, although low attenuation or signal adjacent to the falciform ligament
may represent focal fatty infiltration, it usually does not. When geographic
low signal is seen on contrast-enhanced imaging in the anterior medial segment
but does not show focal fat on opposed-phase imaging, a perfusion abnormality
should be considered rather than a neoplasm.
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Abstract
Introduction
