MR‐guided sclerotherapy of low‐flow vascular malformations using T2‐weighted interrupted bSSFP (T2W‐iSSFP): Comparison of pulse sequences for visualization and needle guidance

Purpose Image-guided treatment of low-flow vascular (venous or lymphatic) malformations presents a challenging visualization problem, regardless of the imaging modality being used for guidance. The purpose of this study was to employ a new magnetic resonance imaging (MRI) sequence, T2-weighted interrupted balanced steady-state free precession (T2W-iSSFP), for real-time image guidance of needle insertion. Materials and Methods T2W-iSSFP uses variable flip angle balanced steady-state free precession (bSSFP, a.k.a. SSFP) to establish T2-weighting and fat suppression. Swine (n = 3) and patients (n = 4, three female, all with venous malformations) were enrolled in the assessment. T2-weighted turbo spin echo (T2-TSE) with spectral adiabatic inversion recovery (SPAIR), SPAIR-T2-TSE or T2-TSE for short, was used as the reference. T2-weighted half Fourier acquired single shot turbo spin echo (T2-HASTE) with SPAIR (SPAIR-T2-HASTE, T2-HASTE for short), fat saturated bSSFP (FS-SSFP), and T2W-iSSFP were imaged. Numeric metrics, namely, contrast-to-noise ratio (CNR) efficiency (CNR divided by the square root of acquisition time) and local sharpness (the reciprocal of edge width), were used to assess image quality. MR-guided sclerotherapy was performed on the same patients using real-time T2W-iSSFP to guide needle insertion. Results Comparing the visualization of needles in the images of swine, the local sharpness (mm−1) was: 0.21 ± 0.06 (T2-HASTE), 0.48 ± 0.02 (FS-SSFP), and 0.49 ± 0.03 (T2W-iSSFP). T2W-iSSFP is higher than T2-HASTE (P < 0.001). For the patient images, their CNR efficiencies were: 797 ± 66 (T2-HASTE), 281 ± 44 (FS-SSFP), and 860 ± 29 (T2W-iSSFP). T2W-iSSFP is higher than FS-SSFP (P < 0.02). The frame rate of T2W-iSSFP was 2.5–3.5 frames per second. All MR-guided sclerotherapy procedures were successful, with all needles (six punctures) placed in the targets. Conclusion T2W-iSSFP provides effective lesion identification and needle visualization. This new pulse sequence can be used for MR-guided sclerotherapy of low-flow vascular malformations. It may have potential use in other MR-guided procedures where heavily T2-weighted real-time images are needed. J. Magn. Reson. Imaging 2015;41:525–535.© 2013 Wiley Periodicals, Inc.