Post contrast three dimensional MP RAGE T1WI sequence compared to brain MRV (TOF study) in diagnosing brain sinus venous thrombosis

doi:10.21203/rs.3.rs-3778785/v1

Aim : To compare the accuracy of MRV TOF and post contrast MP-RAGE sequences in diagnosis of cerebral sinus venous thrombosis .

Methods and materials : After all informed consents were obtained and upon ethical committee approval from the ethical committee in Joradanian Royal medical services in Amman we perform this study as a retrospective study done on 50 patients with cerebral sinus venous thrombosis with 50 pateints control group done at king Hussein medical center in Amman Jordan . The guidelines and regulations of studies conducted in Royal medical services were followed . 68 females and 32 males with age range between 19 and 52 years All patients underwent brain MRI for evaluation of cerebral sinus thrombosis , all studies were done on seimens skyra 3 tesla machine with standardized protocol including 2 D TOF MRV , axial T2WI , axial FLAIR , Axial T1 , SWI and diffusion weighted images along with 3D MP-RAGE post contrast . Images were reviewed by two well experienced neuroradiologists ( Maysoon and Qamar ) in separate sessions , each MRI sequence was reported separately without knowing patients name or clinical history . The results for T2 WI , SWI , MRV TOF and MP-RAGE post contrast were reported . We used a confidence level score to standardize the results Then the results were analyzed using simple statistical methods .

Health sciences/Anatomy

Health sciences/Neurology

To compare the accuracy of MRV TOF and post contrast MP-RAGE sequences in diagnosis of cerebral sinus venous thrombosis .

After all informed consents were obtained and upon ethical committee approval from the ethical committee in Joradanian Royal medical services in Amman we perform this study as a retrospective study done on 50 patients with cerebral sinus venous thrombosis with 50 pateints control group done at king Hussein medical center in Amman Jordan .

The guidelines and regulations of studies conducted in Royal medical services were followed .

68 females and 32 males with age range between 19 and 52 years

All patients underwent brain MRI for evaluation of cerebral sinus thrombosis, all studies were done on seimens skyra 3 tesla machine with standardized protocol including 2 D TOF MRV, axial T2WI, axial FLAIR, Axial T1, SWI and diffusion weighted images along with 3D MP-RAGE post contrast .

Images were reviewed by two well experienced neuroradiologists ( Maysoon and Qamar ) in separate sessions, each MRI sequence was reported separately without knowing patients name or clinical history .

The results for T2 WI, SWI, MRV TOF and MP-RAGE post contrast were reported .

We used a confidence level score to standardize the results

Then the results were analyzed using simple statistical methods .

For each patient 4 sequences were reported for evidence of sinus thrombosis and a score indicating the level of confidence was given by each of the two neuroradiologists , the scoring system is as shown below in table 1:

Table 1: the scores for level of confidence used in the study .

Description	Definitely absent	Probably absent	Uncertain	Probably present	Definitely present
score	1	2	3	4	5

Then the mean of the scores given by the two radiologists were assigned to each sequence . if the score is 4 or 5 it is considered positive and if the score is 1 or 2 it is considered negative .

The sequences evaluated were T2 WI images and the findings considered positive is loss of signal void of the sinuses .

The 2^nd sequence was the Susceptibility weighted images ( SWI ) and it was considered positive in presence of blooming artifact within sinuses or cortical veins

The 3^rd sequence was the MRV TOF images with maximum intensity projection images (MIP ) and these were considered positive if there is non-visualization of part of sinus or presence of filling defect . in case of suspicion of hypoplasia or aplasia of dural sinuses access to the source images is given to the radiologists before scoring the sequence .

The 4^th sequence which is the MP-RAGE post contrast and it was considered positive in case of visualization of the thrombus within the cerebral sinuses .

The results were as in the following table 2

Table 2 : net results after averaging results from neuroradiologists

Sequence	True positive	True negative	False positive	False negative
T2WI	42	32	21	5
SWI	40	30	25	5
MRV-TOF	46	36	15	3
MP-RAGE	48	46	4	2

The sensitivity and specificity for each sequence was then calculated using simple statistical methods as following

Sensitivity = true positive results devided by true positive added to false negative results.

Specificity = true negative devided by true negative added to false positive results .

The results were as following table 3 :

Table 3 : specificity and sensitivity of each sequence

sequence	T2WI	SWI	MRV TOF	MP-RAGE POST CONTRAST
sensetivity	90	89	94	96
specificity	60	54	71	92

After that the results were linked to the satge of the thrombus whether acute , subacute or chronic , and also linked to the anatomical segment involved by the thrombosis and observatios were recorded and will be discussed later in this paper .

Cerebral dural sinus thrombosis is life threatening clinical condition with major impact on health and life style, luckily this serious condition is potentially completely reversible if it is diagnosed early and accurately, and then treated properly.

Cerebral sinus thrombosis accounts for around 1 percent of all strokes worldwide and affects relatively younger age groups than arterial strokes especially women in reproductive age group .

The necessity for prompt and accurate diagnosis made it challenging for both clinicians and radiologists. so that, advances in imaging in both software and hardware are mandatory to improve the diagnostic yield and eventually the prognostic outcome .

MRI is the gold standard method for diagnosis. the routine or basic MRI sequences are subject to misdiagnosis mostly due to variation of signal intensity of flowing blood, the anatomic variation of venous system and the changes of signal intensity of the thrombus according to the clot age .

Susceptibility Weighted images ( SWI ) is a sequence where we use the artifacts to help us in diagnosis, it is used to detect the compounds that distort the local magnetic field such as blood products and calcium by causing blooming artifact. it is proved sensitive for microhemorrhage, in acute sinus thrombosis and in our case proved helpful in detection of cortical vein thrombosis .

MRV TOF sequence improves the accuracy of MRI study as it shows the flowing blood in sinus system and the filling defects. it is done without IV contrast with high sensitivity for sinus thrombosis but it is not that specific due to many factors such as the presence of arachnoid granulation, the normal variants such hypoplasia or aplasia of the dural sinuses, the anatomical variation of number and position of cortical veins. it should be always done as add-on sequence to routine brain MRI study and never done as stand-alone study .

Magnetization prepared rapid gradiant echo sequence done in 3 dimensions ( MP-RAGE ) is one of the great recent advances in imaging of the brain, it captures high tissue contrast and provides high spatial resolution with whole brain coverage in short scan time, it is very important in evaluation of structural brain changes. it has many uses in imaging of multiple sclerosis and and evaluation of neuronal migration disorders .

When done in post contrast it has superior visualization of the intracranial venous system compared to other imaging modalities.

In our study it showed higher sensitivity and specificity in detection of brain sinus thrombosis. it can easily detect anatomic variations in dural sinuses and cortical veins, it can easily delineate thrombus and arachnoid granulation. the confidence level and the time needed for diagnosis is relatively better than with other imaging sequences .

The drawback of this sequence is with chronic sinus thrombosis because the clot might enhance in chronic stage. this is the only case where the TOF MRV is superior to MPRAGE post contrast .

Similar studies were done and the results were comparable to our study and some of these results is shown in the following Table 4 and 5 :

Table 4

sensitivity of sequences in similar studies Specificity :
Name of study	T2WI	SWI	MRV TOF	MP-RAGE POST CONTRAST
Meckel, reisinger et.al	62	49	42	76
Luxia liang et.al	7.7	na	51	83
Galareh sadigh et.al	58	42	na	86

Table 5

specificity of sequences in similar studies
Name of study	T2WI	SWI	MRV TOF	MP-RAGE POST CONTRAST
Meckel, reisinger et.al	98	98	96	99
Luxia liang et.al	92	NA	92	99
Galareh sadigh et.al	97	90	NA	97

All these studies agreed on that the post contrast MP-RAGE is both highly sensitive and specific sequence for evaluation of sinus thrombosis .

In this study several observations should be addressed because of its clinical and radiological implications on patient prognosis .

First is the value of SWI in assessing cortical vein thrombosis, it is proved to be the best imaging sequence with high sensitivity compared with MRV TOF which nearly has no value in assessing cortical veins .

Second is that MRV TOF should not be evaluated separate from other imaging sequences and this proved important in cases of arachnoid granulation, hypoplasia of dural sinuses, cortical vein thrombosis and tumors compressing the dural sinuses .

Next are multiple images from cases in this study with footnots about each image

Mp-rage post contrast has higher sensitivity and specificity than MRV TOF in most cases of cerebral sinus thrombosis except in case of chronic dural sinus thrombosis

Combination of imaging sequences improve the diagnostic yield and improve patient prognosis

SWI is useful in assessing cortical veins

All these sequences should be evaluated as complementary to routine MRI sequences .

Ethical approval :

After all informed consents obtained , The ethical approval from Jordanian Royal medical services ethical committee is obtained before conducting the study . the necessary approvals from head of radiology department . the ethical committee approval for conducting the study and for publication is aattached in decleration section .

Funding : no funds were received for this study .

materials and data:

All materials and data used in this study are available on AGFA enterprise PACS system in king Hussein medical center in Jordanian Royal medical services and may be presented upon request. The person to be contacted regarding this issue is Jameel Shawaqfeh at email [email protected]

Author Contribution

Maysoon Banihani reviewed the images , reported them and each sequence a score based on confidence level of whether or not the pathology was present Qamar Malabeh reviewed the images , reported them and each sequence a score based on confidence level of whether or not the pathology was present .Jameel Shawaqfeh did the results analysis , the statistical work and wrote the manuscript . Maher Khawaldeh did the results analysis , the statistical work and wrote the manuscript .mohammad Alhazaimeh did the results analysis , the statistical work and wrote the manuscript .

Lisette f .van dam et al , current imaging modalities for diagnosing cerebral vein thrombosis , a critical review , thrombosis research 189: 132-139
Luxia liang et al , evaluation of intracranial dural sinuseswith 3 D contrast enhanced MP-RAGE . prospective study comparison with 2D TOF MRV and DSA , AJNR 22:481-491
Vivek Pai et al , pearls and pitfalls in MR diagnosis of dural sinus thrombosis , journal of clinical imaging science .
Galerah sadigh et al , diagnostic performance of MRI sequences for evaluation ofdural venous sinus thrombosis , AJR2016;206:1289-1306
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No competing interests reported.

Post contrast three dimensional MP RAGE T1WI sequence compared to brain MRV (TOF study) in diagnosing brain sinus venous thrombosis

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