Korean J Radiol.  2017 Dec;18(6):973-982. 10.3348/kjr.2017.18.6.973.

Qualitative and Quantitative Comparison of Contrast-Enhanced Fluid-Attenuated Inversion Recovery, Magnetization Transfer Spin Echo, and Fat-Saturation T1-Weighted Sequences in Infectious Meningitis

Affiliations
  • 1Department of Radiology, SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun 248001, India. rajivas23@yahoo.com
  • 2Department of Pathology, SGRR Institute of Medical & Health Sciences, Patel Nagar, Dehradun 248001, India.

Abstract


OBJECTIVE
To compare the contrast-enhanced fluid-attenuated inversion recovery (CE-FLAIR), the CE T1-weighted (CE-T1W) sequence with fat suppression (FS) and magnetization transfer (MT) for early detection and characterization of infectious meningitis.
MATERIALS AND METHODS
Fifty patients and 10 control subjects were evaluated with the CE-FLAIR and the CE-T1W sequences with FS and MT. Qualitative assessment was done by two observers for presence and grading of abnormal leptomeningeal enhancement. Quantitative assessment included computation of net meningeal enhancement, using single pixel signal intensity software. A newly devised FLAIR based scoring system, based on certain imaging features including ventricular dilatation, ependymal enhancement, infarcts and subdural effusions was used to indicate the etiology. Data were analysed using the Student's t test, Cohen's Kappa coefficient, Pearson's correlation coefficient, the intraclass correlation coefficient, one way analysis of variance, and Fisher's exact test with Bonferroni correction as the post hoc test.
RESULTS
The CE-FLAIR sequence demonstrated a better sensitivity (100%), diagnostic accuracy (95%), and a stronger correlation with the cerebrospinal fluid, total leukocyte count (r = 0.75), protein (r = 0.77), adenosine deaminase (r = 0.81) and blood glucose (r = -0.6) values compared to the CE-T1W sequences. Qualitative grades and quantitative meningeal enhancement on the CE-FLAIR sequence were also significantly greater than those on the other sequences. The FLAIR based scoring system yielded a diagnostic accuracy of 91.6% and a sensitivity of 96%. A strong inverse Pearson's correlation (r = -0.95) was found between the assigned score and patient's Glasgow Coma Scale at the time of admission.
CONCLUSION
The CE-FLAIR sequence is better suited for evaluating infectious meningitis and could be included as a part of the routine MR imaging protocol.

Keyword

FLAIR; Meningitis; Cerebrospinal fluid

MeSH Terms

Adenosine Deaminase/cerebrospinal fluid
Adolescent
Adult
Aged
Aged, 80 and over
Blood Glucose/analysis
Child
Child, Preschool
Contrast Media/chemistry
Female
Humans
Leukocyte Count
Magnetic Resonance Imaging/*methods
Male
Meningitis/*diagnosis
Middle Aged
Sensitivity and Specificity
Young Adult
Blood Glucose
Contrast Media
Adenosine Deaminase

Figure

  • Fig. 1 Flow diagram depicting recruitment of subjects and study design following STARD guidelines. CE-FLAIR = contrast-enhanced fluid-attenuated inversion recovery, CE-T1W = contrast-enhanced T1-weighted, CSF = cerebrospinal fluid, FS = fat suppression, MT = magnetization transfer

  • Fig. 2 MR imaging in 75-year-old male with tubercular meningitis. CE-FLAIR (A, D) CE-T1W with MT (B), CE-T1W with FS images (C), DWI (E) depict grade 3 meningeal enhancement on CE-FLAIR sequence (arrows), compared to only grade 2 and grade 1 enhancement on CE-T1W sequences with MT and FS, respectively. Obstructive hydrocephalus and acute infarct (elbow arrow) in pons (due to vasculitis) are also seen. Assigned score of 7 was consistent with tubercular meningitis.

  • Fig. 3 MR imaging in 17-year-old female with pyogenic meningitis. CE-FLAIR (A), CE-T1W with MT (B, D) CE-T1W with FS (C), images DWI (E) reveal better enhancement on CE-FLAIR sequence (arrows), compared to grade 1 enhancement on CE-T1W sequences with MT and hardly any enhancement on CE-T1W sequence with FS. Assigned score of 4 was overlapping, but subdural empyema (elbow arrows) with diffusion restriction (seen along left cerebello-pontine angle) favored pyogenic etiology.

  • Fig. 4 MR imaging in 66-year-old female with viral meningitis. CE-FLAIR (A), CE-T1W with MT (B), CE-T1W with FS images (C) reveal grade 1 enhancement only on CE-FLAIR sequence (elbow arrows). No vascular enhancement is discernible. Assigned score of 1 in this case was consistent with viral etiology.

  • Fig. 5 MR imaging in 32-year-old male presenting with fever, headache and vomiting. CE-FLAIR (A), CE-T1W with MT (B), CE-T1W with FS images (C) reveal grade 2 enhancement on CE-FLAIR sequence, compared to grade 1 enhancement on CE-T1W sequences with MT and FS (arrows). This case was falsely interpreted as pyogenic instead of tubercular meningitis on basis of assigned score of 2.


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