Gastrointestinal Imaging Original Research

Kandpal et al. MRI of Focal Liver Lesions Gastrointestinal Imaging Original Research

Respiratory-Triggered Versus Breath-Hold Diffusion-Weighted MRI of Liver Lesions: Comparison of Image Quality and Apparent Diffusion Coefficient Values
Harsh Kandpal1 Raju Sharma1 K. S. Madhusudhan1 Kulwant Singh Kapoor 2
Kandpal H, Sharma R, Madhusudhan KS, Kapoor KS OBJECTIVE. The purpose of our study was to compare respiratory-triggered and breathhold diffusion-weighted liver MRI and to assess the agreement in the apparent diffusion coefficient (ADC) values between the two sequences. MATERIALS AND METHODS. Forty-eight patients (27 men, 21 women; mean age, 45.2 years) with focal liver lesions underwent respiratory-triggered and breath-hold diffusionweighted MRI (DWI) in addition to routine MRI. Both sequences had identical imaging parameters except for signal averages, which were 6 in respiratory-triggered and 2 in breathhold sequences. A total of 92 lesions (maximum of three lesions per patient; 37 benign, 55 malignant) were evaluated. Lesions were confirmed by typical imaging appearance, histopathology, or follow-up. Signal-to-noise ratio (SNR) of the liver, contrast-to-noise ratio (CNR), and relative contrast ratio of the lesions were measured in each DWI sequence and were statistically compared using the Mann-Whitney U test. The ADC values of normal liver and each category of liver lesions in the two sequences were compared for agreement using Pearsons coefficient and reliability analysis scale. RESULTS. The SNR of the normal liver was significantly better on respiratory-triggered DWI than on breath-hold DWI. The mean CNR of metastases, hepatocellular carcinomas, and abscesses was significantly better in the respiratory-triggered DWI than in the breathhold DWI sequences. The ADC values of liver and focal lesions measured by the two techniques showed good agreement. The SDs of the ADC values of normal liver were similar in the two sequences. CONCLUSION. Respiratory-triggered DWI should be preferred over breath-hold DWI for the evaluation of focal liver lesions because it provides better image quality and SNR without any compromise in the calculated ADC values. iffusion-weighted MRI (DWI) of the abdomen has seen significant improvements since the earliest reports more than two decades ago [1]. Several publications have endorsed its usefulness for the detection and characterization of focal hepatic lesions [213], for assessing treatment response [1416], and for the evaluation of diffuse liver diseases [17]. Unfortunately, DWI is yet to find a place in routine MRI of the liver, partly because the sequence lacks standardization [18]. DWI for liver imaging is typically a spinecho acquisition with motion-probing gradients on either side of the 180 refocusing pulse, followed by a single-shot echoplanar imaging readout. Unequivocal evidence supports the use of parallel imaging for liver DWI [19]; however, the same is not true for some other imaging parameters. DWI

Keywords: comparison, diffusion-weighted MRI, lesions, liver DOI:10.2214/AJR.08.1260 Received May 17, 2008; accepted after revision September 3, 2008.
1 Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Address correspondence to R. Sharma (raju152@yahoo.com). 2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

AJR 2009; 192:915922 0361803X/09/1924915 American Roentgen Ray Society

is most commonly performed during a single breath-hold, but some investigators have also used nonbreath-holding methods such as free-breathing DWI and respiratory-triggered DWI. Respiratory-triggered DWI of the liver has been shown to provide a better relative contrast ratio between malignant liver tumors and adjacent liver and has had less scattering of the apparent diffusion coefficient (ADC) values than free-breathing DWI [20]. More recent reports have shown encouraging results with respiratory-triggered DWI sequences in characterizing liver lesions [21, 22]. However, to our knowledge, a direct comparison of respiratory-triggered DWI and breath-hold DWI with respect to their image quality and ADC values has not been published in the literature. We hypothesized that respiratory-triggered DWI would provide better SNR than

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Kandpal et al. breath-hold DWI without adversely affecting the calculated ADC values. Hence, the aims of our study were to compare the image quality of respiratory-triggered DWI and breathhold DWI and to determine the effect of these sequence designs on the ADC values of liver parenchyma and focal hepatic lesions. Materials and Methods Subject Population
This single-institution study was approved by our institutional review board. Written informed consent was obtained from all patients. Fortyeight patients (27 male, 21 female; mean age, 45.2 years; age range, 1075 years) with focal hepatic lesions were recruited between March 2007 and March 2008. In 30 patients, MRI was performed for characterization of a liver lesion after its initial detection on sonography or CT. In the remaining 18 cases, the lesion was incidentally detected on MRI in patients being scanned for other indications. In patients with multiple lesions, a maximum of three lesions of each type per patient were selected for further analysis. This resulted in a total of 92 lesions (37 benign, 55 malignant) that included 11 hemangiomas, 11 cysts, six abscesses, 12 hepatocellular carcinomas (HCCs), 38 metastases, four tuberculomas, three lymphomas, three focal nodular hyperplasias (FNHs), and four miscellaneous lesions (one each hydatid cyst, biliary cystadenocarcinoma, cholangiocarcinoma, and fibrous tumor) (Fig. 1). The diagnosis was confirmed by the following reference standards: typical imaging findings in all cases of hemangioma, simple hepatic cysts, and FNH; aspiration of pus in all patients with abscess; and histopathologic proof in four HCCs and 35 metastases. The remaining eight HCCs had typical imaging features in patients who had raised -fetoprotein levels, and the remaining three metastatic lesions showed progression at follow-up imaging. Histopathologic proof was available for all lesions in the miscellaneous category. In addition to routine MRI sequences, respiratory-triggered DWI and breath-hold DWI were performed in all patients.
Focal hepatic lesions (n = 92)

Simple cyst (n = 11) Hemangioma (n = 11) Abscess (n = 6) Benign (n = 37) Tuberculoma (n = 4) Focal nodular hyperplasia (n = 3) Solitary fibrous tumor (n = 1) Hydatid cyst (n = 1)

Metastases (n = 38) Hepatocellular carcinoma (n = 12) Malignant (n = 55) Lymphoma (n = 3) Cholangiocarcinoma (n = 1) Biliary cystadenocarcinoma (n = 1)

Fig. 1Flowchart shows details of focal liver lesions that were evaluated with MRI, respiratory-triggered diffusion-weighted imaging (DWI), and breath-hold DWI.

MRI
Patients were examined on a 1.5-T, 32-channel superconducting MR system (Magnetom Avanto, Siemens Medical Solutions) with high-performance gradients (maximum gradient strength, 45 mTm1; maximum slew rate, 200 mTm1s1). Two 6-element body matrix coils placed anteriorly were used in conjunction with two posterior spine clusters (3 channels each) to optimize the SNR. The routine MRI protocol included a transverse T1-weighted fast gradient-recalled dual-echo

sequence (TR/in-phase TE/out-of-phase TE, 128/4.6/2.3; flip angle, 70; matrix, 134 256; section thickness and intersection gap, 7 and 0.7 mm; signal average, 1; field of view, 3540 cm) and a transverse multi-breath-hold T2-weighted fast spin-echo sequence with spectral fat saturation (TR/TE, 3,000/103; flip angle, 150; matrix, 115 256; section thickness and intersection gap, 7 and 0.7 mm; signal average, 1; field of view, 3540 cm). A dynamic contrast-enhanced 3D gradient-echo volumetric interpolated breath-hold examination (VIBE) sequence was performed in the arterial, venous, and delayed phases and, whenever indicated, in a hepatocyte-specific phase, after the injection of 0.1 mmol/kg of body weight of gadobenate dimeglumine at rate of 2 mL/s using a pressure injector. Diffusion-weighted MRITwo diffusionweighted single-shot echoplanar imaging sequences that are part of a vendor-supplied workin-progress package were performed in all patients before administration of contrast material. In diffusion-weighted single-shot echoplanar imaging, diffusion sensitization of a spin-echo sequence is done by placing motion-probing gradients on either side of the 180 pulse followed by a singleshot echoplanar readout in conjunction with parallel imaging. The DWI sequences shared the following common parameters: generalized autocalibrating partially parallel acquisition (GRAPPA) with a twofold acceleration factor, partial Fourier echoplanar imaging readout, spectral fat suppres-

sion, diffusion gradients applied in three orthogonal directions separately (i.e., 3-scan trace method, b values of 0 and 500 s/mm 2, and a sufficiently large field of view to avoid ghosting artifacts). Trace DW images and ADC maps were derived automatically on a voxel-by-voxel basis. GRAPPA was preferred over sensitivity-encoding because it provides better image quality in the abdomen [23]. Chemical shift selective fat suppression was preferred over an inversion-recovery fat-suppression technique because of its better SNR [4]. The noise level was kept at 20 as recommended for body DWI [23]. The shortest possible TE was ensured for all DWI sequences by using a rectangular field of view, parallel imaging, and a large bandwidth so that the TE approached the T2 relaxation time of liver (50 milliseconds at 1.5 T). The maximum b value of 500 s/mm 2 was chosen as an optimal compromise between image quality and adequate diffusion strength [16]. Various studies have reported satisfactory image quality at this b value [17, 18], and the calculated ADC is relatively free of perfusion contamination that predominates at low b values [19]. Other acquisition parameters were as follows: Respiratory-triggered DWIThese sequences used TR/TE, 1,600/60; field of view, 3640 cm; bandwidth, 1,736 Hz/pixel; section thickness and gap, 68 mm and 3060%; signal averages, 6; matrix, 96 192; number of slices, 16; acquisition time, ~ 12 minutes; b values, 0 and 500 s/mm 2. An increased number of signal averages (n = 6) was

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MRI of Focal Liver Lesions

Fig. 230-year-old woman with primary adrenal carcinoma and hepatic metastasis (arrow). AF, Single region of interest was drawn covering almost entire lesion. Lesion is hyperintense on images having b value of 500 s/mm2 (B and E), and apparent diffusion coefficient (ADC) maps (C and F) show restriction of diffusion. Greater signal and better overall image quality in respiratory-triggered (RT) diffusion-weighted imaging (DWI) sequence is apparent. Signal attenuation of left hepatic lobe due to cardiac pulsations is less in respiratory-triggered DW image (B) than in breath-hold (BH) DW image (E). The signal-to-noise ratio of liver, contrast-to-noise ratio, and relative contrast ratio of lesion on respiratory-triggered DWI were 57.3, 108.0, and 2.88, and on breath-hold DWI were 10.0, 13.8, and 2.38; and ADC values were 1.29 and 1.55 10 3 mm2 /s for respiratory-triggered versus breath-hold DWI.

used to improve the SNR and to reduce pulsatility effects. At a TR of 1,600, the acquisition window is limited to the expiratory phase, and the number of slices is sufficient to cover the entire liver in most cases. In cases in which the entire liver could not be covered, the sequence was repeated for additional coverage. Breath-hold DWIThe sequences used were TR/TE, 1,600/63; field of view, 3640 cm; bandwidth, 1,736 Hz/pixel; section thickness and gap, 68 mm and 3060%; signal averages, 2; matrix, 96 192; number of slices 16; acquisition time, 18- to 20-second breath-holds; b values, 0 and 500 s/mm2. The entire liver was covered in one or two breath-holds. The section thickness and intersection gap were kept identical to those in the respiratorytriggered DWI sequence in each case.

Image Analysis
Two abdominal radiologists with 8 and 6 years experience in abdominal MRI who had access to all routine MR images but were blinded to the clinical details, evaluated the DW images in consensus. The size, number (1, 2, 3), and location of lesions (right or left hepatic lobe) were assessed in each case on the routine MR images. Whenever lesions were multiple, the largest

lesions (maximum, three of each type per patient) were chosen for analysis. The presence of any severe ghosting, chemical shift, and or distortion artifacts in the DW images that could hamper image interpretation was recorded in each case. Quantitative comparison of the two sequences was performed by analyzing the DW images at the b value of 500 s/mm 2 and the ADC maps. For lesions smaller than 2 cm, a circular region of interest (ROI) encompassing as much of the lesion as possible was drawn on images with a b value of 500 s/mm2 and on the ADC map, avoiding necrotic or cystic portions of the lesion (Fig. 2). For lesions larger than 2 cm, two ROIs of similar size were drawn and the average of the two values was taken (Fig. 3). The image showing the maximum diameter of the lesion was chosen for drawing the ROI. When the lesion was not well visualized on the images with a b value of 500 s/mm 2, the T2-weighted image, the contrastenhanced T1-weighted image, and the images with a b value of 0 were reviewed for accurate placement of the ROI on the lesion. Likewise, a circular ROI (100 pixels in diameter) was placed on the images with a b value of 500 s/mm 2 and on the ADC map in the liver parenchyma adjacent to the lesion, avoiding artifacts and vessels. To

ensure identical placement of the ROI in the DW images and ADC maps, these two sets of images were simultaneously displayed on the workstation, and both sets were selected using the Ctrl function. Using this function, placing the ROI on the DW image automatically places an identical ROI on the ADC map at the same site. The site and size of the ROI were therefore identical in each of the respiratory-triggered and breath-hold DWI sequences and their ADC maps. For both DWI signal intensity and ADC value, two measurements were taken in each case and the values were averaged. The following parameters were then calculated from respiratory-triggered DW images and breath-hold DW images at a b value of 500 s/mm2: SNR = SIliver / noise, where SI is signal intensity; lesion-to-liver CNR = SIlesion SIliver / noise, and lesion-to-liver relative contrast ratio = SIlesion / SIliver. Likewise, from respiratory-triggered ADC and breath-hold ADC maps, mean ADCliver and mean ADClesion were calculated. Noise measurement with parallel imaging is tricky because the signal and the noise are dependent not only on the coil geometry and acceleration

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Kandpal et al. Respiratory-Triggered DWI and Breath-Hold DWI ADC Maps The mean ADC values of the right lobe of the liver (n = 42) as measured by respiratory-triggered DWI and breath-hold DWI were 1.39 10 3 mm2 /s ( 0.28 10 3 mm2 /s) and 1.35 10 3 mm2 /s ( 0.26 10 3 mm2 /s), respectively. The mean ADC values of the left lobe of the liver (n = 11) were 1.66 10 3 mm2 /s ( 0.41 10 3 mm2 /s) and 1.68 10 3 mm2 /s ( 0.39 10 3 mm2 /s). Correlation and reliability analysis of the ADC values of liver between the two techniques showed that the Pearsons coefficient was 0.66 (p < 0.001), and standardized item on the reliability analysis scale was 0.80, and intraclass correlation was 0.79. The ADC values in each category of liver lesions are shown in Figure 8 and Table 1. The ADC values of each category of lesions in respiratory-triggered DWI and breath-hold DWI were compared for agreement. Pearsons correlation showed significant agreement between the ADC values of lesions on respiratory-triggered DWI and breath-hold DWI (Pearsons coefficient, 0.88; p < 0.001). Reliability analysis scale revealed standardized item of 0.936, interitem correlation of 0.879, and intraclass correlation of 0.933. The SDs of ADCs of liver parenchyma and each category of liver lesions were only slightly larger in respiratorytriggered DWI than in breath-hold DWI. Discussion This study showed that the SNR of normal liver is significantly better with respiratory-

Fig. 340-year-old man with Budd-Chiari syndrome and biopsy-proven hepatocellular carcinoma. Two regions of interest were drawn on the lesion (black arrows in AD) and average value was taken. Contrast-to-noise ratio and relative contrast ratio of lesion on respiratory-triggered (RT) diffusion-weighted imaging (DWI) sequence (A) were 23.0 and 1.74, respectively, and these values on breath-hold DWI sequence (C) were 7.1 and 1.68, respectively. Apparent diffusion coefficient (ADC) value of lesion in ADC map of respiratory-triggered DWI sequence (B) is 1.12 10 -3 mm2 /s. This is similar to ADC value of 1.22 10 -3 mm2 /s calculated from ADC map of breath-hold DWI sequence (D).

Signal-to-Noise Ratio

factor but also vary spatially throughout the MR image. This prohibits the use of a conventional method of measuring noise in which the ROI is placed in the air [24, 25]. As recommended in the literature, we used SD of normal liver signal intensity as an estimate of local noise [24, 25]. The spatial location of the ROI, coil geometry, and the acceleration factor were identical in both respiratory-triggered DWI and breath-hold DWI sequences; therefore, any difference in SNR could be attributed to the sequence itself and not to these potentially confounding variables.

Statistical Analysis
Statistical analysis was performed with SPSS software (version 11.1, SPSS). The Mann-Whitney U test was used to calculate the significance of differences in the values of SNR, CNR, and relative contrast ratio between respiratorytriggered DWI and breath-hold DWI. A p value of < 0.05 was considered significant. Agreement in the ADC values of liver and of liver lesions between respiratory-triggered DWI and breathhold DWI was assessed using Pearsons correlation coefficient and the reliability analysis scale ().

Results Respiratory-Triggered DWI and Breath-Hold DWI Images at b Value of 500 s/mm2 DWI was successful in all patients, and no significant artifact that could hamper image interpretation was seen in any patient. Statistical analysis revealed that the mean SNR of liver in respiratory-triggered DWI (44.2) was significantly better than that in breath-hold DWI (28.1) (p < 0.001) (Fig. 4). The mean CNR of liver lesions on respiratory-triggered DWI was 32.9 and on breath-hold DWI was 16.6; the difference was statistically significant (p = 0.001). Cysts had negative CNR due to their suppression on the images with a b value of 500 s/mm2. However, hemangiomas, despite their increased ADC value (Table 1), were hyperintense to liver on images at b values of 500 s/mm2 because of the T2 shine-through effect (Fig. 5). The mean relative contrast ratios of liver lesions on respiratory-triggered DWI and breath-hold DWI were 1.79 and 1.65, respectively; the difference was not statistically significant (p = 0.2). Box plots showing the range of CNRs and relative contrast ratios of liver lesions are shown in Figures 6 and 7.

150.00

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Fig. 4Box plot compares signal-to-noise ratio (SNR) of normal liver parenchyma in images having b value of 500 s/mm2 of respiratory-triggered diffusionweighted imaging (DWI) and breath-hold DWI sequences. SNR is significantly better in respiratorytriggered DWI sequence (p < 0.001).

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MRI of Focal Liver Lesions

Fig. 543-year-old woman with hepatic hemangioma. AF, Gadolinium-enhanced arterial phase image (A) shows peripheral discontinuous nodular enhancement (arrows), and delayed phase image (D) shows centripetal filling-in of lesion. On diffusion-weighted imaging (DWI) with b value of 500 s/mm2 (respiratory-triggered [RT] DW image [B] and breath-hold [BH] DW image [E]), lesion is hyperintense due to T2 shine-though effect. Apparent diffusion coefficient (ADC) maps (C and F) revealed increased diffusion. Signal-to-noise (SNR) of liver, contrastto-noise ratio (CNR), and relative contrast ratio of lesion on respiratory-triggered DW images were 31.2, 80.8, and 3.59, respectively, and on breath-hold DW images were 22.9, 45.75, and 3.0; and ADC values were 1.80 and 1.79 10 3 mm2 /s for respiratory-triggered and breath-hold DWI. Note that SNR and CNR on respiratory-triggered DW images are higher than on breath-hold DW images.

triggered DWI than with breath-hold DWI. Lesion-to-liver CNR was significantly higher on the respiratory-triggered DWI. No significant difference was noted in the relative contrast ratio between the two techniques. Good agreement was seen in the ADC values of liver parenchyma and focal hepatic lesions, and the scatter of ADC values was nearly similar in both sequences. Liver DWI protocols have varied in published studies. This can be attributed to differences in MR scanners and to the fact that guidelines regarding the optimum imaging parameters are still evolving. Lack of a standardized DWI protocol has prevented widespread integration of this extremely useful technique into routine liver MRI. One of the key issues in liver DWI is to decide between the breath-hold and nonbreath-hold mode of acquisition. Most studies have used breath-hold DWI because of its short acquisition time. Breath-hold DWI is also theoretically better than nonbreath-hold techniques in quantifying the ADC of smaller lesions because it is less likely to be degraded by respiratory motionrelated partial volume av-

eraging artifacts [26]. To our knowledge, our study has shown for the first time that respiratory-triggered DWI using multiple signal averages not only provides substantially improved signal but also provides ADC values

comparable to breath-hold DWI. This vastly improved SNR with respiratory-triggered DWI incurs only a minimal time penalty and can be traded-off for a higher spatial resolution, enabling multiplanar reformation and

150.00 Relative Contrast Ratio of Lesions Respiratorytriggered DWI n = 92 Breath-hold DWI n = 92 4.00

Contrast-to-Noise Ratio

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Fig. 6Box plot shows contrast-to-noise ratio (CNR) of focal liver lesions. Mean CNR on respiratorytriggered diffusion-weighted imaging (DWI) was significantly better than on breath-hold DWI (p = 0.001).

Fig. 7Box plot shows relative contrast ratio of focal liver lesions.

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Kandpal et al.
Fig. 8Box plot shows apparent diffusion coefficient (ADC) values of each type of liver lesion. ADC values and their scatter are similar in two sequences. Lesions with n = 1 are not depicted. FNH = focal nodular hyperplasia, TB = tuberculoma, HCC = hepatocellular carcinoma, RTDWI = respiratory-triggered diffusion-weighted MRI, BHDWI = breath-hold diffusion-weighted MRI.
= 3)

RTDWI BHDWI

TABLE 1: Comparison of Apparent Diffusion Coefficient (ADC) Values on Respiratory-Triggered and Breath-Hold Diffusion-Weighted Imaging (DWI)
ADC Value ( 10 3 mm2 /s) Type of Lesion Right lobe of liver Left lobe of liver Hemangioma Cyst Abscess Metastasis Hepatocellular carcinoma Tuberculoma Lymphoma Focal nodular hyperplasia Fibrous tumor Hydatid cyst Cholangiocarcinoma Biliary cystadenocarcinoma No. 42 11 11 11 6 38 12 4 3 3 1 1 1 1 Respiratory-Triggered DWI 1.39 (0.28) 1.66 (0.41) 2.36 (0.48) 2.90 (0.51) 1.13 (0.43) 1.13 (0.41) 1.27 (0.42) 1.09 (0.21) 1.11 2.15 (0.18) 1.96 1.81 0.76 1.55 Breath-Hold DWI 1.35 (0.26) 1.68 (0.39) 2.22 (0.45) 2.66 (0.44) 1.21 (0.36) 1.06 (0.36) 1.22 (0.34) 0.99 (0.18) 0.89 2.03 (0.24) 1.77 1.99 0.76 1.28

NoteData are ADC values ( SD) of liver parenchyma and focal liver lesions. Statistical agreement between ADC values was present in all categories. SD of ADCs is almost similar for both respiratory-triggered DWI and breath-hold DWI.

the use of multiple and larger b values that can reduce errors in ADC calculation. Unlike respiratory triggering, cardiac triggering increases image acquisition time significantly. However, it has been suggested that multiple averages also increase the probability of data acquisition in the diastolic phase and thus minimize cardiac motion-related signal loss, especially in the left lobe of the liver [9]. Incoherent motionlike cardiac pulsation results in severe signal loss in DWI in the

mediastinum or over the left hepatic lobe. Respiratory motion, on the other hand, is coherent and does not lead to any significant decrease in DWI signal or any substantial errors in the ADC measurement [27]. This relative lack of sensitivity of DWI to respiratory motion makes free-breathing DWI with multiple signal averages useful for whole-body imaging [28]. However, DW trace images are made by fusing individual reconstructed images with different motion-probing gradient directions. Under free-breathing con-

ditions, although these individual images (DWI x, DWIy, and DWI z) are of a reasonably good quality, they are not all acquired in the same phase of respiration. Accordingly, each image section of a DW trace image includes both expiratory and inspiratory data that result in misregistration artifacts and scattering of the ADC values compared with respiratory-triggered DWI [20]. The relative contrast ratio between lesion and liver has been reported to be better in respiratory-triggered DWI than in free-breathing DWI [20]. In our study also, the relative contrast ratio for most lesions was better in respiratorytriggered DWI than in breath-hold DWI, but this did not reach statistical significance. We found that respiratory-triggered DWI was as effective as breath-hold DWI in preventing misregistration, as evidenced from similar ADC values and nearly similar ADC data scattering in both sequences. Respiration can be monitored in current MR scanners in two main ways: by placing an elastic breathing belt on the patients abdomen that senses abdominal wall movement; and by using the navigator-triggered prospective acquisition correction (PACE) technique, in which the diaphragmatic position is assessed periodically by navigator echoes. In our study, we used an elastic belt for respiratory triggering. Recently, navigator-controlled DWI has also been reported [21, 22]. In general, navigator triggering is considered more convenient because it does not require the application of an external monitoring device, eliminates the possibility of inadvertent interruption of the examination due to dislocation of the respiratory device, and is free of susceptibility to artifacts due to additional hardware [29, 30]. Although a comparison of respiratory-triggered DWI and navigatorcontrolled DWI has not been published, navigator-triggered turbo spin-echo T2-weighted images of the liver were recently shown to be better than respiratory-triggered turbo spin-echo T2-weighted images for both lesion detection and characterization and for reducing respiratory artifacts [30]. Our study has important clinical implications. Respiratory-triggered DWI should be preferred to breath-hold DWI because of its superior SNR. Improved SNR can facilitate the detection of lesions on respiratory-triggered DWI better than on breath-hold DWI; although this question was not specifically addressed in our study. Patients referred for hepatic MRI (especially for DWI) are often in poor general condition because of underlying

Apparent Diffusion Coefficient Values

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MRI of Focal Liver Lesions malignant disease and have inadequate breath-holding capacity. Breath-hold DWI in such cases often entails increasing the section thickness with an increased intersection gap that can limit the detection of small hepatic lesions. During attempted breath-holding, some patients in poor health cannot avoid jerky involuntary inspiratory efforts that result in deleterious artifacts in breathhold DWI. Respiratory-triggered DWI is a viable option in these patients. Finally, we believe that in addition to liver imaging, respiratory-triggered DWI should score better than breath-holding DWI for other upper abdominal studies such as renal DWI, in which the organ of interest moves with respiration. Our results hold true for 1.5-T MR scanners but not for 3-T scanners, in which the inherently high SNR may improve breath-hold DW image quality [23]. Although respiratory-triggered DWI is a promising technique, certain pitfalls should be considered. The acquisition time of respiratory-triggered DWI is longer than that of breath-hold DWI; however, in our opinion, the benefits justify this additional time. Although the number of averages can be increased with respiratory-triggered DWI, the total number of sections is limited by the TR. The machine automatically suggests an appropriate TR according to the patients breathing pattern to ensure that acquisition is limited to the expiratory phase. However, we chose a fixed maximum TR (1,600) that provided the maximum number of sections while still limiting the acquisition window to the expiratory phase in most patients. A shorter TR, although desirable in patients with a faster breathing rate, results in fewer slices and a possibly reduced SNR because of T1 saturation; a longer TR acquisition would outlast the expiratory phase. Finally, respiratory-triggered DWI is ineffective if the breathing pattern is irregular, if the respiratory belt has not been placed correctly, or when the respiratory belt fails to detect abdominal wall movement, as in patients with a markedly scaphoid abdomen. The latter two pitfalls can be overcome by using the navigator trigger. The major limitation of our study was that its design was not prospective. Blinded qualitative assessment of respiratory-triggered DWI and breath-hold DWI, especially with regard to the conspicuity of lesions, was not assessed. Finally, we have not compared these DWI sequences with other sequences for the ability to detect and characterize liver lesions because our aim was only to objectively compare the image quality of the two sequences. In conclusion, this study conclusively proves that respiratory-triggered DWI is superior to breath-hold DWI for hepatic imaging because it provides higher SNR, and the ADC values of liver and focal lesions do not vary between the two techniques. We recommend that future DWI studies of the liver incorporate some form of respiratory triggering. Comparison of navigator PACEtriggered DWI and respiratory-triggered DWI should be undertaken to further optimize image quality. References
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