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Contrast-enhanced Three-dimensional MR Portography¹

¹ From the Department of Radiology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki 710-8602, Japan. Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received April 16, 1998; revision requested May 22 and received September 14; accepted September 16. Address reprint requests to Y.W.

View larger version (15K): [in a new window]   Figure 1.  Protocol for contrast-enhanced MR portography. sec = seconds.

View larger version (111K): [in a new window]   Figures 2, 3.  (2) Esophagogastric varix in a 58-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy. (a) Contrast-enhanced 3D MR portogram shows a large gastric varix and splenorenal shunt (arrows), but a dilated coronary vein and esophageal varix (arrowheads) are not clearly seen due to superimposition of the aortic enhancement. (b) Contrast-enhanced 3D MR portogram with arterial-phase subtraction reveals not only the esophageal varix but also a large mediastinal varix. Open arrow = portal vein, solid arrow = inferior vena cava. (3) Mesenteric-gonadal shunt in a 68-year-old man with liver cirrhosis and hepatic encephalopathy. Contrast-enhanced 3D MR portogram reveals a portosystemic collateral pathway from the ileocolic vein (solid arrow) to the right testicular vein (open arrow). Contrast-enhanced CT included only the upper abdomen and thus did not reveal this mesenteric-gonadal shunt. Note the small hepatic hemangioma (arrowhead).

View larger version (110K): [in a new window]   Figures 2, 3.  (2) Esophagogastric varix in a 58-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy. (a) Contrast-enhanced 3D MR portogram shows a large gastric varix and splenorenal shunt (arrows), but a dilated coronary vein and esophageal varix (arrowheads) are not clearly seen due to superimposition of the aortic enhancement. (b) Contrast-enhanced 3D MR portogram with arterial-phase subtraction reveals not only the esophageal varix but also a large mediastinal varix. Open arrow = portal vein, solid arrow = inferior vena cava. (3) Mesenteric-gonadal shunt in a 68-year-old man with liver cirrhosis and hepatic encephalopathy. Contrast-enhanced 3D MR portogram reveals a portosystemic collateral pathway from the ileocolic vein (solid arrow) to the right testicular vein (open arrow). Contrast-enhanced CT included only the upper abdomen and thus did not reveal this mesenteric-gonadal shunt. Note the small hepatic hemangioma (arrowhead).

View larger version (115K): [in a new window]   Figures 2, 3.  (2) Esophagogastric varix in a 58-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy. (a) Contrast-enhanced 3D MR portogram shows a large gastric varix and splenorenal shunt (arrows), but a dilated coronary vein and esophageal varix (arrowheads) are not clearly seen due to superimposition of the aortic enhancement. (b) Contrast-enhanced 3D MR portogram with arterial-phase subtraction reveals not only the esophageal varix but also a large mediastinal varix. Open arrow = portal vein, solid arrow = inferior vena cava. (3) Mesenteric-gonadal shunt in a 68-year-old man with liver cirrhosis and hepatic encephalopathy. Contrast-enhanced 3D MR portogram reveals a portosystemic collateral pathway from the ileocolic vein (solid arrow) to the right testicular vein (open arrow). Contrast-enhanced CT included only the upper abdomen and thus did not reveal this mesenteric-gonadal shunt. Note the small hepatic hemangioma (arrowhead).

View larger version (141K): [in a new window]   Figures 4, 5.  (4) Mesenteric-retroperitoneal shunt in a 56-year-old woman with liver cirrhosis and hepatic encephalopathy. Contrast-enhanced 3D MR portogram shows a large portosystemic collateral pathway from the inferior mesenteric vein (solid arrow) to the left iliac vein (open arrows). Note that the dilated inferior mesenteric vein connects with the confluence of the splenic and superior mesenteric veins. (5) Intrahepatic portosystemic shunt in a 62-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy. (a) Contrast-enhanced 3D MR portogram shows a large intrahepatic portosystemic collateral pathway (solid arrow) from the right portal vein (open arrow) to an accessory hepatic vein. Note that the intrahepatic portal vein branches are small. (b)Axial fat-suppressed T1-weighted MR image (500/18) clearly demonstrates the collateral pathway (arrow).

View larger version (133K): [in a new window]   Figures 4, 5.  (4) Mesenteric-retroperitoneal shunt in a 56-year-old woman with liver cirrhosis and hepatic encephalopathy. Contrast-enhanced 3D MR portogram shows a large portosystemic collateral pathway from the inferior mesenteric vein (solid arrow) to the left iliac vein (open arrows). Note that the dilated inferior mesenteric vein connects with the confluence of the splenic and superior mesenteric veins. (5) Intrahepatic portosystemic shunt in a 62-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy. (a) Contrast-enhanced 3D MR portogram shows a large intrahepatic portosystemic collateral pathway (solid arrow) from the right portal vein (open arrow) to an accessory hepatic vein. Note that the intrahepatic portal vein branches are small. (b) Axial fat-suppressed T1-weighted MR image (500/18) clearly demonstrates the collateral pathway (arrow).

View larger version (119K): [in a new window]   Figures 4, 5.  (4) Mesenteric-retroperitoneal shunt in a 56-year-old woman with liver cirrhosis and hepatic encephalopathy. Contrast-enhanced 3D MR portogram shows a large portosystemic collateral pathway from the inferior mesenteric vein (solid arrow) to the left iliac vein (open arrows). Note that the dilated inferior mesenteric vein connects with the confluence of the splenic and superior mesenteric veins. (5) Intrahepatic portosystemic shunt in a 62-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy. (a) Contrast-enhanced 3D MR portogram shows a large intrahepatic portosystemic collateral pathway (solid arrow) from the right portal vein (open arrow) to an accessory hepatic vein. Note that the intrahepatic portal vein branches are small. (b) Axial fat-suppressed T1-weighted MR image (500/18) clearly demonstrates the collateral pathway (arrow).

View larger version (168K): [in a new window]   Figure 6a.  Gastric varix and splenorenal shunt in a 64-year-old man with liver cirrhosis. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction shows a dilated coronary vein (straight solid arrow), gastric varix (open arrow), and splenorenal shunt (curved arrow). The vertical white line (arrowhead) is an artifact caused by subtraction of the aortic enhancement. (b) Arterial portogram obtained with celiac arteriography also demonstrates these collateral pathways, which are less conspicuous than on the MR portogram (a). (c) Contrast-enhanced MR portogram obtained after balloon-occluded retrograde transvenous obliteration no longer shows the gastric varix, although the splenorenal shunt is still seen to be patent (arrow).

View larger version (163K): [in a new window]   Figure 6b.  Gastric varix and splenorenal shunt in a 64-year-old man with liver cirrhosis. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction shows a dilated coronary vein (straight solid arrow), gastric varix (open arrow), and splenorenal shunt (curved arrow). The vertical white line (arrowhead) is an artifact caused by subtraction of the aortic enhancement. (b) Arterial portogram obtained with celiac arteriography also demonstrates these collateral pathways, which are less conspicuous than on the MR portogram (a). (c) Contrast-enhanced MR portogram obtained after balloon-occluded retrograde transvenous obliteration no longer shows the gastric varix, although the splenorenal shunt is still seen to be patent (arrow).

View larger version (171K): [in a new window]   Figure 6c.  Gastric varix and splenorenal shunt in a 64-year-old man with liver cirrhosis. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction shows a dilated coronary vein (straight solid arrow), gastric varix (open arrow), and splenorenal shunt (curved arrow). The vertical white line (arrowhead) is an artifact caused by subtraction of the aortic enhancement. (b) Arterial portogram obtained with celiac arteriography also demonstrates these collateral pathways, which are less conspicuous than on the MR portogram (a). (c) Contrast-enhanced MR portogram obtained after balloon-occluded retrograde transvenous obliteration no longer shows the gastric varix, although the splenorenal shunt is still seen to be patent (arrow).

View larger version (135K): [in a new window]   Figures 7, 8.  (7) Ascending portal thrombophlebitis in a 2-year-old girl with fever, diarrhea, and hepato-splenomegaly. Contrast-enhanced 3D MR portogram (a) and coronal source image (b) show occlusion of the superior mesenteric vein and portal vein with a hepatopetal collateral pathway through the dilated pancreaticoduodenal venous arcade (arrow) and a hepato-fugal collateral pathway forming an esophageal varix (arrowheads). Note the atrophic right lobe of the liver. (8) Cavernous transformation of the portal vein in an asymptomatic 63-year-old woman. Contrast-enhanced 3D MR portogram clearly shows dilated periportal collateral vessels (arrow) from the superior mesenteric vein and splenic vein to the intrahepatic portal vein branches (arrowhead).

View larger version (149K): [in a new window]   Figures 7, 8.  (7) Ascending portal thrombophlebitis in a 2-year-old girl with fever, diarrhea, and hepato-splenomegaly. Contrast-enhanced 3D MR portogram (a) and coronal source image (b) show occlusion of the superior mesenteric vein and portal vein with a hepatopetal collateral pathway through the dilated pancreaticoduodenal venous arcade (arrow) and a hepato-fugal collateral pathway forming an esophageal varix (arrowheads). Note the atrophic right lobe of the liver. (8) Cavernous transformation of the portal vein in an asymptomatic 63-year-old woman. Contrast-enhanced 3D MR portogram clearly shows dilated periportal collateral vessels (arrow) from the superior mesenteric vein and splenic vein to the intrahepatic portal vein branches (arrowhead).

View larger version (160K): [in a new window]   Figures 7, 8.  (7) Ascending portal thrombophlebitis in a 2-year-old girl with fever, diarrhea, and hepato-splenomegaly. Contrast-enhanced 3D MR portogram (a) and coronal source image (b) show occlusion of the superior mesenteric vein and portal vein with a hepatopetal collateral pathway through the dilated pancreaticoduodenal venous arcade (arrow) and a hepato-fugal collateral pathway forming an esophageal varix (arrowheads). Note the atrophic right lobe of the liver. (8) Cavernous transformation of the portal vein in an asymptomatic 63-year-old woman. Contrast-enhanced 3D MR portogram clearly shows dilated periportal collateral vessels (arrow) from the superior mesenteric vein and splenic vein to the intrahepatic portal vein branches (arrowhead).

View larger version (182K): [in a new window]   Figures 9, 10.  (9) Portal vein obstruction caused by surgery for cancer of the pancreatic tail in an asymptomatic 66-year-old man. Contrast-enhanced 3D MR portogram with arterial-phase subtraction clearly shows obstruction of the superior mesenteric vein (solid arrow) and hepatopetal collateral pathways through the pancreaticoduodenal veins (open arrow). The aorta is not subtracted completely, and the left renal vein and inferior vena cava are superimposed on the portal vein and the collateral pathways. (10) Splenic vein obstruction after endoscopic sclerotherapy in a 61-year-old woman with alcoholic liver cirrhosis. Endoscopic sclerotherapy was performed to treat massive hemorrhage from a ruptured gastric varix. (a) Contrast-enhanced 3D MR portogram does not reveal the splenic vein. Note the filling defect at the confluence of the splenic and superior mesenteric veins (straight solid arrow). A gastric varix (open arrow), splenorenal shunt (arrowhead), and dilated left ovarian vein (curved arrow) are also seen. (b) Arterial portogram obtained with celiac arteriography reveals splenic vein obstruction with a dilated gastroepiploic vein as a hepatopetal collateral pathway. The gastric varix and splenorenal shunt are still patent, and the dilated left ovarian vein is seen emptying toward the pelvis. Iodized oil is seen in the splenic vein and gastric varix.

View larger version (135K): [in a new window]   Figures 9, 10.  (9) Portal vein obstruction caused by surgery for cancer of the pancreatic tail in an asymptomatic 66-year-old man. Contrast-enhanced 3D MR portogram with arterial-phase subtraction clearly shows obstruction of the superior mesenteric vein (solid arrow) and hepatopetal collateral pathways through the pancreaticoduodenal veins (open arrow). The aorta is not subtracted completely, and the left renal vein and inferior vena cava are superimposed on the portal vein and the collateral pathways. (10) Splenic vein obstruction after endoscopic sclerotherapy in a 61-year-old woman with alcoholic liver cirrhosis. Endoscopic sclerotherapy was performed to treat massive hemorrhage from a ruptured gastric varix. (a) Contrast-enhanced 3D MR portogram does not reveal the splenic vein. Note the filling defect at the confluence of the splenic and superior mesenteric veins (straight solid arrow). A gastric varix (open arrow), splenorenal shunt (arrowhead), and dilated left ovarian vein (curved arrow) are also seen. (b) Arterial portogram obtained with celiac arteriography reveals splenic vein obstruction with a dilated gastroepiploic vein as a hepatopetal collateral pathway. The gastric varix and splenorenal shunt are still patent, and the dilated left ovarian vein is seen emptying toward the pelvis. Iodized oil is seen in the splenic vein and gastric varix.

View larger version (153K): [in a new window]   Figures 9, 10.  (9) Portal vein obstruction caused by surgery for cancer of the pancreatic tail in an asymptomatic 66-year-old man. Contrast-enhanced 3D MR portogram with arterial-phase subtraction clearly shows obstruction of the superior mesenteric vein (solid arrow) and hepatopetal collateral pathways through the pancreaticoduodenal veins (open arrow). The aorta is not subtracted completely, and the left renal vein and inferior vena cava are superimposed on the portal vein and the collateral pathways. (10) Splenic vein obstruction after endoscopic sclerotherapy in a 61-year-old woman with alcoholic liver cirrhosis. Endoscopic sclerotherapy was performed to treat massive hemorrhage from a ruptured gastric varix. (a) Contrast-enhanced 3D MR portogram does not reveal the splenic vein. Note the filling defect at the confluence of the splenic and superior mesenteric veins (straight solid arrow). A gastric varix (open arrow), splenorenal shunt (arrowhead), and dilated left ovarian vein (curved arrow) are also seen. (b) Arterial portogram obtained with celiac arteriography reveals splenic vein obstruction with a dilated gastroepiploic vein as a hepatopetal collateral pathway. The gastric varix and splenorenal shunt are still patent, and the dilated left ovarian vein is seen emptying toward the pelvis. Iodized oil is seen in the splenic vein and gastric varix.

View larger version (155K): [in a new window]   Figure 11a.  Tumor thrombus of the right portal vein in a 59-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction shows occlusion of the right portal vein (solid arrow) by a tumor thrombus. Note the splenorenal shunt (open arrow). (b) Coronal source image reveals an enhanced hepatocellular carcinoma (arrows) with a tumor thrombus in the right portal vein. (c) Arterial portogram obtained with superior mesenteric arteriography shows the occlusion of the right portal vein (arrow).

View larger version (183K): [in a new window]   Figure 11b.  Tumor thrombus of the right portal vein in a 59-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction shows occlusion of the right portal vein (solid arrow) by a tumor thrombus. Note the splenorenal shunt (open arrow). (b) Coronal source image reveals an enhanced hepatocellular carcinoma (arrows) with a tumor thrombus in the right portal vein. (c) Arterial portogram obtained with superior mesenteric arteriography shows the occlusion of the right portal vein (arrow).

View larger version (179K): [in a new window]   Figure 11c.  Tumor thrombus of the right portal vein in a 59-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction shows occlusion of the right portal vein (solid arrow) by a tumor thrombus. Note the splenorenal shunt (open arrow). (b) Coronal source image reveals an enhanced hepatocellular carcinoma (arrows) with a tumor thrombus in the right portal vein. (c) Arterial portogram obtained with superior mesenteric arteriography shows the occlusion of the right portal vein (arrow).

View larger version (151K): [in a new window]   Figure 12a.  Resectable bile duct cancer in a 58-year-old woman. (a) Contrast-enhanced 3D MR portogram shows that the portal vein is not encased by the tumor at all, a finding that was confirmed at surgery. The bile duct cancer appears as enhanced parallel lines (arrow). (b) Coronal source image reveals enhanced bile duct cancer of the lower common bile duct with a dilated upstream biliary tree (arrows).

View larger version (167K): [in a new window]   Figure 12b.  Resectable bile duct cancer in a 58-year-old woman. (a) Contrast-enhanced 3D MR portogram shows that the portal vein is not encased by the tumor at all, a finding that was confirmed at surgery. The bile duct cancer appears as enhanced parallel lines (arrow). (b) Coronal source image reveals enhanced bile duct cancer of the lower common bile duct with a dilated upstream biliary tree (arrows).

View larger version (152K): [in a new window]   Figure 13a.  Unresectable malignant islet cell tumor of the pancreatic head in a 57-year-old man. (a) Contrast-enhanced 3D MR portogram shows obstruction of the superior mesenteric vein (arrow). (b) Coronal source image reveals that the poorly enhanced pancreatic head tumor encases the superior mesenteric vein and invades the duodenum (curved arrows). Note the dilated biliary tree (open arrow) and agenesis of the pancreatic tail.

View larger version (160K): [in a new window]   Figure 13b.  Unresectable malignant islet cell tumor of the pancreatic head in a 57-year-old man. (a) Contrast-enhanced 3D MR portogram shows obstruction of the superior mesenteric vein (arrow). (b) Coronal source image reveals that the poorly enhanced pancreatic head tumor encases the superior mesenteric vein and invades the duodenum (curved arrows). Note the dilated biliary tree (open arrow) and agenesis of the pancreatic tail.

View larger version (149K): [in a new window]   Figure 14a.  Hepatic veno-occlusive disease due to anti-phospholipid antibody syndrome in a 39-year-old man with massive ascites and hepatic dysfunction. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction does not reveal the right hepatic lobe, although the right portal vein is seen to be patent (arrow). (b) Coronal source image demonstrates obstruction of the right and middle hepatic veins with no parenchymal enhancement of the right hepatic lobe. The left hepatic vein is well visualized (arrow).

View larger version (175K): [in a new window]   Figure 14b.  Hepatic veno-occlusive disease due to anti-phospholipid antibody syndrome in a 39-year-old man with massive ascites and hepatic dysfunction. (a) Contrast-enhanced 3D MR portogram with arterial-phase subtraction does not reveal the right hepatic lobe, although the right portal vein is seen to be patent (arrow). (b) Coronal source image demonstrates obstruction of the right and middle hepatic veins with no parenchymal enhancement of the right hepatic lobe. The left hepatic vein is well visualized (arrow).

View larger version (148K): [in a new window]   Figure 15a.  Mycotic aneurysm of the superior mesenteric artery in a 62-year-old asymptomatic man. Arterial-phase (a) and portal-phase (b) contrast-enhanced 3D MR portograms clearly show a mycotic aneurysm of the superior mesenteric artery (arrow in a) displacing the superior mesenteric vein (arrow in b).

View larger version (174K): [in a new window]   Figure 15b.  Mycotic aneurysm of the superior mesenteric artery in a 62-year-old asymptomatic man. Arterial-phase (a) and portal-phase (b) contrast-enhanced 3D MR portograms clearly show a mycotic aneurysm of the superior mesenteric artery (arrow in a) displacing the superior mesenteric vein (arrow in b).

View larger version (141K): [in a new window]   Figure 16a.  Splenic artery occlusion and collateral arterial pathways in a 60-year-old man with liver cirrhosis and hematemesis. Contrast-enhanced CT showed dilated vessels in the pancreatic tail. (a) Arterial-phase contrast-enhanced 3D MR portogram shows many small arterial collateral pathways in the left upper quadrant (arrows). There is no early portal venous enhancement, and the splenic artery is not seen. (b) Contrast-enhanced 3D MR portogram shows an enlarged spleen and dilated splenic vein. No portosystemic shunt is seen. (c) Celiac arteriogram shows occlusion of the splenic artery with collateral vessels.

View larger version (164K): [in a new window]   Figure 16b.  Splenic artery occlusion and collateral arterial pathways in a 60-year-old man with liver cirrhosis and hematemesis. Contrast-enhanced CT showed dilated vessels in the pancreatic tail. (a) Arterial-phase contrast-enhanced 3D MR portogram shows many small arterial collateral pathways in the left upper quadrant (arrows). There is no early portal venous enhancement, and the splenic artery is not seen. (b) Contrast-enhanced 3D MR portogram shows an enlarged spleen and dilated splenic vein. No portosystemic shunt is seen. (c) Celiac arteriogram shows occlusion of the splenic artery with collateral vessels.

View larger version (147K): [in a new window]   Figure 16c.  Splenic artery occlusion and collateral arterial pathways in a 60-year-old man with liver cirrhosis and hematemesis. Contrast-enhanced CT showed dilated vessels in the pancreatic tail. (a) Arterial-phase contrast-enhanced 3D MR portogram shows many small arterial collateral pathways in the left upper quadrant (arrows). There is no early portal venous enhancement, and the splenic artery is not seen. (b) Contrast-enhanced 3D MR portogram shows an enlarged spleen and dilated splenic vein. No portosystemic shunt is seen. (c) Celiac arteriogram shows occlusion of the splenic artery with collateral vessels.

View larger version (172K): [in a new window]   Figure 17a.  Ileal angiodysplasia in an 84-year-old woman with massive gastrointestinal hemorrhage. (a) Coronal source image reveals the bleeding point as a hypervascular lesion (solid arrow) with dilated ileal veins (open arrow) in the right lower quadrant. (b) Superior mesenteric arteriogram also reveals angiodysplasia of the terminal ileum (arrow).

View larger version (176K): [in a new window]   Figure 17b.  Ileal angiodysplasia in an 84-year-old woman with massive gastrointestinal hemorrhage. (a) Coronal source image reveals the bleeding point as a hypervascular lesion (solid arrow) with dilated ileal veins (open arrow) in the right lower quadrant. (b) Superior mesenteric arteriogram also reveals angiodysplasia of the terminal ileum (arrow).

View larger version (173K): [in a new window]   Figure 18.  Pseudodissection of the portal venous system in a 69-year-old man with liver cirrhosis. Contrast-enhanced 3D MR portogram demonstrates a long, dark stripe that resembles dissection in the middle of the superior mesenteric vein (solid arrows). An esophageal varix is also seen (open arrow).