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Dynamic Subtraction Contrast-enhanced MR Angiography: Technique, Clinical Applications, and Pitfalls¹

¹ From the Department of Radiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 8, 1999; revision requested April 20 and received May 17; accepted May 18. Address reprint requests to Y.W.

View larger version (39K): [in a new window]   Figure 1.   Normal appearance in a healthy volunteer. Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows the lower body. The injection doses were 0.04, 0.03, and 0.03 mmol/kg for imaging the abdomen, thighs, and calves, respectively. (Reprinted, with permission, from reference 10.)

View larger version (23K): [in a new window]   Figure 2.   Imaging procedure and data acquisition. inj = injection. (Adapted and reprinted, with permission, from reference 10.)

View larger version (133K): [in a new window]   Figure 3a.   Abdominal aortic coarctation. Dynamic subtraction MR angiograms from four of five phases acquired show vascular enhancement by tracking a 0.04-mmol/kg bolus of gadopentetate dimeglumine. In the arterial phase (a), abdominal aortic coarctation (arrow) and the renal arteries are well visualized with minimal venous enhancement. The portal veins (arrowheads in b), hepatic veins (arrows in c), and inferior vena cava (arrowheads in d) are demonstrated in the different phases.

View larger version (134K): [in a new window]   Figure 3b.   Abdominal aortic coarctation. Dynamic subtraction MR angiograms from four of five phases acquired show vascular enhancement by tracking a 0.04-mmol/kg bolus of gadopentetate dimeglumine. In the arterial phase (a), abdominal aortic coarctation (arrow) and the renal arteries are well visualized with minimal venous enhancement. The portal veins (arrowheads in b), hepatic veins (arrows in c), and inferior vena cava (arrowheads in d) are demonstrated in the different phases.

View larger version (138K): [in a new window]   Figure 3c.   Abdominal aortic coarctation. Dynamic subtraction MR angiograms from four of five phases acquired show vascular enhancement by tracking a 0.04-mmol/kg bolus of gadopentetate dimeglumine. In the arterial phase (a), abdominal aortic coarctation (arrow) and the renal arteries are well visualized with minimal venous enhancement. The portal veins (arrowheads in b), hepatic veins (arrows in c), and inferior vena cava (arrowheads in d) are demonstrated in the different phases.

View larger version (135K): [in a new window]   Figure 3d.   Abdominal aortic coarctation. Dynamic subtraction MR angiograms from four of five phases acquired show vascular enhancement by tracking a 0.04-mmol/kg bolus of gadopentetate dimeglumine. In the arterial phase (a), abdominal aortic coarctation (arrow) and the renal arteries are well visualized with minimal venous enhancement. The portal veins (arrowheads in b), hepatic veins (arrows in c), and inferior vena cava (arrowheads in d) are demonstrated in the different phases.

View larger version (20K): [in a new window]   Figure 4.   Signal intensity as a function of gadopentetate dimeglumine (Gd-DTPA) concentration for various pulse sequences: spin echo (SE) (500/15); turbo spin echo (TSE) (500/15, echo train length of three); gradient and spin echo (GraSE) (500/15, echo train length of three, echo-planar imaging factor of three); 3D spoiled fast field echo (FFE) (8.8/2.8, 35° flip angle); 3D spoiled turbo field echo (TFE) (8/2.5, 20° flip angle); and two-dimensional (2D) nonspoiled fast field echo (111/2.3, 70° flip angle). mM = millimoles per liter.

View larger version (126K): [in a new window]   Figure 5a.   Dose escalation study. Dynamic subtraction MR angiograms obtained after a bolus injection of 0.01 (a), 0.02 (b), 0.03 (c), 0.05 (d), and 0.1 (e) mmol/kg of gadopentetate dimeglumine show that 0.03 mmol/kg is the minimum dose necessary to image the main arteries of the thighs, such as the superficial and deep femoral arteries.

View larger version (122K): [in a new window]   Figure 5b.   Dose escalation study. Dynamic subtraction MR angiograms obtained after a bolus injection of 0.01 (a), 0.02 (b), 0.03 (c), 0.05 (d), and 0.1 (e) mmol/kg of gadopentetate dimeglumine show that 0.03 mmol/kg is the minimum dose necessary to image the main arteries of the thighs, such as the superficial and deep femoral arteries.

View larger version (122K): [in a new window]   Figure 5c.   Dose escalation study. Dynamic subtraction MR angiograms obtained after a bolus injection of 0.01 (a), 0.02 (b), 0.03 (c), 0.05 (d), and 0.1 (e) mmol/kg of gadopentetate dimeglumine show that 0.03 mmol/kg is the minimum dose necessary to image the main arteries of the thighs, such as the superficial and deep femoral arteries.

View larger version (128K): [in a new window]   Figure 5d.   Dose escalation study. Dynamic subtraction MR angiograms obtained after a bolus injection of 0.01 (a), 0.02 (b), 0.03 (c), 0.05 (d), and 0.1 (e) mmol/kg of gadopentetate dimeglumine show that 0.03 mmol/kg is the minimum dose necessary to image the main arteries of the thighs, such as the superficial and deep femoral arteries.

View larger version (114K): [in a new window]   Figure 5e.   Dose escalation study. Dynamic subtraction MR angiograms obtained after a bolus injection of 0.01 (a), 0.02 (b), 0.03 (c), 0.05 (d), and 0.1 (e) mmol/kg of gadopentetate dimeglumine show that 0.03 mmol/kg is the minimum dose necessary to image the main arteries of the thighs, such as the superficial and deep femoral arteries.

View larger version (11K): [in a new window]   Figure 6.   Signal intensity of the lower abdominal aorta as a function of time after a bolus injection of 0.04 mmol/kg of gadopentetate dimeglumine in a healthy young volunteer. The first pass of the injected gadopentetate dimeglumine occurs 13 seconds after injection and peaks at 17 seconds. The duration of the first pass is about 12 seconds.

View larger version (150K): [in a new window]   Figure 7a.   Iliac artery aneurysm. (a) Nonenhanced source image shows an aneurysm of the right common iliac artery with a hyperintense mural thrombus (arrow). (b) Arterial-phase source image shows enhancement of the aneurysmal lumen (arrowhead) at the level of the thrombus. (c) Subtracted source image shows only the enhanced aneurysmal lumen; the thrombus is no longer seen. Note that aliased information (arrows in b) is eliminated with subtraction.

View larger version (145K): [in a new window]   Figure 7b.   Iliac artery aneurysm. (a) Nonenhanced source image shows an aneurysm of the right common iliac artery with a hyperintense mural thrombus (arrow). (b) Arterial-phase source image shows enhancement of the aneurysmal lumen (arrowhead) at the level of the thrombus. (c) Subtracted source image shows only the enhanced aneurysmal lumen; the thrombus is no longer seen. Note that aliased information (arrows in b) is eliminated with subtraction.

View larger version (140K): [in a new window]   Figure 7c.   Iliac artery aneurysm. (a) Nonenhanced source image shows an aneurysm of the right common iliac artery with a hyperintense mural thrombus (arrow). (b) Arterial-phase source image shows enhancement of the aneurysmal lumen (arrowhead) at the level of the thrombus. (c) Subtracted source image shows only the enhanced aneurysmal lumen; the thrombus is no longer seen. Note that aliased information (arrows in b) is eliminated with subtraction.

View larger version (99K): [in a new window]   Figure 8a.   Abdominal aortic aneurysm. (a) Contrast-enhanced MR angiogram shows an abdominal aortic aneurysm (arrows), but bilateral iliac arteries are not demonstrated. (b) Dynamic subtraction MR angiogram clearly shows the aneurysm (arrows) and iliac arteries (arrowheads) owing to subtraction of background signal, such as that from fatty tissue.

View larger version (93K): [in a new window]   Figure 8b.   Abdominal aortic aneurysm. (a) Contrast-enhanced MR angiogram shows an abdominal aortic aneurysm (arrows), but bilateral iliac arteries are not demonstrated. (b) Dynamic subtraction MR angiogram clearly shows the aneurysm (arrows) and iliac arteries (arrowheads) owing to subtraction of background signal, such as that from fatty tissue.

View larger version (19K): [in a new window]   Figure 9.   Postprocessing by using double subtraction. inj = injection, MIP = maximum intensity projection.

View larger version (55K): [in a new window]   Figure 10a.   Deep vein thrombosis due to antiphospholipid antibody syndrome. (a) Arterial-phase dynamic subtraction MR angiogram obtained with two separate injections of 0.05 mmol/kg of gadopentetate dimeglumine shows no occlusion of the main arteries of the lower extremity. (b) Venous image from dynamic subtraction MR angiography obtained by using double subtraction shows occlusion of the left popliteal and femoral veins (arrows).

View larger version (65K): [in a new window]   Figure 10b.   Deep vein thrombosis due to antiphospholipid antibody syndrome. (a) Arterial-phase dynamic subtraction MR angiogram obtained with two separate injections of 0.05 mmol/kg of gadopentetate dimeglumine shows no occlusion of the main arteries of the lower extremity. (b) Venous image from dynamic subtraction MR angiography obtained by using double subtraction shows occlusion of the left popliteal and femoral veins (arrows).

View larger version (140K): [in a new window]   Figure 11a.   Esophageal varix and splenorenal shunt in a patient with liver cirrhosis. (a) Portal-phase dynamic subtraction MR angiogram obtained with a single injection of 0.1 mmol/kg of gadopentetate dimeglumine shows an esophageal varix (arrows) and splenorenal shunt (arrowheads), which are not clearly seen due to superimposition of the enhanced abdominal aorta. (b) MR portogram obtained by using double subtraction clearly shows the portal venous system (open arrows), along with the esophageal varix (solid arrows) and splenorenal shunt (arrowheads). (Reprinted, with permission, from reference 24.)

View larger version (145K): [in a new window]   Figure 11b.   Esophageal varix and splenorenal shunt in a patient with liver cirrhosis. (a) Portal-phase dynamic subtraction MR angiogram obtained with a single injection of 0.1 mmol/kg of gadopentetate dimeglumine shows an esophageal varix (arrows) and splenorenal shunt (arrowheads), which are not clearly seen due to superimposition of the enhanced abdominal aorta. (b) MR portogram obtained by using double subtraction clearly shows the portal venous system (open arrows), along with the esophageal varix (solid arrows) and splenorenal shunt (arrowheads). (Reprinted, with permission, from reference 24.)

View larger version (14K): [in a new window]   Figure 12.   Postprocessing by using subtraction and addition. inj = injection, MIP = maximum intensity projection.

View larger version (110K): [in a new window]   Figure 13a.   Prolonged circulation time in a 78-year-old patient. (a) Early-phase dynamic subtraction MR angiogram shows enhancement of the proximal abdominal aorta (arrows). (b) Image from the next phase of dynamic subtraction MR angiography shows enhancement of the distal abdominal aorta (arrowheads). (c) Arterial image from dynamic subtraction MR angiography obtained by adding a and b shows the entire abdominal aorta and iliac arteries.

View larger version (122K): [in a new window]   Figure 13b.   Prolonged circulation time in a 78-year-old patient. (a) Early-phase dynamic subtraction MR angiogram shows enhancement of the proximal abdominal aorta (arrows). (b) Image from the next phase of dynamic subtraction MR angiography shows enhancement of the distal abdominal aorta (arrowheads). (c) Arterial image from dynamic subtraction MR angiography obtained by adding a and b shows the entire abdominal aorta and iliac arteries.

View larger version (131K): [in a new window]   Figure 13c.   Prolonged circulation time in a 78-year-old patient. (a) Early-phase dynamic subtraction MR angiogram shows enhancement of the proximal abdominal aorta (arrows). (b) Image from the next phase of dynamic subtraction MR angiography shows enhancement of the distal abdominal aorta (arrowheads). (c) Arterial image from dynamic subtraction MR angiography obtained by adding a and b shows the entire abdominal aorta and iliac arteries.

View larger version (49K): [in a new window]   Figure 14a.   Atherosclerotic occlusive disease. (a) Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows long segmental occlusions of the right superficial femoral artery (solid arrows) and the left external iliac and superficial femoral arteries (solid arrowheads). Note the reconstitution of the bilateral distal superficial femoral arteries via small collateral arteries. Also note the false-positive occlusions of the right external iliac artery (open arrow) and left popliteal artery (open arrowhead) resulting from inappropriate positioning of the imaging volume. (b) Conventional angiogram also shows reconstitution of the bilateral distal superficial femoral arteries via small collateral arteries. (Reprinted, with permission, from reference 10.)

View larger version (57K): [in a new window]   Figure 14b.   Atherosclerotic occlusive disease. (a) Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows long segmental occlusions of the right superficial femoral artery (solid arrows) and the left external iliac and superficial femoral arteries (solid arrowheads). Note the reconstitution of the bilateral distal superficial femoral arteries via small collateral arteries. Also note the false-positive occlusions of the right external iliac artery (open arrow) and left popliteal artery (open arrowhead) resulting from inappropriate positioning of the imaging volume. (b) Conventional angiogram also shows reconstitution of the bilateral distal superficial femoral arteries via small collateral arteries. (Reprinted, with permission, from reference 10.)

View larger version (68K): [in a new window]   Figure 15a.   Iliac artery aneurysm. (a) Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows an aneurysm of the right common iliac artery (arrows) and distal abdominal aorta (arrowhead). Note the irregular lumen of the bilateral femoral arteries. (b) Coronal source image shows both the patent lumen and a mural thrombus of the aneurysm (arrowheads). (c) Conventional angiogram show only the lumen of the aneurysm.

View larger version (182K): [in a new window]   Figure 15b.   Iliac artery aneurysm. (a) Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows an aneurysm of the right common iliac artery (arrows) and distal abdominal aorta (arrowhead). Note the irregular lumen of the bilateral femoral arteries. (b) Coronal source image shows both the patent lumen and a mural thrombus of the aneurysm (arrowheads). (c) Conventional angiogram show only the lumen of the aneurysm.

View larger version (48K): [in a new window]   Figure 15c.   Iliac artery aneurysm. (a) Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows an aneurysm of the right common iliac artery (arrows) and distal abdominal aorta (arrowhead). Note the irregular lumen of the bilateral femoral arteries. (b) Coronal source image shows both the patent lumen and a mural thrombus of the aneurysm (arrowheads). (c) Conventional angiogram show only the lumen of the aneurysm.

View larger version (41K): [in a new window]   Figure 16.   Patent Y graft. Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows patency of a Y graft (arrows). The stricturelike regions correspond to the anastomoses (arrowheads).

View larger version (50K): [in a new window]   Figure 17.   Patent femorofemoral bypass graft. Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows patency of a femorofemoral bypass graft (arrows). Note the occlusion of the right iliac artery (arrowheads).

View larger version (57K): [in a new window]   Figure 18.   Takayasu arteritis. Dynamic subtraction MR angiogram obtained with two separate injections of gadopentetate dimeglumine shows aortic occlusion from the upper thoracic descending aorta to the abdominal aorta (solid arrows). A long aortoaortic bypass graft is clearly seen (solid arrowheads). The stricturelike region corresponds to an anastomosis (open arrow). Also note the stenosis of the left carotid artery (open arrowhead).

View larger version (47K): [in a new window]   Figure 19.   Takayasu arteritis. Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows multiple aortic aneurysms (arrows) and narrowing of the thoracic aorta (solid arrowhead). The right renal artery shows marked dilatation of the proximal part and stenosis of the distal part (open arrowhead).

View larger version (83K): [in a new window]   Figure 20.   Aortic dissection (DeBakey type III). Dynamic subtraction MR angiogram obtained with three separate injections of gadopentetate dimeglumine shows the true lumen (solid arrows) compressed by the patent pseudolumen (solid arrowheads). Note the thrombus in the pseudolumen (open arrows). The left renal artery (open arrowhead) branches off from the true lumen.

View larger version (90K): [in a new window]   Figure 21a.   Dissection of the abdominal aorta. Dynamic subtraction MR angiogram (a) and coronal source image (b) show an abdominal aortic dissection that involves the left renal artery. The true lumen of the left renal artery (arrow) demonstrates severe stenosis due to compression by the pseudolumen (arrowheads).

View larger version (92K): [in a new window]   Figure 21b.   Dissection of the abdominal aorta. Dynamic subtraction MR angiogram (a) and coronal source image (b) show an abdominal aortic dissection that involves the left renal artery. The true lumen of the left renal artery (arrow) demonstrates severe stenosis due to compression by the pseudolumen (arrowheads).

View larger version (138K): [in a new window]   Figure 22a.   Renal artery occlusion causing renal infarction. (a) Dynamic subtraction MR angiogram shows complete occlusion of the proximal left renal artery (arrow). The distal left renal artery is not enhanced. (b) Conventional angiogram also shows complete occlusion of the left renal artery (arrow).

View larger version (173K): [in a new window]   Figure 22b.   Renal artery occlusion causing renal infarction. (a) Dynamic subtraction MR angiogram shows complete occlusion of the proximal left renal artery (arrow). The distal left renal artery is not enhanced. (b) Conventional angiogram also shows complete occlusion of the left renal artery (arrow).

View larger version (152K): [in a new window]   Figure 23a.   Renal artery aneurysm in a patient with renovascular hypertension. Dynamic subtraction MR angiogram (a) and conventional angiogram (b) show a saccular aneurysm of the distal left renal artery (arrow).

View larger version (174K): [in a new window]   Figure 23b.   Renal artery aneurysm in a patient with renovascular hypertension. Dynamic subtraction MR angiogram (a) and conventional angiogram (b) show a saccular aneurysm of the distal left renal artery (arrow).

View larger version (151K): [in a new window]   Figure 24.   Uterine arteriovenous malformation in a 28-year-old woman with massive uterine bleeding. Dynamic subtraction MR angiogram shows a uterine arteriovenous malformation as tortuous and dilated uterine vessels (arrows). Note the early venous return (arrowheads).

View larger version (141K): [in a new window]   Figure 25.   Mesenteric-gonadal shunt in a patient with hepatic encephalopathy. Dynamic subtraction MR angiogram shows a portosystemic shunt from the superior mesenteric vein (arrows) to the gonadal vein (arrowheads). (Reprinted, with permission, from reference 24.)

View larger version (126K): [in a new window]   Figure 26.   Pseudodissection. Dynamic subtraction MR angiogram shows a long dark line in the abdominal aorta (arrows) that mimics a dissection.

View larger version (130K): [in a new window]   Figure 27.   Ghost artifact. Dynamic subtraction MR angiogram shows ghost artifacts (arrows) parallel to the intensely enhanced abdominal aorta.