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Contrast-enhanced Three-dimensional Fast Spoiled Gradient-Echo Renal MR Imaging: Evaluation of Vascular and Nonvascular Disease¹

¹ From the Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr, Rm H-1307, Stanford, CA 94305-5105. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received September 9, 1999; revision requested November 5 and received December 2; accepted December 13. Address correspondence to F.G.S. (e-mail: gsommer@leland.stanford.edu).

	Abstract

Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

 
Breath-hold contrast materialenhanced three-dimensional (3D) fast spoiled gradient-echo (FSPGR) sequences are valuable techniques for evaluation of renal arteries and veins and diagnosis of significant renal arterial stenosis at magnetic resonance (MR) imaging. The excellent spatial and contrast resolution with these techniques, combined with the ability to perform studies in multiple vascular phases, also make them attractive for the diagnosis of a wide range of nonvascular processes that affect the kidneys, including renal infections, renal parenchymal diseases, and renal trauma. Particularly when combined with T1- and T2-weighted MR imaging, the contrast-enhanced techniques are highly effective for characterization of renal masses owing to the ability to portray dynamic contrast enhancement. The ability to display venous structures with contrast-enhanced 3D FSPGR techniques helps staging of renal cell carcinoma. This article presents examples of the wide range of vascular and nonvascular renal diseases that may be effectively imaged with contrast materialenhanced 3D FSPGR techniques and illustrates the usefulness of the techniques for renal MR imaging.

Index Terms: Kidney, infection, 81.20 • Kidney, injuries, 81.41 • Kidney, MR, 81.12143 • Kidney neoplasms, diagnosis, 81.30 • Magnetic resonance (MR), vascular studies, 961.12942 • Renal arteries, stenosis or obstruction, 961.122, 961.12942, 961.721

	Introduction

Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

 
Gadolinium-enhanced renal magnetic resonance (MR) imaging is attractive as an alternative to other techniques for evaluation of native and transplanted kidneys because it can be used in patients with renal failure or iodine allergies (1). In this study, we used a contrast materialenhanced three-dimensional (3D) fast spoiled gradient-echo (FSPGR) technique with radio-frequency and gradient spoiling. Although our sequence was customized to take advantage of the enhanced gradients of our MR imaging system (Signa; GE Medical Systems, Milwaukee, Wis), similar sequences for rapid contrast-enhanced 3D imaging are available with all current MR imaging systems.

Recent developments in 3D FSPGR sequences led to their increased usefulness for renal imaging (2–4). Multiphasic studies of the kidneys are possible during enhancement with gadolinium-based contrast material; both the renal arteries and veins and the renal parenchyma can be evaluated with high spatial and contrast resolution. Beyond the vascular imaging for which the sequences were originally designed, a new imaging dimension is now possible. The techniques are particularly valuable for imaging of the renal parenchyma (5) and evaluation of contrast enhancement in renal masses (6–11). An attractive feature of the sequences is that each of the sequential phases may be acquired in a breath-hold interval; thus; respiratory degradation is minimized. Also, with use of contemporary techniques to correctly determine the timing of administration of a bolus of contrast material, a single dose of gadolinium-based contrast material, 0.1 mmol per kilogram of body weight, can be used. Since a true 3D acquisition is used, a wide variety of effective display reformatting techniques, such as maximum intensity projection and volume rendering, can be used in addition to conventional display in the typical coronal acquisition plane.

We find the contrast-enhanced 3D FSPGR technique (3) valuable for a wide range of renal vascular and nonvascular applications.

	MR Imaging Technique

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In this study, all patients underwent MR imaging with a 1.5-T system with enhanced magnetic field gradients (gradient strength, 22 mT/m; gradient slew rate, 120 mT/m/msec). The contrast-enhanced 3D FSPGR sequence developed at our institution (3) was performed typically in a coronal plane with a 512 x 192 matrix, 3–4-mm section thickness, and 32 phase encodings with zero filling to produce 64 coronal sections. Other parameters include a flip angle of 25°, 0.5 signals acquired, and minimum repetition time of approximately 4.6 msec and echo time of 1.6 msec (3). These factors generally resulted in acquisition with an approximately 30-second breath hold. A precontrast acquisition was performed, and after the bolus of contrast material was administered, three acquisitions were generally performed sequentially, with time allowed for patient respiration between phases. In general, the torso phased array was used for data acquisition in the first vascular phase of the study, and the body coil was used for acquisition in subsequent phases.

Gadopentetate dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ) was administered, generally at a dose of 0.1 mmol/kg with a power injector at 2–3 mL/sec with a saline solution flush and imaging delay from 5 seconds in small children to 15 seconds in adults. Early in our experience, we performed a timing bolus injection to determine the appropriate delay time. Later, we found that estimation of the expected optimal delay produced equally good results, as long as multiple acquisitions were performed (generally three phases). Image reformatting was performed with a workstation (Sun; Sun Microsystems, Palo Alto, Calif) and commercially available software (advantage windows version 2.0; GE Medical Systems).

	Vascular Imaging

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The ability to perform a multiphasic study of the renal vasculature with high spatial resolution by using a contrast-enhanced 3D FSPGR sequence led to successful application of the technique to evaluation of native kidneys in renal transplant donors (2,12) and transplanted kidneys in recipients (13,14) (Figs 1, 2). Correlative studies show an accuracy with contrast-enhanced 3D FSPGR techniques similar to that with computed tomographic (CT) angiography for the evaluation of renal transplant donors (10). Evaluation of the renal parenchyma in normal and transplanted kidneys is facilitated with the multiphasic study, which clearly depicts the renal medulla and cortex in various phases, including precontrast, corticomedullary, and tubular nephrographic phases (Fig 3).

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.   Normal renal transplant vasculature in a healthy renal transplant donor. (a, b) Oblique sliding thin-slab maximum intensity projection images from contrast-enhanced 3D FSPGR imaging depict each renal artery. (c) Curved-planar reformatted image in a later phase shows normal renal veins. (d) Volume-rendered image shows the renal arteries.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.   Normal renal transplant vasculature in a healthy renal transplant donor. (a, b) Oblique sliding thin-slab maximum intensity projection images from contrast-enhanced 3D FSPGR imaging depict each renal artery. (c) Curved-planar reformatted image in a later phase shows normal renal veins. (d) Volume-rendered image shows the renal arteries.

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.   Normal renal transplant vasculature in a healthy renal transplant donor. (a, b) Oblique sliding thin-slab maximum intensity projection images from contrast-enhanced 3D FSPGR imaging depict each renal artery. (c) Curved-planar reformatted image in a later phase shows normal renal veins. (d) Volume-rendered image shows the renal arteries.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 1d.   Normal renal transplant vasculature in a healthy renal transplant donor. (a, b) Oblique sliding thin-slab maximum intensity projection images from contrast-enhanced 3D FSPGR imaging depict each renal artery. (c) Curved-planar reformatted image in a later phase shows normal renal veins. (d) Volume-rendered image shows the renal arteries.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.   Renal transplant vasculature in a 1-year-old renal transplant recipient. Full-thickness (a) and oblique sliding thin-slab (3-cm section thickness) (b) maximum intensity projection images from contrast-enhanced 3D FSPGR imaging show the renal artery.

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.   Renal transplant vasculature in a 1-year-old renal transplant recipient. Full-thickness (a) and oblique sliding thin-slab (3-cm section thickness) (b) maximum intensity projection images from contrast-enhanced 3D FSPGR imaging show the renal artery.

View larger version (159K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.   Normal renal enhancement patterns in a patient with normal function and kidneys: Precontrast (a) and postcontrast corticomedullary phase (b) and tubular nephrographic phase (c) images from dynamic contrast-enhanced 3D FSPGR show normal renal enhancement.

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.   Normal renal enhancement patterns in a patient with normal function and kidneys: Precontrast (a) and postcontrast corticomedullary phase (b) and tubular nephrographic phase (c) images from dynamic contrast-enhanced 3D FSPGR show normal renal enhancement.

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.   Normal renal enhancement patterns in a patient with normal function and kidneys: Precontrast (a) and postcontrast corticomedullary phase (b) and tubular nephrographic phase (c) images from dynamic contrast-enhanced 3D FSPGR show normal renal enhancement.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.   Atherosclerotic renal arterial stenosis (50% diameter) is seen on the coronal contrast-enhanced 3D FSPGR source MR image (a), oblique sliding thin-slab maximum intensity projection image (b), and selective digital subtraction angiogram obtained prior to angioplasty (c).

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.   Atherosclerotic renal arterial stenosis (50% diameter) is seen on the coronal contrast-enhanced 3D FSPGR source MR image (a), oblique sliding thin-slab maximum intensity projection image (b), and selective digital subtraction angiogram obtained prior to angioplasty (c).

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.   Atherosclerotic renal arterial stenosis (50% diameter) is seen on the coronal contrast-enhanced 3D FSPGR source MR image (a), oblique sliding thin-slab maximum intensity projection image (b), and selective digital subtraction angiogram obtained prior to angioplasty (c).

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.   Renal arterial venous malformation. Oblique sliding thin-slab maximum intensity projection (a) and arterial phase curved-planar (b) reformatted images from contrast-enhanced 3D FSPGR imaging depict tortuous arterial branches and prominent early enhancement of the right renal vein.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.   Renal arterial venous malformation. Oblique sliding thin-slab maximum intensity projection (a) and arterial phase curved-planar (b) reformatted images from contrast-enhanced 3D FSPGR imaging depict tortuous arterial branches and prominent early enhancement of the right renal vein.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 6.   Aortic dissection affecting renal arteries. Delayed contrast-enhanced 3D FSPGR MR image depicts aortic dissection extending into the left renal artery. A large portion of the left kidney (arrow) is not enhanced, consistent with infarction.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.   Renal transplant venous thrombosis. Contrast-enhanced 3D FSPGR images clearly show the main transplant artery (a) and several branches (b) in the left iliac fossa. (c) On delayed phase image, the transplant kidney is not enhanced, consistent with infarction.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.   Renal transplant venous thrombosis. Contrast-enhanced 3D FSPGR images clearly show the main transplant artery (a) and several branches (b) in the left iliac fossa. (c) On delayed phase image, the transplant kidney is not enhanced, consistent with infarction.

View larger version (179K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.   Renal transplant venous thrombosis. Contrast-enhanced 3D FSPGR images clearly show the main transplant artery (a) and several branches (b) in the left iliac fossa. (c) On delayed phase image, the transplant kidney is not enhanced, consistent with infarction.

	Renal Infection

Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.   Acute pyelonephritis depicted with contrast-enhanced 3D FSPGR imaging. (a) Precontrast MR image. (b) On early corticomedullary phase MR image, striated enhancement of the right kidney is prominent. (c) On 5-minute delayed image, the enhancement pattern is still abnormal, which helps confirm bilateral excretion of gadopentetate dimeglumine. The nonenhancing fluid (arrow) medial to the lower pole of the right kidney, which is evident in b and c, may represent a perinephric abscess, but a sterile urinoma could have an identical appearance.

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.   Acute pyelonephritis depicted with contrast-enhanced 3D FSPGR imaging. (a) Precontrast MR image. (b) On early corticomedullary phase MR image, striated enhancement of the right kidney is prominent. (c) On 5-minute delayed image, the enhancement pattern is still abnormal, which helps confirm bilateral excretion of gadopentetate dimeglumine. The nonenhancing fluid (arrow) medial to the lower pole of the right kidney, which is evident in b and c, may represent a perinephric abscess, but a sterile urinoma could have an identical appearance.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.   Acute pyelonephritis depicted with contrast-enhanced 3D FSPGR imaging. (a) Precontrast MR image. (b) On early corticomedullary phase MR image, striated enhancement of the right kidney is prominent. (c) On 5-minute delayed image, the enhancement pattern is still abnormal, which helps confirm bilateral excretion of gadopentetate dimeglumine. The nonenhancing fluid (arrow) medial to the lower pole of the right kidney, which is evident in b and c, may represent a perinephric abscess, but a sterile urinoma could have an identical appearance.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.   Psoas abscess. (a) Axial T2-weighted MR image depicts renal and perinephric inflammation, which extends to the left psoas muscle, as an ill-defined area of increased signal intensity. (b) Contrast-enhanced 3D FSPGR MR image demonstrates enhancement of corresponding regions of infection in the left kidney and left psoas muscle. A simple cyst is present in the upper pole of the right kidney.

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.   Psoas abscess. (a) Axial T2-weighted MR image depicts renal and perinephric inflammation, which extends to the left psoas muscle, as an ill-defined area of increased signal intensity. (b) Contrast-enhanced 3D FSPGR MR image demonstrates enhancement of corresponding regions of infection in the left kidney and left psoas muscle. A simple cyst is present in the upper pole of the right kidney.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.   Reflux nephropathy depicted with contrast-enhanced 3D FSPGR imaging. (a) Corticomedullary phase image depicts a small left kidney with a striated enhancement pattern. (b) On the tubular nephrographic phase image, the areas of scarring and cortical thinning are depicted clearly.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.   Reflux nephropathy depicted with contrast-enhanced 3D FSPGR imaging. (a) Corticomedullary phase image depicts a small left kidney with a striated enhancement pattern. (b) On the tubular nephrographic phase image, the areas of scarring and cortical thinning are depicted clearly.

	Detection and Characterization of Renal Masses

Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.   Multilocular cystic nephroma depicted with contrast-enhanced 3D FSPGR imaging. (a) Corticomedullary phase image reveals a septated cystic mass in the left kidney. (b) Delayed image reveals that the left renal cystic lesion involves the renal sinus and displaces the renal pelvis, in a manner characteristic of multilocular cystic nephroma, with some enhancement in the septations (arrow).

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.   Multilocular cystic nephroma depicted with contrast-enhanced 3D FSPGR imaging. (a) Corticomedullary phase image reveals a septated cystic mass in the left kidney. (b) Delayed image reveals that the left renal cystic lesion involves the renal sinus and displaces the renal pelvis, in a manner characteristic of multilocular cystic nephroma, with some enhancement in the septations (arrow).

View larger version (172K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.   Autosomal dominant polycystic kidney disease. (a) Contrast-enhanced 3D FSPGR MR image depicts several cysts with internal hemorrhage as hyperintense. (b) Fat-saturated fast spin-echo T2-weighted MR image depicts the cysts as iso- or hypointense. In a, the high spatial resolution, contrast sensitivity, and breath-hold technique allow evaluation of the intervening solid renal parenchyma and clearly define the nonenhancing cysts.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.   Autosomal dominant polycystic kidney disease. (a) Contrast-enhanced 3D FSPGR MR image depicts several cysts with internal hemorrhage as hyperintense. (b) Fat-saturated fast spin-echo T2-weighted MR image depicts the cysts as iso- or hypointense. In a, the high spatial resolution, contrast sensitivity, and breath-hold technique allow evaluation of the intervening solid renal parenchyma and clearly define the nonenhancing cysts.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.   Renal cell carcinoma. Fat-saturated fast spin-echo T2-weighted (a) and contrast-enhanced 3D FSPGR (b) MR images reveal a solid left renal mass. In b, the mass, arteries, and veins can be simultaneously evaluated. (c) Curved-planar image reformatted from b shows that the mass (arrow) involves the renal vein at only the renal hilum.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.   Renal cell carcinoma. Fat-saturated fast spin-echo T2-weighted (a) and contrast-enhanced 3D FSPGR (b) MR images reveal a solid left renal mass. In b, the mass, arteries, and veins can be simultaneously evaluated. (c) Curved-planar image reformatted from b shows that the mass (arrow) involves the renal vein at only the renal hilum.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 13c.   Renal cell carcinoma. Fat-saturated fast spin-echo T2-weighted (a) and contrast-enhanced 3D FSPGR (b) MR images reveal a solid left renal mass. In b, the mass, arteries, and veins can be simultaneously evaluated. (c) Curved-planar image reformatted from b shows that the mass (arrow) involves the renal vein at only the renal hilum.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 14a.   Renal cell carcinoma with renal vein and inferior vena caval invasion. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and contrast-enhanced 3D FSPGR (c, d) MR images reveal a solid right renal mass. In c and d, tumor extension (arrows in d) into the inferior vena cava enhances progressively, which can help differentiate between bland thrombus and tumor thrombus.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 14b.   Renal cell carcinoma with renal vein and inferior vena caval invasion. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and contrast-enhanced 3D FSPGR (c, d) MR images reveal a solid right renal mass. In c and d, tumor extension (arrows in d) into the inferior vena cava enhances progressively, which can help differentiate between bland thrombus and tumor thrombus.

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 14c.   Renal cell carcinoma with renal vein and inferior vena caval invasion. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and contrast-enhanced 3D FSPGR (c, d) MR images reveal a solid right renal mass. In c and d, tumor extension (arrows in d) into the inferior vena cava enhances progressively, which can help differentiate between bland thrombus and tumor thrombus.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 14d.   Renal cell carcinoma with renal vein and inferior vena caval invasion. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and contrast-enhanced 3D FSPGR (c, d) MR images reveal a solid right renal mass. In c and d, tumor extension (arrows in d) into the inferior vena cava enhances progressively, which can help differentiate between bland thrombus and tumor thrombus.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 15a.   Angiomyolipoma. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and arterial (c) and delayed phase (d) contrast-enhanced 3D FSPGR MR images reveal a solid left renal mass. In a and b, the mass is isointense to fat, but a hemorrhagic cyst could have a similar appearance. In c and d, the mass (arrow) is seen to enhance.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 15b.   Angiomyolipoma. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and arterial (c) and delayed phase (d) contrast-enhanced 3D FSPGR MR images reveal a solid left renal mass. In a and b, the mass is isointense to fat, but a hemorrhagic cyst could have a similar appearance. In c and d, the mass (arrow) is seen to enhance.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 15c.   Angiomyolipoma. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and arterial (c) and delayed phase (d) contrast-enhanced 3D FSPGR MR images reveal a solid left renal mass. In a and b, the mass is isointense to fat, but a hemorrhagic cyst could have a similar appearance. In c and d, the mass (arrow) is seen to enhance.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 15d.   Angiomyolipoma. Fat-saturated fast spin-echo T2-weighted (a), T1-weighted spin-echo (b), and arterial (c) and delayed phase (d) contrast-enhanced 3D FSPGR MR images reveal a solid left renal mass. In a and b, the mass is isointense to fat, but a hemorrhagic cyst could have a similar appearance. In c and d, the mass (arrow) is seen to enhance.

	Renal Trauma

Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.   Renal laceration from blunt trauma. (a) Axial fat-saturated fast spin-echo T2-weighted MR image reveals a hypointense right renal laceration. (b) Contrast-enhanced 3D FSPGR MR image reveals that enhancement in the right kidney is less than that in the left kidney. The region of hematoma is the nonenhanced focus (arrow) at the lateral lower pole. A small amount of fluid is also seen around the left kidney.

View larger version (175K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.   Renal laceration from blunt trauma. (a) Axial fat-saturated fast spin-echo T2-weighted MR image reveals a hypointense right renal laceration. (b) Contrast-enhanced 3D FSPGR MR image reveals that enhancement in the right kidney is less than that in the left kidney. The region of hematoma is the nonenhanced focus (arrow) at the lateral lower pole. A small amount of fluid is also seen around the left kidney.

	Conclusions

Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

	Footnotes

 
See the commentary by Frager following this article.

Abbreviations: FSPGR = fast spoiled gradient-echo, 3D = three-dimensional

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Top Abstract Introduction MR Imaging Technique Vascular Imaging Renal Infection Detection and Characterization... Renal Trauma Conclusions References

 

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