MRN has come a long way in the past 2 decades. Excellent depiction of 3D nerve anatomy and pathology is currently possible. Further technical developments in diffusion-based nerve and muscle imaging, whole-body MRN, and nerve-specific MR contrast agents will likely play a major role in advancing this novel field and understanding peripheral neuromuscular diseases in the years to come.

They have presented a novel methodology employing dMRI to derive representative 4D-MRI. This set of techniques are practical in that (1) they employ MRI sequences that are standard across commercial vendors; (2) the 2D imaging planes can be oriented onto an arbitrary axis (e.g., sagittal, coronal, axial[ellipsis (horizontal)]); (3) the image processing techniques are relatively simple. Systematically applying this and similar dMRI-based techniques in patients is a crucial next step to demonstrate efficacy beyond CT-only based practice.

Purpose: Current pretreatment, 4D imaging techniques are suboptimal in that they sample breathing motion over a very limited “snapshot” in time. Heretofore, long‐duration, 4D motion characterization for radiotherapy planning, margin optimization, and validation have been impractical for safety reasons, requiring invasive markers imaged under x‐ray fluoroscopy. To characterize 3D tumor motion and associated variability over durations more consistent with treatments, the authors have developed a practical dynamic MRI (dMRI) technique employing two orthogonal planes acquired in a continuous, interleaved fashion. Methods: 2D balanced steady‐state free precession MRI was acquired continuously over 9–14 min at approximately 4 Hz in three healthy volunteers using a commercial 1.5 T system; alternating orthogonal imaging planes (sagittal, coronal, sagittal, etc.) were employed. The 2D in‐plane pixel resolution was 2 × 2 mm2 with a 5 mm slice profile. Simultaneous with image acquisition, the authors monitored a 1D surrogate respiratory signal using a device available with the MRI system. 2D template matching‐based anatomic feature registration, or tracking, was performed independently in each orientation. 4D feature tracking at the raw frame rate was derived using spline interpolation. Results: Tracking vascular features in the lung for two volunteers and pancreatic features in one volunteer, the authors have successfully demonstrated this method. Registration error, defined here as the difference between the sagittal and coronal tracking result in the SI direction, ranged from 0.7 to 1.6 mm (1σ) which was less than the acquired image resolution. Although the healthy volunteers were instructed to relax and breathe normally, significantly variable respiration was observed. To demonstrate potential applications of this technique, the authors subsequently explored the intrafraction stability of hypothetical tumoral internal target volumes and 3D spatial probability distribution functions. The surrogate respiratory information allowed the authors to show how this technique can be used to study correlations between internal and external (surrogate) information over these prolonged durations. However, compared against the gold standard of the time stamps in the dMRI frames, the temporal synchronization of the surrogate 1D respiratory information was shown to be likely unreliable. Conclusions: The authors have established viability of a novel and practical pretreatment, 4D tumor centroid tracking method employing a commercially available dynamic MRI sequence. Further developments from the vendor are likely needed to provide a reliably synchronized surrogate 1D respiratory signal, which will likely broaden the utility of this method in the pretreatment radiotherapy planning context.

Purpose: To evaluate whether the addition of the threedimensional diffusion-weighted reversed fast imaging with steady state free precession (3D DW-PSIF) sequence improves the identification of peripheral nerves in the distal extremities.Materials and Methods: Twelve MR neurography (MRN) studies of the distal upper extremity and 12 MRN studies of distal lower extremity were evaluated. From the 24 subjects who were enrolled, 10 had clinically suspected peripheral neuropathy, whereas 14 suffered from various orthopedic diseases and had no clinical signs of neuropathy. In each examination, the ability to identify each peripheral nerve on T2-weighted and 3D DW-PSIF sequences was evaluated using a semi-quantitative (0-2) scale. Thereafter, a total certainty score was registered for each sequence.Results: Combining the results of all studies, the mean certainty score was 1.92 6 0.28 on the 3D DW-PSIF images and 1.50 6 0.72 on the T2-weighted images (P < 0.001). In the upper extremity studies, the corresponding certainty scores were 2.0 and 1.70 6 0.55, respectively (P ¼ 0.008), and in the lower extremity studies, 1.86 6 0.35 and 1.36 6 0.79, respectively (P < 0.001). Conclusion:The 3D DW-PSIF images provide improved identification of the nerves compared with the T2-weighted images, and should be incorporated in the MRN protocol, whenever accurate nerve localization and/or presurgical evaluation are required.

Three-dimensional (3D) diffusion-weighted reversed fast imaging with steady state precession (3D DW-PSIF) MR sequence has the potential to create nerve-specific images. The authors describe the technical issues and their initial experience with this imaging technique employed for peripheral MR neurography.