Cranial vault imaging for pediatric head trauma using a radial VIBE MRI sequence

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  • 1 Division of Plastic and Reconstructive Surgery and
  • | 2 Mallinckrodt Institute of Radiology, Washington University in St. Louis, Missouri; and
  • | 3 Department of Neurosurgery, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida
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OBJECTIVE

Head trauma is the most common indication for a CT scan. In this pilot study, the authors assess the feasibility of a 5-minute high-resolution 3D golden-angle (GA) stack-of-stars radial volumetric interpolated breath-hold examination (VIBE) MRI sequence (GA-VIBE) to obtain clinically acceptable cranial bone images and identify cranial vault fractures compared to CT.

METHODS

Patients younger than 18 years of age presenting after head trauma were eligible for the study. Three clinicians reviewed and assessed 1) slice-by-slice volumetric CT and inverted MR images, and 2) 3D reconstructions obtained from inverted MR images and the gold standard (CT). For each image set, reviewers noted on 5-point Likert scales whether they recommended that a repeat scan be performed and the presence or absence of cranial vault fractures.

RESULTS

Thirty-one patients completed MRI after a clinical head CT scan was performed. Based on CT imaging, 8 of 31 patients had cranial fractures. Two of 31 patients were sedated as part of their clinical MRI scan. In 30 (97%) of 31 MRI reviews, clinicians agreed (or strongly agreed) that the image quality was acceptable for clinical diagnosis. Overall, comparing MRI to acceptable gold-standard CT, sensitivity and specificity of fracture detection were 100%. Furthermore, there were no discrepancies between CT and MRI in classification of fracture type or location.

CONCLUSIONS

When compared with the gold standard (CT), the volumetric and 3D reconstructed images using the GA-VIBE sequence were able to produce clinically acceptable cranial images with excellent ability to detect cranial vault fractures.

ABBREVIATIONS

GA = golden angle; PETRA = pointwise encoding time reduction with radial acquisition; UTE = ultra-short echo time; VIBE = volumetric interpolated breath-hold examination.

OBJECTIVE

Head trauma is the most common indication for a CT scan. In this pilot study, the authors assess the feasibility of a 5-minute high-resolution 3D golden-angle (GA) stack-of-stars radial volumetric interpolated breath-hold examination (VIBE) MRI sequence (GA-VIBE) to obtain clinically acceptable cranial bone images and identify cranial vault fractures compared to CT.

METHODS

Patients younger than 18 years of age presenting after head trauma were eligible for the study. Three clinicians reviewed and assessed 1) slice-by-slice volumetric CT and inverted MR images, and 2) 3D reconstructions obtained from inverted MR images and the gold standard (CT). For each image set, reviewers noted on 5-point Likert scales whether they recommended that a repeat scan be performed and the presence or absence of cranial vault fractures.

RESULTS

Thirty-one patients completed MRI after a clinical head CT scan was performed. Based on CT imaging, 8 of 31 patients had cranial fractures. Two of 31 patients were sedated as part of their clinical MRI scan. In 30 (97%) of 31 MRI reviews, clinicians agreed (or strongly agreed) that the image quality was acceptable for clinical diagnosis. Overall, comparing MRI to acceptable gold-standard CT, sensitivity and specificity of fracture detection were 100%. Furthermore, there were no discrepancies between CT and MRI in classification of fracture type or location.

CONCLUSIONS

When compared with the gold standard (CT), the volumetric and 3D reconstructed images using the GA-VIBE sequence were able to produce clinically acceptable cranial images with excellent ability to detect cranial vault fractures.

In Brief

The goal of this study was to perform high-resolution 3D cranial bone MRI in pediatric patients without sedation. When compared with the gold standard (CT), the authors found that the 5-minute golden-angle stack-of-stars radial volumetric interpolated breath-hold examination MRI sequence was able to produce clinically acceptable cranial images with excellent ability to detect cranial vault fractures. This study will allow for future work to provide clinicians with a rapid diagnostic tool without radiation and sedation safety concerns.

Head trauma is common in the pediatric population, accounting for 600,000–1,600,000 emergency room visits per year in the US.1 Skull fractures can be present in 10%–30% of the head injuries in children.2 Variation in the use of head CT is high (20%–70%) when evaluating fracture and intracranial hemorrhage in trauma patients.3 Some patients undergo repeated CT to assess healing, exacerbating the cumulative risk of radiation exposure. Unfortunately, there is currently no established substitute for CT to diagnose cranial abnormalities. Use of MRI, a diagnostic imaging technique without ionizing radiation, has not yet been established to evaluate the cranium. Prior studies have shown the value and feasibility of an MRI brain sequence in detecting intracranial hemorrhage or parenchymal injury for patients presenting with head trauma, but skull fractures were frequently missed.1,4,5 Previously described MRI protocols for imaging cranial bone, such as the "black-bone" gradient echo sequence, pointwise encoding time reduction with radial acquisition (PETRA), the ultra-short echo time (UTE) sequence, or the zero echo time sequence, have not translated into clinical use due to operator-dependent postprocessing, poor osseous/soft-tissue contrast, and motion artifacts when performed without sedation.4–6

We utilized a fast low-angle shot (FLASH) golden-angle (GA) 3D stack-of-stars radial volumetric interpolated breath-hold examination (VIBE) sequence (GA-VIBE), which is more robust to motion when compared to a Cartesian black-bone acquisition.7,8 Our objective in this study was to assess the feasibility of the GA-VIBE sequence to obtain clinically acceptable cranial bone images for evaluation of patients presenting with head trauma in comparison to the gold-standard CT scan.

Methods

Study Participants and Criteria

IRB approval from Washington University School of Medicine was obtained before participant recruitment. Informed consent was obtained from the parents of all participants. Inclusion criteria for the study were being younger than 18 years of age and undergoing evaluation for cranial fracture following head trauma using a standard clinical CT scan. All patients meeting these criteria were considered study candidates, except for those suspected of having undergone nonaccidental trauma. For cases with a cranial vault fracture, MRI was performed within 3 weeks of the CT scan for patients younger than 6 months of age and within 12 weeks for patients older than 6 months of age. For cases without a fracture, MRI was performed within 6 months of the CT scan. Exclusion criteria were time between CT and MRI greater than the limits noted above, undergoing cranial procedures between CT and MRI, and contraindication to MRI.

Imaging Parameters

CT scans (Siemens Somatom Definition Flash or Force CT) were obtained using standard clinical pediatric imaging protocols. Slice thickness varied from 0.6 to 1 mm with an in-plane resolution of 0.31–0.39 mm. Other parameters were 0.5-second rotation time, 64 × 0.6 collimation, 220 mAs, 70–150 kVp, a pitch of 1, and 512 × 512 matrix. Bone kernel reconstructions were performed.

A spoiled gradient echo GA-VIBE sequence was used to obtain high-resolution MR images (Siemens 3-T Prisma, 3-T Vida, or 1.5-T Aera). This GA-VIBE sequence is a hybrid radial sequence with radial k-space coverage in-plane and Cartesian coverage along the slice direction.7 The imaging parameters of the GA-VIBE for both the 3-T and 1.5-T scans were FOV 192 or 220 mm2 depending on the head size, 224 slices, transverse orientation, a slice partial Fourier factor of 5/8, a flip angle of 3°–5°, and a 320 × 320 acquisition matrix, resulting in a voxel size of 0.6–0.7 × 0.6–0.7 × 0.8 mm3, with a scan duration of 5 minutes. The 3-T and 1.5-T scans differed in the following parameters: TR/TE = 4.84/2.47 msec (3 T) versus 7.7/4.76 msec (1.5 T), bandwidth 410 or 411 Hz/pixel (3 T) versus 280 Hz/pixel (1.5 T), and number of radial lines = 400 (3 T) versus 250 (1.5 T). In the GA-VIBE images, bone has low signal intensity, resulting in the bone appearing black. The GA-VIBE protocol was designed to optimize the contrast between bone and surrounding soft tissues by using proton density weighting (low flip angle) and an in-phase echo time to preserve fat signal. Manual motion censoring was performed to remove motion-corrupted radial k-space lines prior to a multicoil nonuniform fast Fourier transform image reconstruction.9

All the CT and MR images were interpolated to 0.30 × 0.30 × 0.50 mm3. N4Bias correction methods were used to bias-correct the MRI data using the FSL toolbox (FMRIB) to correct spatial signal variations.10 A level-set method was used to generate a binary mask to include only the head for the MR and CT images using MATLAB (The MathWorks).11 Each participant’s MR image was registered to their CT scan using the FSL toolbox with a 12-parameter affine registration to match the CT orientation.12 The intensity value of each voxel within the mask region was subtracted from the global maximum of the volume using MATLAB. The inversion resulted in zero intensity for the air voxels and the highest intensities for the bone. A smooth, recursive, gaussian image filter was applied to the inverted images.

The CT and MR images were processed in 3D Slicer (version 4.10) to render 3D reconstructions of the skull.13 Using the “segment editor” module, multiple editing tools were utilized including thresholding, islands, scissors, and margin. These final images were 3D rendered using "volume rendering." Various parameters such as shift, volume properties, and advanced lighting options were employed for better visualization. The MRI postprocessing time ranged from approximately 30 minutes to 2 hours per participant, and the CT postprocessing time was approximately 10 minutes per participant.

Three board-certified clinicians, a craniofacial plastic surgeon (K.B.P.), a diagnostic neuroradiologist (M.S.G.), and a pediatric neurosurgeon (M.D.S.), reviewed the CT (processed with a routine bone kernel) and volumetric-inverted MR images along with 3D skull renderings to evaluate for cranial vault fractures. Clinicians were provided with each participant’s appropriate medical history and reason for imaging. Clinicians were able to view the slice-by-slice volumetric images and 3D surface renderings using RadiAnt DICOM viewer software (version 2020.2, Medixant). After importing the DICOM images, clinicians were able to adjust brightness and contrast, apply a sharpening filter if needed, and switch orientation via multiplanar reconstruction.

Data Analysis

Clinicians reviewed each participant’s MR images together, blind to the CT and diagnosis, and reached a consensus regarding the location and type of any cranial vault fractures. Fractures were classified based on the AOCMF guidelines.14 In addition, the clinicians were asked to assess the quality of the images for clinical diagnosis and if a repeat scan was required using a 5-point Likert scale. For example, "The imaging quality allows for clinical diagnosis of bony fractures: 1) strongly agree, 2) agree, 3) neither agree nor disagree, 4) disagree, 5) strongly disagree." Following MRI review, the clinicians immediately reviewed the CT scan of the same participant together, assessing image quality, need for repeat imaging, and identification and classification of any cranial fractures. After completion of the review of both CT and MR images for a participant, clinicians were asked to consider the acceptability of MR images for clinical diagnosis on a 4-point scale (inadequate, sufficient, good, and excellent). Responses were collected and descriptive statistics were generated using Excel 2013 (Microsoft). Image quality responses between modalities were compared using Fisher’s exact test, which was performed in R (version 4.0.3, R Core Team, 2020). Statistical significance was defined a priori as p < 0.05.

Results

Thirty-three participants were enrolled between 2019 and 2021. Two were excluded due to excessive motion and inability to complete the scan. Of the remaining 31 participants, 17 were male and 14 were female. Participant age at MRI ranged from 19 days to 17 years old (median 10.9 years, IQR 6.9–15.0 years). The time from CT to MRI ranged from 1 to 168 days (median 22 days, IQR 17–53 days). Two of the 31 participants were sedated during their MRI, as the GA-VIBE sequence was added to a clinical MRI scan. Demographic and diagnostic details of the 31 participants are shown in Table 1.

TABLE 1.

Patient demographics and clinician review of CT imaging data

Participant No.Age at MRI (yrs), SexDays From CT to MRISedated MRIMRI Strength (T)Cranial Fractures on CT
11.6, F1Yes1.5Depressed frontal & nondisplaced parietal/temporal fractures
20.1, M1No3Parietal fracture, nondisplaced
36.5, M8No3None
410.9, F22No3Frontal fracture, nondisplaced
510.9, M4Yes3None
63.6, F18No3None
78.6, F168No3None
816.8, F102No3None
914.0, M110No3None
106.8, F153No3None
117.1, M103No3None
1216.4, F144No3None
1312.6, M9No 3None
144.2, M62No3Occipital fracture, nondisplaced
155.0, F17No3Occipital fracture, nondisplaced
1614.6, F70No 3None
1716.2, M38No3None
1815.4, M22No3None
197.8, F23No3None
205.6, F24No 3Frontal fracture, nondisplaced
219.9, M26No3None
2217.1, M14No3None
2314.6, M21No3None
2410.2, F22No 3None
258.6, M30No3None
268.4, M33No1.5Parietal fracture, nondisplaced
2715.8, M15No3None
2813.7, M44No 3None
2915.9, F20No3None
3016.1, M18No3None
3114.4, F19No3Occipital fracture, nondisplaced

Clinician Reviews

Based on CT, 8 of 31 patients had 1 or more cranial fractures (Supplemental Fig. 1). Sample volumetric slices and 3D renderings of CT and inverted MR images of 2 participants who had fractures are demonstrated in Figs. 1 and 2. Overall, comparing MRI to gold-standard CT, the sensitivity and specificity of fracture detection were 100% for acceptable CT and MR scans. Furthermore, there were no discrepancies between CT and MRI in classification of fracture type or location.

FIG. 1.
FIG. 1.

Participant 1. Images obtained in a 1.6-year-old with multiple fractures. Arrows indicate fracture. A and E: Axial CT (A) and MRI (E) volumetric samples. B and F: CT (B) and MRI (F) 3D-reconstructed front views. C and G: Coronal CT (C) and MRI (G) volumetric samples. D and H: CT (D) and MRI (H) 3D-reconstructed profiles. Figure is available in color online only.

FIG. 2.
FIG. 2.

Participant 31. Images obtained in a 14-year-old with occipital bone fracture. Arrows indicate fracture. A and C: Axial CT (A) and MRI (C) volumetric samples. B and D: CT (B) and MRI (D) 3D-reconstructed rear views. Figure is available in color online only.

In 30 (97%) of 31 MRI reviews, clinicians agreed (or strongly agreed) that the image quality was acceptable for clinical diagnosis prior to CT review. After CT review, 1 of the 31 MR images (in participant 18) was confirmed to need repeat imaging due to motion. Similarly, reviewers found that 30 (97%) of the 31 CT scans were acceptable for diagnosis and felt the need for repeat scanning on 1 of the CT scans (participant 26) due to motion. The strength of agreement differed slightly but not significantly between CT and MRI; clinicians strongly agreed that imaging was acceptable on 28 CT scans and 25 MR images (p = 0.707; Table 2). Overall, compared to CT, 22 of the MR images were graded as excellent, 6 as good, 2 as sufficient, and 1 as unacceptable for clinical diagnosis.

TABLE 2.

Survey responses regarding image quality for MRI and CT scans

ResponseImaging AcceptableNeed Another Scan
CTMRCTMR
Strongly disagree002825
Disagree1*1*25
Neither agree nor disagree0000
Agree251*1*
Strongly agree282500
p value0.7070.707

The MR images of participant 18 and the CT scan of participant 26 were deemed unacceptable for clinical diagnosis, with clinician desire for additional scanning.

Discussion

In this preliminary case series, we showed the potential value of the GA-VIBE sequence in producing CT-like volumetric images and 3D rendering of the cranium in children undergoing evaluation for cranial vault fracture. Clinicians were able to identify cranial vault fractures on acceptable MR images, although 1 case was deemed unacceptable for diagnosis due to motion.

Dremmen and colleagues proposed a conventional gradient echo black-bone sequence with Cartesian k-space sampling to identify bone fractures in pediatric head trauma imaging, producing a sensitivity of 67% and specificity of 88%.5 Conversely, the UTE preserves the bone signal. A UTE sequence needs a short radiofrequency excitation pulse, quick switching between radiofrequency transmission and receiving, rapid gradients, k-space sampling during gradient ramping, and a 3D radial acquisition to achieve the shortest possible echo time. Eddy currents and gradient delays distort the k-space trajectory, leading to blurring and artifacts. The PETRA sequence was developed to overcome these challenges by using radial half-projections to sample outer k-space and single pointwise on a Cartesian trajectory for the center k-space.15 However, the Cartesian center k-space sampling makes PETRA less robust to motion artifacts than the radial UTE. Both the gradient echo black-bone and the PETRA sequence showed poor accuracy to detect nondisplaced fractures without sedation.4,5 The proposed GA-VIBE method optimizes image contrast between bone and the surrounding soft tissue, and it is intrinsically less sensitive to motion due to its non-Cartesian acquisition pattern. Lindberg and colleagues used a gradient recalled echo sequence and T2-weighted images on children younger than 6 years of age presenting with traumatic brain injury.1 Impressively, they successfully performed unsedated MRI on 223 of 225 participants and were able to identify traumatic brain injuries in 5 participants that were missed by CT. However, MRI missed 6 of 8 nondepressed skull fractures. In our case series, clinicians were able to correctly identify all cranial vault fractures using MRI, including those on nonsedated participants. In 1 case (participant 14), the clinicians identified the nondisplaced occipital fracture via MRI, but also pointed out that in this scan performed 9 weeks after injury there were also expected findings of healing and adjacent intracranial fluid products, suggesting a resolving hematoma.

Although the sensitivity and specificity of MRI to fractures were 100% in our small sample, the reviewers felt that one of the MR images was unacceptable for clinical diagnosis due to motion artifacts (participant 18). Head motion is a major source of image degradation in pediatric MRI.16 Sedation is commonly used to minimize movement in clinical MRI examinations.17 The sedation rate in head MRI is reported as approximately 60%–65% in patients 1–6 years old and 32% for all patients younger than 18 years of age.17 Efforts have been made to reduce the need for sedation by shortening scan time and by using a multidisciplinary team to coordinate imaging with the patient’s biorhythms.1,18 However, despite these efforts, sedation continues to be used to obtain clinically acceptable images. Therefore, it is highly desirable to develop MRI technology to provide images free of motion artifacts without resorting to sedation. MRI motion correction consists of detecting, estimating, and then correcting 3D rigid head motion. Self-navigated MRI methods have been used to detect and correct periodic respiratory or cardiac motions, or 2D in-plane rigid head motion.19–25 We will expand on this prior work to develop a model for motion transformation to correct for a wide range of 3D (in- and through-plane) head motions in the future.

The proposed GA-VIBE scan was optimized for a 3-T scanner, while 1.5-T scanners are more common in the clinical setting. A GA-VIBE scan was applied to 2 participants with cranial fractures using a 1.5-T scanner (participants 1 and 26). As demonstrated in Fig. 1, the fractures are visible, but the lambdoid sutures are less visible on the axial view MR versus CT images. In this case, the left parietal/temporal fracture was identified in the coronal view. Further work is needed to compare images obtained from 3-T and 1.5-T scanners and determine the impact of motion for unsedated 1.5-T MRI in a large patient cohort.

This study focused on evaluating the utility of the GA-VIBE sequence for cranial vault fractures. Skull base fractures were not included and are known to be more difficult to identify. Our future goal is to investigate the clinical utility of the GA-VIBE sequence for skull base fractures, once we achieve our aims in creating automated and motion-corrected CT-like images for the cranial vault. Another limitation of MRI is poor compliance for unsedated scans, particularly in children between 1 and 6 years of age. We were able to image 4 participants in this age range without sedation. However, due to poor compliance, MR images from 2 participants were omitted. In addition, during the pilot phase of this study, we focused our enrollment on older children (> 8 years of age) to ensure success in completing an unsedated MRI scan. Enrollment of participants is ongoing, and currently we do not exclude patients based on age or concern for compliance due to the availability of advanced techniques (such as pediatric MRI technicians, child-life team, noise reduction, and use of foam cushions and vacuum immobilizers) to improve the success rate for unsedated MRI.26

Conclusions

The proposed GA-VIBE is a promising MRI method to achieve CT-like volumetric images and 3D renderings of the cranial bone in children with head trauma to allow for diagnosis of cranial vault fractures. Compared to the previously proposed MRI techniques, it is intrinsically more robust to motion. Future directions include the automation of postprocessing and motion correction, as well as decreasing scan time to ensure wide clinical utility.

Acknowledgments

This research was supported by the following Washington University Institute of Clinical and Translational Sciences grants: no. UL1 TR000448, the Mallinckrodt Institute of Radiology, and the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health (NIH) under award no. R01EB032713. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Disclosures

Dr. Patel reports being a consultant to Stryker CMF.

Author Contributions

Conception and design: Patel, An. Acquisition of data: Eldeniz, Commean, Eshraghi Boroojeni, Jammalamadaka, Merrill, Smyth, Goyal. Analysis and interpretation of data: Patel, Skolnick, Eshraghi Boroojeni. Drafting the article: Patel, Skolnick, Commean, An. Critically revising the article: An. Reviewed submitted version of manuscript: Patel, Jammalamadaka, Smyth, Goyal. Approved the final version of the manuscript on behalf of all authors: Patel. Statistical analysis: Skolnick. Administrative/technical/material support: Merrill. Study supervision: Patel, An.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

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Supplementary Materials

Illustration from Cinalli et al. (pp 119–127). Printed with permission from © CC Medical Arts.
  • View in gallery

    Participant 1. Images obtained in a 1.6-year-old with multiple fractures. Arrows indicate fracture. A and E: Axial CT (A) and MRI (E) volumetric samples. B and F: CT (B) and MRI (F) 3D-reconstructed front views. C and G: Coronal CT (C) and MRI (G) volumetric samples. D and H: CT (D) and MRI (H) 3D-reconstructed profiles. Figure is available in color online only.

  • View in gallery

    Participant 31. Images obtained in a 14-year-old with occipital bone fracture. Arrows indicate fracture. A and C: Axial CT (A) and MRI (C) volumetric samples. B and D: CT (B) and MRI (D) 3D-reconstructed rear views. Figure is available in color online only.

  • 1

    Lindberg DM, Stence NV, Grubenhoff JA, et al. Feasibility and accuracy of fast MRI versus CT for traumatic brain injury in young children. Pediatrics. 2019;144(4):e20190419.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Nelson EL, Melton LJ III, Annegers JF, Laws ER, Offord KP. Incidence of skull fractures in Olmsted County, Minnesota. Neurosurgery. 1984;15(3):318324.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Stanley RM, Hoyle JD Jr, Dayan PS, et al. Emergency department practice variation in computed tomography use for children with minor blunt head trauma. J Pediatr. 2014;165(6):12011206.e2.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Kralik SF, Supakul N, Wu IC, et al. Black bone MRI with 3D reconstruction for the detection of skull fractures in children with suspected abusive head trauma. Neuroradiology. 2019;61(1):8187.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Dremmen MHG, Wagner MW, Bosemani T, et al. Does the addition of a “black bone” sequence to a fast multisequence trauma MR protocol allow MRI to replace CT after traumatic brain injury in children?. AJNR Am J Neuroradiol. 2017;38(11):21872192.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

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