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Dynamic 3D MR-Defecography
Dynamische 3D-MR-Defäkografie
Epidemiological studies have estimated
the incidence of chronic constipation to be
up to 27 % of the general population. The
gold standard to evaluate affected patients
is the dynamic entero-colpo-cysto-defecography. In the clinical routine 2 D MR-defecography is also performed, but only one to
three 2 D slices at a temporal footprint of
about one second are acquired. To improve
the detection of lateral localized pathologies, we developed and implemented
dynamic 3 D MR-defecography. Each 3 D
block consisted of seven slices with an inplane spatial resolution of 1.3 × 1.3mm² to
2.3 × 2.3mm² and an image update rate between 0.8 s and 1.3 s. We used a fast bSSFP
sequence with a modified stack-of-stars
sampling scheme for data acquisition and
a modified FISTA compressed sensing algorithm to reconstruct the undersampled
datasets. We performed a study including
6 patients to optimize the acquisition
parameters with respect to image quality.
Epidemiological studies have shown that
the incidence of chronic obstructive diseases is up to 27 % of the general population. The gold standard to evaluate affected
patients is the radiographic method of
entero-colpo-cysto defecography (ECCD)
(Cappabianca et al. Int J Colorectal Dis
2011; 26: 1191 – 1196). Two major disadvantages of ECCD are the application of ionizing radiation in the pelvic floor region
and the unpleasant measurement procedure for patients. Contrast agent has to be
administered to the rectum, bladder, vagina and the small intestine of the patient.
In the clinical routine, 2 D MR-defecography is often applied as a supplementary
method. MR-defecography only requires
rectal filling with sonographic gel as the
contrast agent and no ionizing radiation
has to be administered in the pelvic floor
region. However, imaging of the fast dynamic and non-periodic defecation process is challenging due to the lengthy
data acquisition in MR imaging. Thus,
with standard methods only a very limited number of 2 D slices can be sampled
to still achieve a sufficient temporal resolution for the single slices.
Consequently, both ECCD and MR-defecography feature restricted spatial coverage and therefore lack information about
the lateral extent of obstruction-related
pathologies like rectoceles or intussusceptions. Nevertheless, newer sampling trajectories and acceleration techniques in MR
imaging have the potential to overcome
the limitations named above. While parallel imaging is already widely used in the
clinical routine, the compressed sensing
(CS) technique (Lustig et al. Magn Reson
Med 2007; 58: 1182 – 1195) is still restricted to research. Nevertheless, CS has been
proven to allow reconstruction of highly
undersampled data, especially in acquisitions of dynamic processes, thereby significantly accelerating the scan time. CS uses
information about the object to be imaged,
which is already known before the measurement, and includes this prior knowledge as a constraint in the image reconstruction process. By doing this, less data
is needed to obtain images free of under-
Epidemiologische Studien schätzen die Inzidenz chronischer Obstipation auf bis zu
27 % der Gesamtbevölkerung. In der Regel
wird zur Untersuchung betroffener Patienten die Entero-Colpo-Cysto-Defäkografie
verwendet. Auch die 2D-MR-Defäkografie
wird im klinischen Alltag angewendet,
jedoch wird hier lediglich die Dynamik in
ein bis drei 2D-Schichten dargestellt. Die
Evaluation von lateral gelegenen Pathologien kann hierdurch beeinträchtigt sein.
Deshalb haben wir eine 3D-MR-Defäkografie entwickelt und implementiert. Jeder
3D-Block bestand aus sieben Schichten
mit einer räumlichen Auflösung zwischen
1,3 × 1,3mm² und 2,3 × 2,3mm². Die Bildaktualisierungsrate lag zwischen 0,8 s und
1,3 s. Wir verwendeten für die Datenakquisition eine modifizierte Stack-of-Stars
bSSFP-Sequenz und für die Datenrekonstruktion einen modifizierten FISTAcompressed-sensing-Algorithmus. Für die
Optimierung der Akquisitionsparameter
hinsichtlich der Bildqualität haben wir eine
Studie mit 6 Patienten durchgeführt.
sampling artifacts. Therefore, it is possible
to acquire more slices within a certain
amount of time and thereby cover the dynamics of the defecation process not only
in single 2 D slices but in a complete 3 D
In this paper, we propose a 3 D MR-defecography setup that uses an extended radial
bSSFP stack-of-stars (Wech T. Fortschr
Röntgenstr 2014; 186: 37 – 41) imaging sequence for data acquisition and a modified
“Fast Iterative Shrinkage Threshold Algorithm – FISTA” (Beck A. et al. SIIMS 2009;
2: 183 – 202) compressed sensing algorithm for data reconstruction. We applied
this setup to 6 female patients in order to
optimize the imaging protocol with respect
to the sampling strategy as well as the spatial and temporal resolution.
Materials and Methods
All measurements were performed on 3 T
whole-body systems (MAGNETOM Prisma
and MAGNETOM Skyra, Siemens Healthcare GmbH, Erlangen) equipped with a 32channel body array coil. All reconstruction
algorithms were implemented using Matlab 2014b (The Mathworks, Natick, MA,
Data acquisition was performed using a
sagittal 3 D bSSFP stack-of-stars imaging
sequence. This technique uses standard
phase encoding in the kz-direction and a
radial sampling scheme in each of the kxky-planes. The most straightforward implementation of the stack-of-stars trajectory
acquires each kz-partition of a 3 D block
one after another and with the same num▶ Fig. 1a).
ber of spokes in each partition (●
In addition to this version, two supplementary features were implemented. The first
one is density weighting (DW), which is
▶ Fig. 1b. The number of spokes
shown in ●
varies between the different partitions of
the 3 D block and increases towards the
central partition. We acquired seven partitions from kz,min = -3 to kz,max = 3 and applied two different undersampling patterns for kx,y. Compared to full Nyquist
sampling at kx,y = max, the undersampling
factors R from the center partition kz = 0 to
the outer partitions were R = 3, 4, 5, 6 (DW
sampling 1) and R = 3, 4, 8, 10 (DW sampling 2), respectively. The second feature is
view sharing, in which the order of the acquired partitions is changed from linear to
a rearranged order while the central partition is sampled more often. The corresponding sampling scheme is shown in
●▶ Fig. 1c. In every partition the spokes are
Ratz V et al. Dynamic 3D MR-Defecography … Fortschr Röntgenstr · DOI http://dx.doi.org/10.1055/s-0042-109071
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
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Fig. 1 a Standard stack-of-stars sampling scheme. Each time frame (which
is equivalent to one 3 D volume) consists of seven partitions (kz = -3…3)
that are measured one after another. b In case of density weighting, the
number of acquired spokes increases towards the center partition. c Additional view sharing that acquires the partitions in a rearranged order and
acquires the center partition kz = 0 more often was implemented. Therefore, the number of reconstructed time frames is almost doubled.
Table 1
Tab. 1
Abb. 1 a Standard „Stack-of-Stars“ Abtastungsschema. Jedes 3D-Volumen
besteht aus sieben Partitionen (kz = -3…3), welche der Reihe nach gemessen werden. b Beim „density-weighting“ nimmt die Anzahl an gemessenen
radialen Linien zur Mitte hin zu. c Im Gegensatz zum Standardschema werden beim „view-sharing“ die einzelnen Partitionen nicht linear, sondern in
einer umsortierten Reihenfolge gemessen. Dabei wird die mittlere Partition
kz = 0 zweimal pro 3D-Volumen gemessen, wodurch nahezu doppelt so
viele 3D-Volumen („time frames“) rekonstruiert werden können.
Measurement parameters of all 6 female patients and their age.
Messparameter aller 6 weiblichen Patienten und deren Alter.
matrix size
voxel size/mm3
DW sampling
256 × 256 × 8
280 × 280 × 32
2.2 × 2.2 × 4
256 × 256 × 8
300 × 300 × 32
2.3 × 2.3 × 4
384 × 384 × 7
270 × 270 × 56
1.4 × 1.4 × 8
256 × 256 × 7
256 × 256 × 42
2.0 × 2.0 × 6
448 × 448 × 7
300 × 300 × 35
1.3 × 1.3 × 5
448 × 448 × 7
300 × 300 × 35
1.3 × 1.3 × 5
Temporal and spatial resolution parameters, the repetition time (TR) and echo time (TE), as well as the applied DW sampling scheme are shown.
Parameter zur zeitlichen und räumlichen Auflösung, Repetitionszeit (TR) und Echozeit (TE), sowie das verwendete DW-Sampling-Schema sind dargestellt.
sampled in linear order and every second
spoke is measured in the reversed direction to compensate for eddy currents.
Data were initially gridded onto a Cartesian
grid using the parallel imaging technique
of self-calibrated GRAPPA operator gridding (GROG). Subsequently, data reconstruction was performed using a compressed
sensing technique, which enforces sparsity
in the spatial wavelet domain. In general,
this optimization problem can be mathematically expressed by
min || Fu m – y ||22 + λ ||Ψm||1
where m represents the image data to
be reconstructed and y is the undersampled k-space measurement. The operator
Fuas applies a Fourier transform and
masks k-space data not sampled. The first
term of the equation thus enforces data
consistency between the current solution
and the undersampled acquisition. The
second term enforces the reconstructed
image to be sparse in the wavelet domain.
ψ represents a wavelet transform operator which is applied to the solution m.
The regularization parameter λ realizes a
trade-off between data consistency and
sparsity in the wavelet transform domain.
To effectively perform the optimization,
we implemented a modified FISTA algorithm in analogy to Wech T. et al. (Wech
T. et al. IEEE Transactions on Medical Imaging 2015; 35: 912 – 920).
The described acquisition and reconstruction scheme was applied to 6 female patients. The study was approved by the
ethics committee of our institution and
written informed consent was obtained
from all patients participating in the study.
All patients underwent a clinically indicated 2 D MR-defecography examination.
The MR-defecography protocol consisted
of three static high-resolution 2 D TSE sequences for scouting (FOV: 350 × 350mm²,
voxel size: 0.7 × 0.7mm², slice thickness: 3 mm, flip angle: 150°, TR = 3780 ms,
TE = 82 ms) and a dynamic 2 D examination
was performed thereby acquiring three
separated sagittal 2 D slices using a bSSFP
sequence (FOV: 320 × 320mm², voxel size:
0.6 × 0.6mm², slice thickness = 8 mm, flip
angle: 50°, TR = 3.48 ms, TE = 1.55 ms). The
rectum was contrasted with 200 ml of sonographic gel.
After this 2 D examination the patient’s
rectum was refilled with sonographic
gel and the proposed 3 D examination
scheme was applied. During both dynamic measurements the patients were asked
to strain and squeeze and then to evacuate the rectum. The imaging parameters
of the 3 D sequence of all patients are
▶ Table 1. We used an in-plane
shown in ●
spatial resolution from 1.3 × 1.3mm² to
2.3 × 2.3mm² with a slice thickness of 4 to
8 mm. Depending on the spatial resolution and on the density weighting
scheme, we obtained a temporal resolution from 1.2 to 2.1 seconds. By applying
view sharing, the respective time frames
were updated every 0.8 s to 1.3 s. For
the first two patients a standard stack-of▶ Fig. 1a) was
stars sampling scheme (●
used. The undersampling factor in all partitions was R = 4 and eight partitions were
measured in these cases, while for all
other patients the additional features of
Ratz V et al. Dynamic 3D MR-Defecography … Fortschr Röntgenstr · DOI http://dx.doi.org/10.1055/s-0042-109071
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Technical Innovations
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density weighting and view sharing were
applied for seven partitions. Patients 3
and 4 were measured using DW sampling
1 with lower undersampling factors in the
outer partitions and patients 5 and 6 were
examined using DW sampling 2 with
higher undersampling factors in the outer
partitions. The flip angle was between 39°
and 42°.
The compressed sensing reconstructed datasets allowed examination of the defecation process within the whole acquired
▶ Fig. 2 shows one central slice
3 D volume. ●
of a single time point for each patient to allow comparison of the different sampling
schemes. The sagittal view visualizes the
rectum of the six patients that was filled
with 200 ml of sonographic gel.
All patients had a small (< 2 cm), medium
(2 – 4 cm) or large (> 4 cm) anterior rectocele. The images acquired without density
weighting and without view sharing (DW
sampling 0, patients 1 & 2) indeed show
the pathology. However, compared to the
images of patients 5 and 6, significant blurring due to the low spatial resolution of the
images impairs diagnosis. The second sampling scheme (DW sampling 1, patients 3 &
4) resulted in images that also allow detection of the rectocele in each case, but an increased level of incoherent artifacts (see
white arrow) remains after application of
the proposed reconstruction method. The
results obtained using DW sampling 2 feature the best image quality with high spatial resolution and low artifact power.
▶ Fig. 3 depicts a dynamic imThe top of ●
age series exemplarily for slice five in patient 5. The series clearly shows the evolution of a small anterior rectocele. The
▶ Fig. 3,
series presented at the bottom of ●
Video 1 shows all slices of time frame
7. Identical images are indicated by the
white squares. The lateral extent of the
rectocele can be accurately evaluated by
the extended spatial coverage of the newly proposed imaging technique. While
banding artifacts are present in the bright
fat tissues, none are visible within the patient’s rectum.
Discussion and Conclusion
The proposed 3 D MR-defecography method offers the possibility to visualize
the defecation process of patients with
pelvic floor disorders with extended cov-
Fig. 2 A central slice of all patients. Patients 1 and 2 were examined without density weighting and
view sharing (DW sampling 0), patients 3 and 4 were examined with DW sampling 1 and patients 5 and
6 were examined with DW sampling 2. Patients 5 and 6 feature the highest spatial resolution, the
highest undersampling factors and nonetheless the highest image quality.
Abb. 2 Eine mittlere Schicht aller Patienten. Patient 1 und 2 wurden ohne „density-weighting“ und
„view-sharing“ untersucht (DW-Sampling 0), die Patienten 3 und 4 mit DW-Sampling 1 und die Patienten 5 und 6 mit DW-Sampling 2. Die Patienten 5 und 6 besitzen die höchste räumliche Auflösung,
die höchsten Unterabtastungsfaktoren und trotzdem die beste Bildqualität.
erage. Not only the anterior-posterior but
also the lateral extent of a given pathology can be evaluated. Furthermore, the
extended coverage provides more flexibility, because it is easier to angle a 3 D
volume properly than to angle a single
2 D slice. However, it has to be considered
that the whole examination depends lar-
gely on the individual patient and how
strong the motion is during the defecation process.
We optimized the sampling scheme of our
3 D MR-defecography method to get optimized image quality with highly reduced data acquisition. We varied the acquisition parameters within an acceptable
Ratz V et al. Dynamic 3D MR-Defecography … Fortschr Röntgenstr · DOI http://dx.doi.org/10.1055/s-0042-109071
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Fig. 3 Temporal progress of the defecation process of patient 5 (top). It is
shown how a small anterior rectocele evolves during defecation. Due to the
3 D measurement, the lateral extent of the rectocele can be evaluated in all
slices of the 3 D block. At the bottom all slices of time frame 7 are shown.
Identical images are indicated by white squares.
range regarding temporal and spatial resolution in 6 patients to determine an
optimal trade-off. The first two patients
showed that it is possible to visualize the
defecation process with standard stackof-stars sampling. However, the sampling
has three disadvantages.
First, only a small undersampling factor
R = 4 was possible, because the standard
stack-of-stars sampling has no variation in
Abb. 3 (Oben) Zeitlicher Verlauf der Defäkation von Patient 5. Es ist zu
sehen, dass sich während der Entleerung eine kleine anteriore Rektozele
bildet. Durch die 3D-Messung ist es möglich die laterale Ausdehnung der
Pathologie zu untersuchen. In der unteren Bilderserie sind alle Schichten
von Bild 7 der oberen Bilderserie dargestellt. Identische Bilder sind durch
weiße Rahmen gekennzeichnet.
the kz-direction and in this case a higher
undersampling factor would result in severe undersampling artifacts. Second, the
sampling doesn’t consider the fact that the
higher signal energy is located in the center of the 3 D k-space and that missing
data in this region leads to stronger artifacts in the reconstructed images than
missing data in the k-space periphery.
Third, the number of reconstructed time
frames can almost be doubled using the
view sharing feature, which is reasonable
for better dynamic visualization.
Therefore, we improved the sampling pattern with respect to these three points and
adapted the two different DW sampling
schemes. With the variation in the kz-direction in combination with our 3 D data reconstruction, higher undersampling factors
were possible. For patient 3 we invested
Ratz V et al. Dynamic 3D MR-Defecography … Fortschr Röntgenstr · DOI http://dx.doi.org/10.1055/s-0042-109071
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Technical Innovations
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(DW sampling 2). This solution seemed to
be the optimal trade-off of a good temporal
and spatial resolution. An even higher spatial resolution would further prolong the
scan time and higher undersampling factors would again increase the artifact level.
Our proposed method shows that the fast,
non-periodic, dynamic defecation process can be visualized with 3 D MR imaging using a density-weighted and view-
shared stack-of-stars sampling scheme in
combination with a 3 D FISTA compressed
sensing reconstruction algorithm.
The next step comprises the comparison of
our approach with the standard defecography methods in a larger patient collective.
V. Ratz, T. Wech, A. Schindele, A. Dierks, A. Sauer,
J. Reibetanz, A. Borzi, T. Bley, H. Köstler, Würzburg,
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
this time gain in a higher spatial resolution,
which led to good image quality. For patient 4 we invested the time gain in an
even higher image update rate than for patients 1 and 2. That, however, led to an increase in the artifact level that impaired diagnosis. Therefore, we further increased
the spatial resolution and compensated the
accompanying time loss with higher undersampling factors in the outer partitions
Ratz V et al. Dynamic 3D MR-Defecography … Fortschr Röntgenstr · DOI http://dx.doi.org/10.1055/s-0042-109071