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Magnetic Resonance Imaging of the Normal Tongue: Qualitative Evaluation of Fat-Suppressed Contrast Enhanced Images

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Magnetic Resonance Imaging of the Normal Tongue: Qualitative Evaluation of Fat-Suppressed Contrast Enhanced Images Bulletin of the Osaka Medical College 49 1, 2 21-28, 2003 21 Original Article Magnetic Resonance Imaging of the Normal Tongue: Qualitative Evaluation of Fat-suppressed Contrast Enhanced Images Yasunori ARIYOSHI1), Masashi SHIMAHARA1), Yasuo UESUGI2), Isamu NARABAYASHI2) 1) Department of Oral Surgery, Osaka Medical College 2) Department of Radiology, Osaka Medical College Key Words : magnetic resonance imaging, fat suppression, tongue, anatomy ABSTRACT Objective: For diagnosing the lesions on magnetic resonance imaging (MRI), it is necessary to understand normal structures on each sequence. In this study, we attempted to clarify structures of the normal tongue on fat -suppressed enhanced MRI qualitatively. Clinical material and method: Twenty-seven fat-suppressed enhanced MR images of normal tongue were studied, which were obtained using a T1 weighted spin echo pulse sequence (T1WI- SE) with the chemical shift selective (CHESS) method by a superconducting MRI scanner operating at 1.5T. Tongue structures and their signal intensities on fat-suppressed enhanced images were assessed and compared to those obtained by non-enhanced T1WI. Results: Normal tongues were found to be composed of a symmetrical high signal area (HSA), low signal area (LSA), lingual septum, bilateral sublingual gland, and genioglossus muscle on non- enhanced T1WI. In the fat-suppressed enhanced images, HSA and lingual septum signal intensities were suppressed. Further, though the lingual mucosa was well visualized in fat-suppressed enhanced images (P<0.05), differentiation of HSA and LSA was difficult as compared to the non- enhanced scans (P<0.05). Conclusion: Fat-suppressed enhanced scans demonstrated simple anatomical structures as com- pared to conventional T1WI with independent signal intensity. Accordingly, we conclude that it is necessary to use both sequence for diagnosing the mass lesion located in the tongue. Introduction dardized protocol for evaluating head and neck lesions, which consists of plain T1-spin echo (SE), Magnetic resonance imaging (MRI) has become plain fat-suppressed (FS) T2 turbo-spin echo (TSE), an essential modality for evaluating mass lesions in and FS-T1-TSE after Gd-DTPA. Clinically, we have the oral and maxillofacial region, and clinical utility used plain T1 weighted images (conventional or fast has also been reported (ARIYOSHI et al., 1998, 2000, spin echo; conventional T1WI or FSE-T1WI), FSE- 2003). In addition, fat-suppressed techniques have T2 weighted images (T2WI) with or without fat sup- also been used to improve lesion detectability when pression, and dynamic enhanced T1WI followed by surrounded by fatty tissue and/or to estimate fat-suppressed enhanced T1WI. However, for diag- whether the lesion includes fatty materials (LENZ et nosing lesions located in the tongue using a combina- al., 2000). Lenz et al. (2000) presented the stan- tion of these complex sequences, it is necessary to 21 22 Y. ARIYOSHI, M. SHIMAHARA, Y. UESUGI, I. NARABAYASHI clarify normal structures as revealed by each TR/TE) or FSE T1WI (400-600/8-14/2-3, sequence. Especially, T1WI showed good anatomical TR/TE/ET) and FSE-T2WI (4000/102/16-18, structure of head and neck (LENZ et al., 2000), it is TR/TE/ET), coronal and/or axial contrast important to clarify whether or not the structure enhanced fat-suppressed T1WI were obtained by which could be detected on non-enhanced T1WI simultaneous intravenous bolus injection of could also be detected on fat suppressed contrast gadopentetate dimeglumine (Magnevist, Japan- enhanced MRI. Scheling, Osaka, Japan) at 0.1 mmol /kg body In the present study, we observed delineated nor- weight. The contrast medium was injected intra- mal tongues and their surrounding structures using veneously within 15 seconds. All image slices that fat-suppressed contrast enhanced MRI and compare included the tongue were used for estimation. the results to those seen with non-enhanced T1WI. The fat-suppressed method utilized in the present study was the chemical shift selective (CHESS) Materials and methods method (HASSE et al., 1985; SZUMOWSKI et al., 1999). The study specimens were contrast enhanced 2. Images analysis fat-suppressed images of tongues from 27 patients Structures that composed the tongue and floor (mean age standard deviation = 55.3 14.2 of the mouth were qualitatively assessed to deter- years old, male to female ratio=16:11). These mine whether those detected by non-enhanced examinations were performed to diagnose the T1WI were also detectable in fat-suppressed lesion which occurred in the oral and maxillofacial enhanced scans. For statistical analysis, a 2 test region except for the tongue and the floor of the was used for comparing the detectability of each mouth. None of the patients had lesions in the structure between the two types of scans, with tongue or floor of the mouth seen clinically and/or P<0.05 considered to be significant. In addition, radiologically, and none suffered from malignant the signal intensity of each of those structures on entities or aggressive inflammatory processes sys- fat-suppressed images were assessed and classi- temically. The images were not affected by appar- fied into 3 groups; high, intermediate, and low ent artifacts, including motion and susceptibility, (Table 1). The qualitative evaluations were inde- while tongue shape was determined to be symmet- pendently performed by two oral surgeons (Y.A. rical by viewing selected slices. and M.S.), with findings and/or types accepted The MRI scanner used was a SIGNA (General when both agreed. Electric Medical Systems, Milwaukee, WI) operat- ing at 1.5 Tesla. The head coil that had a diameter Result of 28 cm or the surface coil was used. All sequences were performed with a slice thickness 1) Anatomical structures on non-enhanced T1WI of 5.0 mm with an intersection gap of 0 to 1mm, a On non-enhanced T1WI, the normal tongue 256 x 224 imaging matrix, and a field of view of 26 was delineated as a low signal structure with near- cm. ly the same signal as the surrounding muscula- After obtaining conventional (400-500/40, ture, including the muscles of mastication. The Table 1 Qualitative classification of fat suppressed enhanced MRI 22 Bulletin of the Osaka Medical College 49 1, 2 21-28, 2003 Fat Suppressed MRI of the Normal Tongue 23 portion corresponding to the intrinsic tongue mus- lingual septum could not be detected as an inde- culature was composed of a symmetrical high sig- pendent structure, and in 15 of 18, the signal nal area (HSA) and a surrounding low signal area intensity of the lingual septum was suppressed (LSA) in all cases. There were no cases in which and depicted as a low signal linear structure, while the intrinsic tongue musculature could be identi- it was depicted as a high signal linear or dot-like fied. In the center of the tongue, a high signal lin- structure in the other 3 cases. The anterior and/or ear structure was clearly delineated in 20 tongues. lower portion of the lingual septum tended to At the premolar level, the symmetrical intermedi- show a high signal intensity, while the posterior ate to high signal intensity structures correspond- portion showed a suppressed low signal intensity. ing to the sublingual gland were able to be identi- The sublingual glands were delineated as symmet- fied between the genioglossus muscles and rical enhanced structures, and their signal intensi- mandibular body in all cases except one case. In ties showed an equal high signal intensity as com- contrast, the mucosal surface of the dorsum pared to the surrounding structures, including the tongue was identified in only 5 cases. intrinsic tongue musculatures and genioglossus muscle. The mucosal surface of the tongue, espe- 2) Anatomical structures on fat-suppressed cially, the dorsum surface, was enhanced strongly enhanced MRI and more easily depicted than the ventral surface. In fat-suppressed enhanced MR images, the Differentiation between the dorsum tongue area corresponding to the intrinsic tongue muscu- mucosa and palatal mucosa was difficult in cases latures was delineated as an intermediate signal where an air space were absent between those structure in many of the cases (HSA; 18 out of 27 two structures (Figure 1,2, Table 2). cases, LSA; 21 out of 27 cases, respectively), though differentiation of each intrinsic tongue 3) Comparison between fat-suppressed enhanced musculature was impossible in all of the cases. It scans and non-enhanced T1WI was difficult to divide those areas into HSA and Differentiation between the HSA and LSA was LSA, excluding 4 cases. The genioglossus muscles quite difficult to obtain on fat-suppressed could be detected in 24 cases as an intermediate enhanced scans as compared to non-enhanced to low signal structure, whereas it could not be T1WI (p<0.05). Conversely, the lingual mucosa differentiated from the intrinsic tongue muscula- was well visualized on fat-suppressed scans as ture in the remaining 3 cases. In 9 tongues, the compared to non-enhanced T1WI (p<0.05). Other Table 2 Signal intensity on fat suppressed enhanced MRI Bulletin of the Osaka Medical College 49 1, 2 21-28, 2003 23 24 Y. ARIYOSHI, M. SHIMAHARA, Y. UESUGI, I. NARABAYASHI Fig. 1 Plain T1WI and fat suppressed enhanced image (coronal scan) Left: Non-enhanced T1WI, Right: fat-suppressed enhanced MRI. The signal from the lingual septum is apparently suppressed and shows a low signal linear structure at the center of the tongue (arrow). The HSA of the intrinsic tongue musculature was also sup- pressed, and showed rather low signals as compared to the LSA. Fig. 2 Plain T1WI and fat-suppressed enhanced image (axial scan). Left: Non-enhanced T1WI, Right: fat-suppressed enhanced image. The signal intensity of the lingual septum is apparently suppressed, however, the low signal linear structure cannot be detected in the fat-suppressed enhanced image.
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