Neuroradiolog y / Head and Neck Imaging • Original Research

Shah et al.
3-T T1-Weighted Imaging of Extradural Spinal Lesions

Neuroradiology/Head and Neck Imaging

Original Research

Comparison of Gadolinium-
Enhanced Fat-Saturated T1-
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Weighted FLAIR and Fast Spin-

Echo MRI of the Spine at 3 T for
Evaluation of Extradural Lesions
Komal B. Shah1 OBJECTIVE. Inversion recovery has been used to correct the loss of CSF and tissue contrast
Nandita Guha-Thakurta at 3 T versus 1.5 T but has not been formally investigated in the spine after IV administration of
Dawid Schellingerhout gadolinium-based contrast agent. The purpose of this study is to compare two sequences for gad-
John E. Madewell olinium-enhanced spine imaging at 3 T—fat-saturated T1-weighted FLAIR and fat-saturated T1-
Ashok J. Kumar weighted fast spin-echo (FSE)—for evaluation of extradural lesions and CSF-cord contrast.
MATERIALS AND METHODS. After IV administration of gadolinium-based con-
Colleen M. Costelloe
trast agent, fat-saturated T1-weighted FSE and FLAIR sequences were obtained in 156 MRI
Shah KB, Guha-Thakurta N, Schellingerhout D, scans of 143 patients at 3 T. Three experienced radiologists compared these sequences for
Madewell JE, Kumar AJ, Costelloe CM conspicuity differences in bone lesions, disk lesions, other epidural lesions, and cord-CSF
contrast. A 7-point visual rating scale was used, with lower numbers indicating increased
conspicuity on gadolinium-enhanced fat-saturated T1-weighted FLAIR and higher numbers
indicating increased conspicuity on gadolinium-enhanced fat-saturated T1-weighted FSE.
RESULTS. A slight increase in the conspicuity of gadolinium-enhancing bone lesions
(mean score, 3.6; p < 0.0001), disk lesions (mean score, 3.5; p < 0.0001), and epidural le-
sions (mean score, 3.4; p < 0.0001) was seen on fat-saturated T1-weighted FLAIR compared
with fat-saturated T1-weighted FSE. A higher degree of contrast between the spinal cord and
CSF was seen on fat-saturated T1-weighted FLAIR, by a large margin (mean score, 1.8; p <
0.0001). All enhancing lesions seen on fat-saturated T1-weighted FSE images were also seen
on fat-saturated T1-weighted FLAIR images.
CONCLUSION. Decreased CSF-cord contrast at 3 T, as seen on T1-weighted FSE, can be
regained by using T1-weighted FLAIR. Fat-saturated T1-weighted FLAIR may increase conspi-
cuity of gadolinium-enhancing extradural lesions compared with fat-saturated T1-weighted FSE.

Keywords: 3 T, contrast enhancement,
MRI techniques, spine
DOI:10.2214/AJR.10.4887
Received May 1, 2010; accepted after revision
March 4, 2011.
1
All authors: Department of Diagnostic Imaging,
University of Texas M. D. Anderson Cancer Center,
1515 Holcombe Blvd, Unit 370, Houston, TX 77030.
Address correspondence to K. B. Shah
(komal.shah@mdanderson.org).
AJR 2011; 197:697–703
0361–803X/11/1973–697
© American Roentgen Ray Society
O
ne of the advantages of high-field-
strength MRI is the potential to
increase signal-to-noise ratios and,
thus, image quality. The promise
of high-field-strength imaging is often not
met, however, because of new problems intro-
duced by these systems. One such problem is
found in 3-T imaging of the spine. T1-weight-
ed fast spin-echo (FSE) sequences of the spine
at 3 T show lower contrast between the CSF
and the spinal cord compared with 1.5-T im-
aging (Fig. 1).
The paradoxical loss of contrast between
CSF and cord at 3 T is attributed to a rela-
tively large increase in T1 relaxation time of
the spinal cord with increasing field strength
[1], whereas the T1 relaxation time of CSF
increases relatively slowly with increasing
field strength. Stanisz et al. [2] found that
the mean (± SD) T1 relaxation time of the
rat spinal cord at 1.5 T was 745 ± 37 mil-
liseconds and the time at 3 T was 993 ± 47
milliseconds. Rooney et al. [1] found that the
T1 relaxation time for intracranial CSF at 1.5
T was 4070 ± 65 milliseconds and the time
at 4 T was 4472 ± 85 milliseconds. Because
the increase in T1 relaxation time as a func-
tion of magnetic field strength is expected to
be linear [2], the T1 relaxation time for CSF
at 3 T would fall between the two values giv-
en. Thus, the T1 relaxation time of the spinal
cord increases by about 20% between 1.5 T
and 3 T, whereas the T1 relaxation time for
CSF increases by less than 10%.
Adequate CSF nulling is important to dif-
ferentiate syrinx or syringomyelia from cord
edema and to avoid unnecessary suspicion of
subarachnoid tumor seeding. One suggested
solution to the problem of lost CSF-cord con-
trast at 3 T is the use of FLAIR sequences
(Fig. 2), which have a broader dynamic con-
trast range and can recover some of the lost

AJR:197, September 2011 697

 Shah et al.
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A B C
Fig. 1—67-year-old man with bone metastasis resulting from prostate cancer, 2 months after radiation treatment to T4.
A, Image of 3-T contrast-enhanced fat-saturated T1-weighted fast spin-echo (FSE) sequence (TR/TE, 700/14.544; inversion time [TI], 0; echo-train length [ETL], 4) shows
enhancing metastasis at T4 (arrow) and disk-osteophyte complex at T8–9 (asterisk). Cord and CSF are barely distinguishable from each other.
B, Image of 3-T contrast-enhanced fat-saturated T1-weighted FLAIR sequence (TR/TE, 3562/21.5; TI, 1238; ETL, 8) obtained immediately before fat-saturated T1-
weighted FSE shows improved cord-CSF distinction.
C, Comparison 1.5-T contrast-enhanced fat-saturated T1-weighted FSE sequence (TR/TE, 450/11.3; TI, 0; ETL, 3) obtained 10 weeks after 3-T scan shows typical cord-
CSF contrast. Compared with FSE sequence (A), deficiency of CSF-cord contrast at 3 T is evident.

contrast between spine and cord at 3 T [3, 4].
Inversion recovery has been used success-
fully in unenhanced spine imaging studies at
both 1.5 and 3 T and has been shown to im-
prove CSF-cord distinction and detection of
cord and marrow lesions at 1.5 T [5, 6]. How-
ever, it is not known whether inversion re-
covery affects evaluation of contrast-enhanc-
ing intradural and extradural spine lesions.
At our institution, spine imaging is more
commonly requested for evaluation of bone
metastasis than for cord pathology or de-
generative change. Fat-saturated T1-weight-
ed imaging after the IV administration of
gadolinium-based contrast agent has been
shown to improve specificity for the diag-
nosis of bone metastases [7, 8], and this se-
quence is routinely performed at our insti-
tution. With respect to the brain, an early
study of gadolinium-enhanced T1-weight-
ed FLAIR at 1.5 T concluded that enhanc-
ing lesions were much less conspicuous on
T1-weighted FLAIR [9], whereas a more
recent study showed improved conspicuity
of enhancing brain lesions on T1-weighted
FLAIR at 1.5 T compared with contrast-en-
hanced T1-weighted FSE [10]. The purpose
of our study is to evaluate the clinical util-
ity of gadolinium-enhanced fat-saturated T1-
weighted FLAIR by comparing the conspi-
cuity of bone and soft-tissue spine lesions
to gadolinium-enhanced fat-saturated T1-
weighted FSE sequences at 3 T.
Materials and Methods
Patients
This retrospective study was approved by the in-
stitutional review board, and written informed con-
sent was waived. The study was conducted in ac-
cordance with HIPAA guidelines. All consecutive
combined thoracic and lumbar spine MRI scans
performed at 3 T between February and July 2008,
which included contrast-enhanced fat-saturated
T1-weighted FSE and fat-saturated T1-weighted
FLAIR in the sagittal plane, were reviewed.
Image Acquisition
Scans were obtained on 3-T MRI units ca-
pable of 8- or 16-channel reconstruction (Excite
HD or HDxt, GE Healthcare). The parameters
for fat-saturated T1-weighted FSE were TR/TE
of 700–800/12–13 and TI of 0. For fat-saturated
T1-weighted FLAIR, parameters were TR/TE of
2000–3600/21–22 and TI of 824–1238. IV contrast
consisted of 0.1 mmol/kg gadopentetate dimeglu-
mine (Magnevist, Bayer Healthcare Pharmaceuti-
cals). The thoracic and lumbar spines were scanned
using separate FOVs, at a single appointment, us-
ing high-definition cervico-thoraco-lumbar coils.
The order in which the contrast-enhanced sagit-
tal sequences (thoracic fat-saturated T1-weighted
FSE, thoracic fat-saturated T1-weighted FLAIR,
lumbar fat-saturated T1-weighted FSE, and lum-
bar fat-saturated T1-weighted FLAIR) were to be
scanned was not specified.
Image Analysis
All MRI scans were reviewed on a PACS (iSite,
Philips Healthcare). Sagittal contrast-enhanced
sequences were reviewed independently by one
musculoskeletal radiologist with 6 years of expe-
rience and two neuroradiologists each with 3 years
of experience. Readings were independent and not
in consensus.
A visual rating system of 1–7 was used to evalu-
ate lesion conspicuity in the following diagnostic
categories: enhancing bone lesions, disk-osteophyte
complexes, and other epidural lesions. A score of 1

698 AJR:197, September 2011

 3-T T1-Weighted Imaging of Extradural Spinal Lesions
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A B
C D
AJR:197, September 2011 699
Fig. 2—30-year-old woman with von Hippel-Lindau
syndrome, thoracic cord syringomyelia, and
hemangioblastoma (not shown but seen equally well
on 3-T contrast-enhanced fat-saturated T1-weighted
FLAIR and fat-saturated T1-weighted fast spin-echo
[FSE]).
A, Image of 1.5-T contrast-enhanced fat-saturated
T1-weighted FSE sequence (TR/TE, 500/16.3;
inversion time [TI], 0; echo-train length [ETL], 3)
shows syringomyelia at C7 and from T4 through T10.
B, Image of 3-T contrast-enhanced fat-saturated T1-
weighted FSE sequence (TR/TE, 900/12.8; TI, 0; ETL,
4) obtained 3 months later, at same time as images
shown in (C) and (D), shows decreased CSF-cord
contrast (arrowhead), possibly causing confusion as
to edema versus syringomyelia.
C, Image of 3-T contrast-enhanced fat-saturated
T1-weighted FLAIR sequence (TR/TE, 2994/21.8;
TI, 1067; ETL, 8) shows significantly improved CSF-
cord contrast clearly indicating fluid within cord
(arrowhead).
D, Image of 3-T T2-weighted FSE obtained at same
time as the images obtained in (A) and (B) reveals
intramedullary T2 hyperintensity, which may be in
keeping with edema or syringomyelia.
signified that the lesion was much more conspicu-
ous on the gadolinium-enhanced fat-saturated T1-
weighted FLAIR sequence, and a score of 7 signi-
fied that the lesion was much more conspicuous on
the gadolinium-enhanced fat-saturated T1-weight-
ed FSE sequence (Fig. 3). When multiple lesions in
a category were present, the readers were asked to
give a single overall score for all lesions in that cat-
egory. When chemical shift artifact was present in
the thoracic spine, the reviewer was asked to focus
on lesions that were not affected by the artifact. The
scale of 1 to 7 was also used to evaluate CSF-cord
contrast, with 1 indicating much higher CSF-cord
contrast on fat-saturated T1-weighted FLAIR and
7 indicating much higher CSF-cord contrast on fat-
saturated T1-weighted FSE.
The influence of the order of image acquisition
(injection time bias) was evaluated by comparing
the results of two subsets of patients: those who
had both thoracic and lumbar sagittal gadolinium-
enhanced fat-saturated T1-weighted FLAIR se-
quences performed before gadolinium-enhanced
fat-saturated T1-weighted FSE sequences, and
those who had both thoracic and lumbar gado-
linium-enhanced fat-saturated T1-weighted FSE
sequences performed before contrast-enhanced
fat-saturated T1-weighted FLAIR. Average con-
spicuity scores of these two subsets were compared
with each other and to a score of 4 (neutral).
Statistical Analysis
All statistical analyses were performed using
commercially available software (SAS version
9.1.3 for Windows, SAS Institute). The frequen-
cies of ratings were summarized by diagnostic
category (bone lesions, disk-osteophyte complex-
es, and other epidural lesions) and reader. Average
ratings for each lesion category were calculated

1 4
2 3 5 6
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Much more Equally
conspicuous conspicuous
on FLAIR
for pooled data. The conspicuity scores were trans-
formed to the logarithmic scale before subsequent
statistical analyses.
Assessment of Conspicuity and Sequence
of Scans
Each lesion category was analyzed separately.
Because there were multiple observations per pa-
tient, a linear mixed model was used to account
for the correlation between observations from the
same patient. The mean and standard error were
estimated from the linear mixed model. The es-
timated mean was compared against log4, and a
p value was provided on the basis of z statistics.
Estimates of the mean and corresponding 95% CI
were back-transformed to the raw scale for report-
ing. A linear mixed model was also used to assess
whether the sequence of scans affected the conspi-
cuity of the scores.
Interobserver Agreement
Agreement between readers was assessed by
using weighted kappa statistic. Scores were col-
lapsed into the following categories for analysis:
3 or less, 4, and 5 or greater. The 95% CIs for the
weighted kappa values were calculated. The fol-
lowing criteria explain the kappa values: a kap-
pa value of 0.20 or less indicated poor agreement,
0.21–0.40 indicated fair agreement, 0.41–0.60 in-
dicated moderate agreement, 0.61–0.80 indicated
good agreement, and 0.81–1.00 indicated excel-
lent agreement [11].
Results
Patients
There were 156 scans of 143 patients (101
scans of women [mean age, 56 ± 13 years; age
range, 20–90 years] and 55 scans of men [mean
age, 58 ± 13 years; age range, 18–79 years]).
Imaging
Both contrast-enhanced fat-saturated T1-
weighted FLAIR and fat-saturated T1-weight-
ed FSE sequences were similar in duration
(3.5–4 minutes). All scans were rated for
CSF-cord distinction. In 99.6% of cases, the
score for CSF-cord distinction was 3 or less
(one reviewer gave a score of 4 on two scans).
Bone lesions were detected on 129 of 156
700 AJR:197, September 2011
Shah et al.
Fig. 3—Rating
7 system for evaluation
of conspicuity of
lesions and CSF-cord
distinction on FLAIR
and fast spin-echo (FSE)
sequences.
Much more
conspicuous
on SE
scans, disk-osteophyte complexes were de-
tected on 138 scans, and 68 scans showed oth-
er epidural lesions. In 68 scans with epidural
lesions, 56 were due to metastasis (as diag-
nosed by the presence of a focal enhancing
epidural mass extending from a bone metasta-
sis), including three cases of pathologic frac-
ture. Two cases of suspected insufficiency
fracture, one case of diskitis, and four Tarlov
cysts were also seen. The rest of the epidural
lesions were due to degenerative changes. All
lesions seen on gadolinium-enhanced fat-sat-
urated T1-weighted FSE were also identifiable
on gadolinium-enhanced fat-saturated T1-
weighted FLAIR. One enhancing bone lesion
seen on fat-saturated T1-weighted FLAIR was
not visible on the fat-saturated T1-weighted
FSE sequence because of motion artifact.
Four scans revealed leptomeningeal en-
hancement, presumably due to metastasis.
Two scans revealed a syrinx, defined as fluid
signal without enhancement, within the cord.
One of the scans with syrinx also included
intramedullary enhancing lesions.
In 55 of 156 scans, the gadolinium-en-
hanced fat-saturated T1-weighted FLAIR se-
quence was performed before the gadolini-
um-enhanced fat-saturated T1-weighted FSE
sequence in the thoracic spine, as well as in
the lumbar spine. In 60 of 156 scans, the gad-
olinium-enhanced fat-saturated T1-weighted
FSE sequence was obtained before the gad-
olinium-enhanced fat-saturated T1-weighted
FLAIR in the thoracic spine, as well as in
the lumbar spine. In the remaining 41 scans,
the order of scanning was not consistent;
for example, the thoracic contrast-enhanced
TABLE 1: Scores for Conspicuity of Bone, Disk and Other Epidural Lesions,
and for CSF-Cord Distinction
Diagnostic Category
Bone lesion
Disk-osteophyte complex
Other epidural disease
CSF-cord distinction
Note—p values indicate significant differences in the ratings from a score of 4 (neutral value); p < 0.0001 for
all comparisons.
sagittal scan may have been performed us-
ing fat-saturated T1-weighted FSE before
fat-saturated T1-weighted FLAIR, but in the
lumbar spine, the fat-saturated T1-weighted
FLAIR sequence was performed first.
Analysis
Table 1 summarizes the average conspicu-
ity ratings in each category. The qualitative
contrast between CSF and spinal cord was
much greater on contrast-enhanced fat-sat-
urated T1-weighted FLAIR than on fat-sat-
urated T1-weighted FSE, and the difference
was statistically significant (mean score, 1.8;
p < 0.0001). For bone lesions, the mean con-
spicuity score was 3.6, the score for disk-os-
teophyte complexes was 3.5, and the score
for other epidural lesions was 3.4, indicating
a mild increase in conspicuity on contrast-
enhanced fat-saturated T1-weighted FLAIR.
These mean conspicuities were significantly
different from a score of 4 (p < 0.0001).
Comparison of Gadolinium-Enhanced Fat-
Saturated T1-Weighted FLAIR and Fat-
Saturated T1-Weighted FSE by Scan Sequence
Injection-time bias was tested by compar-
ing the results of patients with gadolinium-
enhanced fat-saturated T1-weighted FLAIR
performed before fat-saturated T1-weighted
FSE with the results of patients whose scans
were performed in the opposite order. Across
all diagnostic categories, the average rating
when fat-saturated T1-weighted FLAIR was
performed first was 3.7, whereas the average
rating when fat-saturated T1-weighted FSE
was performed first was 3.4 (Table 2). This
difference in conspicuity between the two se-
quences when FLAIR was performed before
FSE was not statistically significant (p = 0.15
for bone lesions, p = 0.20 for disk-osteophyte
complexes, and p = 0.11 for epidural lesions).
Interobserver Agreement
Frequency graphs of the ratings in each
diagnostic category by reader are shown in
Score, Mean (95% CI)
3.6 (3.5–3.7)
3.5 (3.4–3.6)
3.4 (3.2–3.6)
1.8 (1.7–2.0)
 3-T T1-Weighted Imaging of Extradural Spinal Lesions

TABLE 2: Scores for Conspicuity According to When Contrast-Enhanced noise ratio, contrast, and contrast-to-noise ra-
Fat-Saturated T1-Weighted Fast Spin-Echo (FSE) and Contrast- tio. Zhao et al. [12] reported improved contrast
Enhanced Fat-Saturated T1-Weighted FLAIR Was Performed between normal and neoplastic bone marrow
Order of Scan Sequences Bone Lesions Disk-Osteophyte Complex Other Epidural Disease signal using T1-weighted FSE without gado-
FSE performed first 3.4 (3.2–3.6) 3.4 (3.2–3.5) 3.4 (3.1–3.6)
linium enhancement at 3 T compared with
1.5 T. Lavdas et al. [13] showed qualitative
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FLAIR performed first 3.7 (3.5–3.9) 3.7 (3.4–4.0) 3.7 (3.4–4.0)

pa 0.15
Note—Except for p values, data are mean score (95% CI).
aIndicates significance of difference between the two groups.
Figures 4–6. For bone lesions (Fig. 4), all re-
viewers gave scores of 3 or 4 for 75–80% of
scans. For disk-osteophyte complexes (Fig.
5), reviewer 1 gave more scores of 4 than any
other, whereas reviewers 2 and 3 gave mainly
scores of 3 and 5. For epidural lesions (Fig.
6), reviewers 1 and 3 gave mainly scores of 4,
whereas reviewer 2 slightly favored a score of
3, but again all reviewers gave a score of 3 or
4 in 73–85% of cases. Reviewer 3 rated fewer
scans for epidural lesions than did reviewers
1 and 3. Figure 7 shows that nearly all ratings
for CSF-cord distinction were less than 3.
Table 3 shows kappa statistics for the di-
agnostic categories. Kappa statistics could
not be calculated for CSF-cord distinction
because all reviewers rated nearly all of the
scans at 3 or less and only one reviewer gave
two scans a score of 4. Kappa values also
could not be calculated for reviewers 1 and
0.20
2 and for reviewers 2 and 3 with respect to
epidural lesions; these reviewer pairs com-
prised a small number of scans, with very
few scores of 5 or greater. The kappa value
for reviewers 1 and 3 with respect to epidural
lesions was 0.15 (95% CI, 0.15–0.44).
Discussion
Recent investigations of 3-T spine imag-
ing have found improvements in signal-to-
TABLE 3:  Interobserver Agreement for Bone Lesions and Disk-Osteophyte
Complexes
Reader Pair
Readers 1 and 2
Readers 2 and 3
Readers 1 and 3
improvement in contrast-to-noise and signal-
0.11 to-noise ratios and quantitative improvement
using unenhanced T1-weighted FLAIR com-
pared with unenhanced T1-weighted FSE for
CSF nulling, viewing normal anatomic struc-
tures, and evaluating degenerative and meta-
static bone lesions at 3 T. Lavdas et al. [14] also
recently found that chemical shift artifact in
the thoracic spine was decreased on contrast-
enhanced fat-saturated T1-weighted FLAIR
compared with contrast-enhanced fat-saturat-
ed T1-weighted FSE. However, the use of T1-
FLAIR imaging after IV administration of
gadolinium-based contrast agent in the spine
at 3 T has not been previously evaluated.
Disk-Osteophyte Complexes, κ
Bone Lesions, κ (95% CI) (95% CI)
0.29 (0.15–0.44) 0.08 (−0.09 to 0.25)
0.29 (0.15–0.44) 0.47 (0.26–0.68)
0.49 (0.36–0.63) 0.20 (0–0.40)

80 Reader 1 40 Reader 1 35 Reader 1

Reader 2 Reader 2 Reader 2
Reader 3 Reader 3 Reader 3
70 35 30

60 30
25

50 25
Frequency (%)

Frequency (%)

Frequency (%)

20

40 20
15
30 15

10
20 10

5
10 5

0 0 0
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
Conspicuity Rating Conspicuity Rating Conspicuity Rating

Fig. 4—Plot of frequency of conspicuity ratings
for bone lesions by reader. Each line represents
one reviewer. Reviewer 1 gave scores of mostly 4.
Reviewer 2 gave mostly scores of 3. Reviewer 3 gave
relatively even number of scores of 3 and 4.
Fig. 5—Plot of frequency of conspicuity ratings for
disk-osteophyte complexes by reader. Reader 1 gave
mostly scores of 4. Readers 2 and 3 gave mostly
scores of 3 and 5. Number of scans each reader
scored for disk-osteophyte complex varied by reader.
Fig. 6—Plot of frequency of conspicuity ratings for
epidural lesions by reader. Readers 1 and 3 gave
mainly scores of 4, whereas reader 2 gave mainly
scores of 3 and 4. Number of scans rated for epidural
lesions varied by reader.

AJR:197, September 2011 701


140 Reader 1
Reader 2
Reader 3
120
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100
Frequency (%)
80
60
40
20
0 Assuming that the gradual washout contin-
1 2 3 4 5 6
Conspicuity Rating
Fig. 7—Plot of frequency of conspicuity ratings for
CSF-cord distinction by reader. All but two scores
(99.6%) were 3 or less.
Our study found that all extradural lesion
conspicuity was increased on contrast-en-
hanced fat-saturated T1-weighted FLAIR com-
pared with contrast-enhanced fat-saturated T1-
weighted FSE. Conspicuity has been defined
as lesion contrast against surround complexi-
ty [15]. The increased conspicuity on FLAIR
may be due to increased lesion contrast inher-
ent to the sequence, as seen on unenhanced
comparison of 3-T T1-weighted FLAIR and
T1-weighted FSE [13], as a result of broader
dynamic contrast range [6], or because of ac-
cumulation of gadolinium-based contrast agent
within the lesion over time. Alternatively, in-
creased conspicuity can arise from decreased
surround complexity, perhaps because of sup-
pression of background marrow fluid content.
We did not quantify lesion contrast or surround
complexity, but quantification with the aim of
defining the mechanism of increased conspicu-
ity could be pursued in further studies.
The finding that enhancing lesions were
more conspicuous on the second of the two
scans (i.e., lower average score for all le-
sions when gadolinium-enhanced fat-satu-
rated T1-weighted FSE was performed first
vs higher average score when gadolinium-
enhanced fat-saturated T1-weighted FLAIR
was performed first) might have been com-
patible with an injection-time bias, but the
difference was not statistically significant.
Although we could not control the time
702 AJR:197, September 2011
Shah et al.
elapsed after contrast injection in this retro-
spective study, we did find that the average
scan time for the fat-saturated T1-weighted
FLAIR and fat-saturated T1-weighted FSE
sequences in our study was 3.5–4.0 minutes.
A review of prior studies of dynamic en-
hancement of bone malignancies, including
bone metastases, reveals that steep time-en-
hancement curves, on first-pass dynamic im-
aging, are usually seen within 40 seconds af-
ter injection [16, 17]. In malignancies, this
may be followed by an early phase washout
or plateau, within about 80 seconds of injec-
tion. Typically, the time-intensity curve in
these studies is not extended past 5 minutes;
Chen et al. [17] found a gradual washout at
280 seconds for both malignant and nonma-
lignant categories of bone lesions examined.
7 ued, our second scan would have been ex-
pected to show decreased signal intensity and
decreased conspicuity in contrast-enhancing
lesions, compared with the first scan. This was
not the case. It may be that a second plateau is
reached after the late (280 seconds) gradual
washout and that both of our scans fell into
this plateau, such that there was no significant
difference between our two scans.
Interobserver agreement in our study over-
all was no better than moderate. This is most
likely because of the choice of a qualitative
7-point scale, in which reviewers could make
fine distinctions between one rating and the
adjacent one. Variability in the number of
epidural lesions rated was due to differences
in interpretation of whether the cortex of the
bone was involved by bone metastasis, which
can be difficult to distinguish by MRI.
Because an increase in contrast intensity can
be an indication of disease progression in pa-
tients with cancer with bony metastases, use
of the gadolinium-enhanced fat-saturated T1-
weighted FLAIR sequence could result in a
spurious appearance of progressive metastasis
compared with a prior gadolinium-enhanced fat-
saturated T1-weighted FSE. When comparing
gadolinium-enhanced fat-saturated T1-weight-
ed FLAIR to a prior gadolinium-enhanced fat-
saturated T1-weighted FSE sequence, increased
conspicuity of bone metastasis in itself should
not be construed as progression of metastasis;
evidence of increased size or number of metas-
tases should be sought.
In summary, comparison of sagittal con-
trast-enhanced fat-saturated T1-weighted FSE
and FLAIR on 156 spine MRI scans revealed
that all extradural lesions were identifiable by
the reviewers on T1-weighted FLAIR and that
slightly increased conspicuity of all bone le-
sions, disk-osteophyte complexes, and other
epidural lesions was perceived on contrast-
enhanced T1-weighted FLAIR. The results
of this study suggest that contrast-enhanced
fat-saturated T1-weighted FLAIR can replace
contrast-enhanced fat-saturated T1-weighted
FSE for diagnosis of extradural lesions and
may be advantageous because abnormalities
that are more conspicuous tend to be easier to
detect than ones that are less conspicuous. Of
note, our study was limited by its retrospec-
tive design. The results of this study can be
verified in a prospective manner.
The marked improvement in contrast be-
tween CSF and spinal cord on contrast-en-
hanced fat-saturated T1-weighted FLAIR
image suggests that detection of enhancing in-
tradural lesions, as well as syrinx and syrin-
gomyelia, may be improved by using this se-
quence at 3 T. This idea will be investigated in
future studies. Intradural lesions were not inves-
tigated in our study because of the lack of posi-
tive findings in this selected group of patients.
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