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Private Cairo clinic spearheads practical MR spectroscopy in Egypt

Best Practice
Abbas, Yasser, M.D., Ph.D. Cairo, Misr Radiology Center Egypt
Ibrahim, Ahmed, MD Cairo, Misr Radiology Center Egypt

Since 2003, radiologists at MRC (Cairo, Egypt) have used their Philips spectroscopy package to assist in the characterization of focal brain lesions, which represent nearly 50% of MRC's brain referrals. The similar MR appearance of a range of disparate brain pathologies (tumor, infection, infarction and demyelination), on occasion, can make an accurate diagnosis difficult, according to MRC co-owner Yasser Abd Elazim Abbas, M.D., Ph.D.. Fortunately, while these pathologies can look alike on conventional MR images, their spectroscopic signatures are as distinct as fingerprints, facilitating the diagnosis and informing treatment decisions. MRC is the first private scanning facility in Egypt to offer MR spectroscopy and is still the leading private imaging center in Egypt using MRS as a routine practical tool.

 

   Prof. Abbas  Prof. Abbas and Dr. Ibrahim       Misr Radiology Center, Cairo
  Prof. Abbas
Prof. Abbas and Dr. Ibrahim
      Misr Radiology Center, Cairo
  

Misr Radiology Center (MRC) regards MRS as critical tool in comprehensive neuro exam

The array of tools for brain MRI has expanded continuously since the modality's inception. Methods such as diffusion- and perfusion-weighted imaging, BOLD fMRI, diffusion tensor imaging, SENSE and MR spectroscopy (MRS) - combined with proven standard sequences - hone the diagnostician's ability to identify pathology and to recommend appropriate treatment options. In the comprehensive neuro exam, MR spectroscopy in particular is a powerful technique that exploits metabolic differences between tissues to help clinicians differentiate pathologies and pathology from normal tissues. Metabolic differences depicted on MRS spectra often can be stark and reveal more than anatomical images.

 

This perception of MRS drove MRC co-owner Dr. Yasser Abbas in 2003 to integrate MRS into the center's comprehensive neuro exam. "We wanted to acquire MRS at our facility because when we do conventional brain MRI - even with sophisticated techniques such as DWI and post-contrast perfusion scanning - we don't get to the full answer in some cases, particularly in attempting to characterize certain brain lesions. We saw MRS as a non-invasive practical tool that could help us."

Training is first step

MRC officials appreciated the challenges associated with acquiring and performing MRS. The cost of the software package was not inconsiderable, yet the cost per patient could not exceed about $200 USD, making return on investment a rather long-term prospect. MRS scan times ranging from 30 to 45 minutes could also impact throughput on high MRS volume days - although high MRS volume via referrals wasn't guaranteed since most Egyptian clinicians were unfamiliar with MRS. Finally, though MRC radiologists and technologists understood the clinical potential of MRS, none of the staff had any real MRS experience, nor was there a Ph.D.-level spectroscopist in Egypt who could teach them.

 

MRC concentrated on what they considered the obvious first step: training.

 

"Training is critical because MRS is a different kind of MR imaging," Dr. Abbas says. "There's more physics and exam setup is different - you need to do shimming, water suppression and many other small steps that our clinical staff had never experienced before."

 

The Philips Egypt scientific office recommended that MRC contact Ulrike Dydak, Ph.D., of the Institute of Biomedical Engineering, University and ETH (Zurich), to conduct clinical MRS training at MRC. "Dr. Dydak is one of a kind," he says. "There's no one in Egypt, and only a few people worldwide, who offer such training. She was dedicated and the training went well."

 

Because Dr. Dydak's training emphasized the practical application of MRS and not study interpretation, Dr. Abbas sought additional training by traveling abroad, reading articles, attending conferences and by building his own experience caseby- case. Of course, MRS was not widely known in Egypt, so referrals were not exactly pouring in, Dr. Abbas recalls.

A growing caseload

"In my plan to get referrals, I provided free lectures to Ain Shams University clinical departments that are interested in brain imaging - such as neurology, neurosurgery, ENT and psychiatry," he says. "Additionally, I allowed 15 Ph.D. students from various clinical departments to use the system to complete their doctoral theses in spectroscopy and attained publicity that way. MRC also accepted cases below cost, if the patient couldn't afford full price. By this strategy and our encouraging results, we developed a very good referral base that expanded rapidly - from two cases per week to eight cases a week now."

 

"I am also indebted to Dr. Frank Traeber, the leading MR spectroscopist at the University of Bonn, who provided valuable opinions regarding difficult cases we encountered initially," Dr. Abbas adds.

 

For MRS studies, MRC reserves 7-10 a.m. each day, a slower time for those Cairenes who frequent private imaging centers and prefer later appointments. This "dead time" is suitable for conducting the 30-45 minute MRS studies, as most patients schedule their conventional MRI studies for late afternoon and early evening when it's cooler.

Characterization of brain focal lesions

About 80% of MRC's neuro cases are for characterization of brain lesions, most of which fall into one of four broad classifications: tumor, infection, infarction and demyelination. "Sometimes, identifying the type of lesion with the aid of conventional images is obvious and we confirm this with the assistance of MRS; and sometimes it's not, or maybe the lesion appears to be 70% one group and 30% another," he says. "Clinicians want this closer to 100% accuracy and MRS can help."

 

MRS is part of MRC's comprehensive neuro protocol, which also includes standard and post-contrast sequences and diffusion- and perfusion-weighted imaging. When characterization of a focal lesion is ambiguous, MRS often can help the physician resolve the lesion's identity. To facilitate interpretation of MRS spectra and data, MRC routinely requests all clinical and laboratory data from the referring physician and obtains either a recent MRI or performs an MRI examination just before the MRS study. Two additional steps are part of the postscan evaluation: 1.) Visual or qualitative assessment of peak heights of the various normal metabolites and the occurrence of any abnormal metabolites and 2.) Quantitative evaluation by calculating the pertinent metabolic ratios, e.g., Choline (Ch)/Creatine (Cr), Ch/N-acetyl aspartate (NAA), NAA/Cr and comparing with agematched controls.

Ratios as metabolic signatures

The body of MRS clinical work worldwide has resulted in an impressive list of pathologies which can be identified by their metabolic ratios. For example, high grade glial tumors will have the following signature: ­­increased Cho, decreased NAA, decreased Cr, ­­increased Lipids & Lactate, while meningiomas will have a similar signature but with ­­increased Alanine. Other examples: Infection/Encephalitis: decreased NAA, ­­increased Cho, ­­increased Myo-inisotol, ­­increased Lipids, lactate and amino acids; Ischemia/Infarction: decreased NAA with ­­increased Lactate & Cho days after acute insult.

 

"MRC radiologist Dr. Ahmed Samir Ibrahim was instrumental in helping set up our MRS tools and in establishing accurate metabolic ratios," Dr. Abbas notes.

MRS Cases

The cases listed below (links), comprising conventional images and accompanying spectra, demonstrate how clinical images per se aren't the only useful tools to assist in diagnosis. MR spectra aid in diagnosis by graphically depicting relative levels of metabolites within voxels of interest.

 

"When a physician can't determine the difference between two lesions using conventional MR, MRS can facilitate diagnosis by showing the distinct metabolic signatures of disparate pathologies, thereby informing our treatment options," Dr. Abbas says.

MRC to extend leadership in Egypt

The enthusiasm with which MRC radiologists pursued enhanced neuro diagnostics coincidentally placed them at the forefront of medical imaging in Egypt, a status that Dr. Abbas enjoys but tries not to prioritize. "It's not important to be the first site with a technique or a technology, it's important to be successful," he says.

 

"Our plans are to extend our MRS success outside the brain - in the prostate, breast and liver - and to do this we are prepared to invest in Philips' latest MR spectroscopy package. This will also include spectroscopic imaging with SENSE, which - from what I've seen - is a spectacular, very fast technique for brain studies. In addition, we are preparing to explore BOLD fMRI as well as DTI tractography - with the aim of also bringing these techniques to the clinical forefront in Egypt."



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