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Exclusion of brain lesions: is MR contrast medium required after a negative fluid-attenuated inversion recovery sequence?

¹ Institute of Diagnostic Radiology and ² Biometric Research Group, Clinic of Thoracic and Cardiovascular Surgery, University Hospital Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany

We hypothesized that in patients with negative fluid-attenuated inversion recovery (FLAIR) images T₂ weighted fast spin-echo (FSE) images and T₁ weighted spin-echo (SE) images before and after intravenous administration of gadolinium-based contrast medium display no pathology either. Thus, we assessed the negative predictive value of FLAIR images to rule out MR-detectable brain lesions. 1026 consecutive cranial MR examinations were reviewed. Routine MRI of the brain included T₁ weighted coronal imaging before and after administration of gadopentetate dimeglumine, axial T₂ weighted FSE and fast-FLAIR imaging. The FLAIR images were rated by two radiologists into categories of 0 (without pathologic changes) and 1 (with pathologic changes). Two other radiologists analysed the complete examination. In 284 MR examinations of the brain no abnormalities were found (28%). FLAIR-ratings were false-negative in four cases and false-positive in 30 cases. Sensitivity and specificity of the FLAIR sequence for MR-detectable brain lesions were 99.5% and 89.4%. The unselective application of gadolinium avoided one false-negative MR-reading and improved the sensitivity of the MR-examination from 99.5% to 99.6%. Positive and negative predictive values were 96.1% and 98.4%, respectively. The interobserver reliability was =0.93 for the FLAIR-readers and 0.89 for the readers who rated the complete examination. In conclusion, negative FLAIR images provide a high negative predictive value for MR-detectable brain lesions. Thus, in patients with negative FLAIR images the unselective application of gadolinium seems to be unnecessary.

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