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Current Problems in Diagnostic Radiology 000 (2019) 1 7

Current Problems in Diagnostic Radiology

journal homepage: www.cpdrjournal.com

Common and Uncommon Artifacts in T1 FLAIR SAG Sequences

of MRI Brain
Eleftherios Lavdas, PhDa,b, Maria Papaioannou, BScb, Nadia Boci, BSca,
Efthimios Dardiotis, MDc, Violeta Roka, MD, PhDd, Georgios Sakkas, Phde,
Glykeria Apostolopoulou, BScb, Lida Gogou, Phda, Panayiotis Mavroidis, PhD, DABRf,*
a
Department of Medical Radiological Technologists, Technological Education Institute of Athens, Athens, Greece
b
Department of Medical Imaging, Animus Kyanoys Larisas Hospital, Larissa, Greece
c
Department of Neurology, University Hospital of Larissa, Larissa, Greece
d
Health Center of Farkadona, Trikala, Greece
e
Department of Sport Science, University of Thessaly, Trikala, Greece
f
Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC

A B S T R A C T

Objective: This study aims at identifying, classifying, and measuring the frequency the different artifacts that show up in the images of the Sagittal T1 Fluid Atten-
uated Inversion Recovery (FLAIR) sequence.
Materials and Methods: A total of 101 subjects underwent brain magnetic resonance imaging examination with the following sequences: Axial T1 FLAIR, Axial
T2-weighted imaging, Diffusion Weighted Imaging, 2D Multiple Echo Recombined Gradient Echo, Sagittal T1 FLAIR, Coronal T2 Turbo Spin Echo, Spin Echo T1-
weighted imaging, and 3D Fast Spoiled Gradient-echo. In these images, we observed the following categories of artifacts: (a) ghost artifacts, (b) aliasing behind
the occipital bone, (c) aliasing inside the sphenoid cavity, (d) susceptibility artifacts, and (e) pulsation artifacts. In order to recognize and verify the artifacts, we
used not only the Sagittal T1 FLAIR sequence, but also Sagittal reconstructions from the 3-dimensional Fast Spoiled Gradient-echo sequence and the other rou-
tine sequences.
Results: Aliasing artifacts and especially aliasing of nose are present in 41% of the cases. In 45% of these cases the uncommon aliasing artifacts, which took place
into the brain parenchyma (sphenoid cavity, subarachnoid bay, or pituitary) originated from nose. In 33% of the subjects, ghost artifacts are presented, which
stem from the nose, the orbits, or other pulsating structures (pulsation artifacts) or even from fat tissue. Moreover, susceptibility artifacts comprise 8% of all the
artifacts. Finally, 19% of brains were presented without artifact.
Conclusions: We suggest in addition to T1 FLAIR, the application of Sagittal SE or TSE sequences in magnetic resonance imaging examination of brain, trying to
include the nose in the square of FOV.
© 2019 Elsevier Inc. All rights reserved.

Introduction The fluid attenuated inversion recovery (FLAIR) technique obtains

Magnetic Resonance Imaging (MRI) of the brain is widely used in a
variety of medical applications. Those applications involve research,
diagnosis, treatment, surgical planning, and image guided surgeries.
The magnetic resonance brain images are often corrupted with vari-
ous artifacts and may affect the image of the brain and lead to a
default of the diagnosis.
Specifically, an artifact is a feature appearing in an image that is
not present in the original subject. Those artifacts may be very notice-
able or just a few pixels out of balance but can lead to confusing arte-
factual appearances with pathology that may be misdiagnosed. Many
different kind of artifacts may occur during brain imaging, some
affecting the diagnostic quality, while others may be interpreted as
pathology.1,2
*Reprint requests: Panayiotis Mavroidis PhD, DABR, Department of Radiation Oncol-
ogy, University of North Carolina, 101 Manning Dr, Chapel Hill, NC 27599-7512.
E-mail address: panayiotis_mavroidis@med.unc.edu (P. Mavroidis).
T2-weighted images and also T1-weighted images with nulling of the
cerebrospinal fluid (CSF) signal.3-9 FLAIR is a sequence that attains
heavy T2 weighting with the use of a long TE. Specifically, T1 FLAIR is
a sequence that attains T1 weighting with the use of a long TE.
FLAIR imaging has proved to have an important clinical utility in
several intracranial conditions.2-8,10-14 It has proved to be useful in
head injury, multiple sclerosis, acute subarachnoid hemorrhage, car-
bon monoxide poisoning, tuberous sclerosis, and mesial temporal
sclerosis.4,6,7,9-14 Moreover, the use of FLAIR sequences has been
reported in the diagnosis of intracranial infectious diseases.
In addition, T1 FLAIR sequence presents some important advan-
tages like great nulling of CSF, reduced pulsation and flow artifacts,
very good contrast between white and gray matter and generally bet-
ter CNR, definite imaging of hemorrhages and dysplasia, and ability to
detect high lesions of brain.2,8,9
However, FLAIR’s usefulness has been reported to be limited in
the diagnosis of intracranial tumors.10 Aliasing or Wrap Around arti-
facts occur when the field of view (FOV) is smaller. This is an artifact

https://doi.org/10.1067/j.cpradiol.2019.08.001
0363-0188/© 2019 Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
2 E. Lavdas et al. / Current Problems in Diagnostic Radiology 00 (2019) 1 7

that occurs when the region beyond the body part being imaged proj-
ects on the other side of the image.11 On the other hand, discrete
''ghost'' artifacts may occur along the phase-encode direction when-
ever the position or signal intensity of imaged structures within the
FOV vary or move in a regular (periodic) fashion. Pulsatile flow of
blood or CSF, cardiac motion, and respiratory motion are the most
important subject-related causes of ghost artifacts in clinical MRI.
The intensity of these ghost artifacts increases with the amplitude of
the periodic motion, as well as with the signal intensity of the moving
tissue. Susceptibility artifacts share distortions or local signal change
due to local magnetic field inhomogeneities from a variety of com-
pounds. They are especially encountered while imaging near metallic
orthopedic hardware or dental work.
The purpose of this study is to retrospectively evaluate the com-
mon and uncommon artifacts in T1 SAG sequence in order to avoid
pitfalls in medical findings in relation with MRI brain examinations.
Additionally, we compared T1 SAG FLAIR, 3-dimensional Fast Spoiled
Gradient Echo (3D FSPGR), and all the other routine sequences in
order to verify the presence of the artifacts and avoid misdiagnosis.

Methods

This is retrospective study, which included 101 consecutively

examined subjects (50 male, 51 female; mean age = 55 years; age
range = 17-81 years), who were referred for brain MRI. Of those sub-
jects, 9 were inpatients and 92 outpatients and only a few subjects
were excluded because their images were not diagnostic due to
motion and we could not evaluate the artifacts. For this cohort, we
recorded and classified the technical artifacts which were present in
the MRI scans and specifically in the T1 SAG FLAIR sequences during
those MRI brain examinations. This study was approved by the local
institutional review board and written informed consent was
obtained from all the subjects participating in the study protocol.
The examinations were performed on all the subjects using a 1.5 T
MRI scanner (GE Signa).The following sequences were performed in
every brain examination (Axial T1 FLAIR, Axial T2-weighted imaging,
diffusion-weighted imaging , 2D Multiple Echo Recombined Gradient
Echo, SAG T1 FLAIR, Coronal T2 Turbo Spin Echo, Spin Echo T1-
weighted imaging, and 3D FSPGR. Generally, we used only 1
sequence in sagittal plane in order to find another way to verify the
results.
For the artifacts’ verification we used the FSPGR sequence with 3D
reconstructions in the sagittal plane. In that way, we evaluated
FIG 1. (A) OBL 3D FSPGR; (B) SAG T1 FLAIR; (C) SAG T1 FLAIR. The images show aliasing
whether the artifacts in T1 SAG FLAIR sequence were nominal or not.
artifacts in the sphenoid sinus (arrows). Specifically, the image (A) proves that the
At the same time, we recorded the number and type of artifacts sphenoid cavity is clear without aliasing artifacts due to different dimension of phase
(ghost, aliasing behind occipital bone, aliasing inside the sphenoid encoding. The images (B) and (C) show aliasing artifacts. More specifically, the nose is
cavity, susceptibility, pulsation artifacts). The scan parameters that larger than 15 cm and the artifacts show up in the sphenoid cavity because there was
we used are presented in Table 1. not enough space to be presented behind the occipital bone.
Also, we recorded the anterior-posterior (A/P) dimension of every
brain because the aliasing artifact of the nose is presented in that
dimension. For that reason, we took the larger A/P dimension in the artifact of nose based on whether this was present behind the occipi-
level of nose (nose included) in order to modify the FOV to eliminate tal bone or inside the sphenoid cavity.
that artifact. Additionally, we grouped the subjects with the aliasing
Results

TABLE 1
The aliasing artifacts are presented in the 41% of the cases and in
Summary of the examined sequences that were applied during the MR examinations
the 80% of these cases the dimension of brain (A/P) was over 22 cm.
SAG T1 FLAIR* 3D FSPGR More specifically, it was observed that in cases that the dimension of
Thickness 5.0 1.2 the head is larger than 22 cm this artifact appears in the sphenoid
FOV 24 £ 24 24 £ 18 cavity and when it is smaller than 22 cm and there is enough space
TR 2278 7.8 the artifact shows up behind of occipital bone.
TE 25.9 3 In total, 33% of the subjects presented ghost artifacts from the
NEX 2.0 1.0
Matrix 320 £ 256 256 £ 256
nose, orbits, or other pulsating structures or even from fat tissue.
Phase A/P S/I Also, the frequency of the susceptibility artifacts was around 8% of all
rFOV 100% 75% the artifacts, and they were related to metallic matter like dental
* The inversion time that was used in T1 FLAIR was 750 ms. implants in the jawbone.
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FIG 2. (A, B) SAG 3D FSPGR sequences; (C-E) Different series of T1 SAG FLAIR; (F,G) Different series of T2 Coronal Fast Spin Echo. The figures show aliasing in pituitary (arrows).
In addition, the aliasing artifact of nose was present in 41% of the
cases and in all these subjects the A/P dimension of brain was over
22 cm. As a result, the nose did not appear behind the head but
showed up in the sphenoid cavity. Additionally, around 15% of the
cases presented pulsation artifacts from the vascular structures par-
ticularly in the middle-sagittal slices.
Figures 1-8 show examples of the artifacts examined as well as
images verifying that those findings are artifacts.
Discussion
The aliasing artifacts shown in Figures 1, 2, 5, and 6 are a result of
mismapping of anatomy that lies outside the FOV but within the slice
volume. The selected FOV is smaller than the size of the imaged
object. The anatomy is usually displaced to the opposite side of the
image. It can be caused by nonlinear gradients or by under sampling
of the frequencies contained within the return signal.14 The sampling
rate must be twice the maximal frequency that occurs in the object
(Nyquist sampling limit). If not, the Fourier transform will assign very
low values to the frequency signals greater than the Nyquist limit.
These frequencies will then ‘wrap around’ to the opposite side of the
image (Fig. 1 and 2) showing up as low-frequency signals. In the fre-
quency encoding direction a filter can be applied to the acquired sig-
nal to eliminate frequencies greater than the Nyquist frequency. In
the phase encoding direction, artifacts can be reduced by an
3
increasing number of phase encoding steps but this would increase
image acquisition time. For correction, a larger FOV may be cho-
sen.2,15 Particularly, in our study, we used a larger A/P dimension in
the level of nose with the nose included in order to modify the FOV
and achieve elimination of the aliasing artifact (Fig 1).
As mentioned “ghost” artifacts (Fig. 3, 4, and 7) may occur along
the phase-encoding direction16 whenever the position or signal
intensity of imaged structures within the field-of-view vary or move
in a regular (periodic) fashion. These artifacts may be caused by arte-
rial pulsations, swallowing, breathing, peristalsis, and physical move-
ment of the subject. When projected over anatomy it can mimic
pathology, and needs to be recognized (Fig. 3, 4, and 7). In clinical
brain MRI, pulsatile flow of blood or CSF or 1 of the above aforemen-
tioned causes are the most important and usual subject-related
causes of ghost artifacts. The intensity of these ghost artifacts
increases with the amplitude of the periodic motion such as vascular
pulsation, as well as with the signal intensity of the moving tissue.
The spacing between these ghosts is related to the repetition time
and the frequency of the motion. During our efforts to eliminate
ghost artifacts which are caused by motion artifacts we used T2-fluid
FLAIR recovery sequences with different k-space trajectories (BLADE).
This process and results have been previously repoted.17
FLAIR is a pulse sequence with an inversion time that nulls the
signal from CSF, providing heavy T2 weighting, due to its very long
TE.18-20 However, there is a limitation of FLAIR MRI is the ventricular
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FIG 3. (A, B) SAG T1 FLAIR sequences. The figures show ghost artifacts because of the existence of fat (arrows).

FIG 4. (A) SAG 3D FSPGR sequence; (B) SAG T1 FLAIR sequence. The figures show ghost artifacts in medulla (arrows).

FIG 5. (A, B) Different series of SAG T1 FLAIR. The figures show calcifications from Venus sinuses (red arrows). Crista galli (white arrows). (Color version of figure is available online.)
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FIG 6. (A-F) Different series of SAG T1 FLAIR. The aliasing of nose could be presented even in consecutive images (arrows).

CSF pulsation artifact (VCSFA). This artifact might compromise the multiparametric. Specifically, in the locations where CSF goes into
study of ventricular abnormalities by leading to false-negative or the brain sections, between the inversion pulse and the commence-
false-positive interpretations.21,22 There are many studies which try ment of signal sampling, it is not appropriately nulled, and remains
to explain the VCSFA. It seems that the causes of VCSFA are hyperintense on FLAIR images.18,23
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FIG 7. (A) Images of SAG T1 FLAIR showing ghost artifacts in the subarachnoid bay (arrow). (B, C) Two consecutive images of SAG 3D FSPGR verifying that the subarachnoid bay is
clear.

Vascular pulsation artifacts are recognized by their alignment

with the responsible vessel along the phase encoding direction of the
image. These artifacts reproduce the cross-sectional size and shape of
the responsible vessel, but not necessarily its signal intensity.24-26
There are many studies, which have proposed technical variations to
reduce this artifact, such as, using a wider slice-selective inversion to
increase the inversion of CSF outside the imaging section, to use other
section selective inversion pulses.27 We may try to eliminate this
kind of artifacts with BLADE sequences.28
Susceptibility artifacts (Fig 8) occur as a result of the microscopic
gradients or variations in the magnetic field strength, which occur
near the interfaces of substances of different magnetic susceptibility.
Large susceptibility artifacts are commonly seen surrounding ferro-
magnetic objects inside diamagnetic materials (such as the human
body). These gradients cause dephasing of spins and frequency shifts
of the surrounding tissues. The net results are bright and dark areas
with spatial distortion of surrounding anatomy. Those artifacts can
be made less prominent by performing imaging at low magnetic field
strength, using smaller voxels, decreasing TE, and increasing receiver
bandwidth. We may eliminate those artifacts by decreasing time of
echo and increase receiver bandwidth.29 It should be mentioned that
Gradient-echo and echo-planar sequences should be avoided,
because they accentuate susceptibility artifacts. The use of spin-echo
and particularly fast spin-echo sequences should be considered. FIG 8. SAG T1 FLAIR sequence. Susceptibility artifacts in the oral cavity from possible
The magnetic resonance artifacts in brain cause image degrada- dental metal implants (white arrow) and ghost artifact in the same line. (red arrow).
tion, and can occasionally mimic pathological lesions. Particularly, (Color version of figure is available online.)
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we consider that they are more distinct in the sagittal plane. The pur-
pose of this study is to learn how to recognize the artifacts (common
and uncommon) and especially the aliasing that nose may cause,
which are rarely described in the literature. At the beginning of this
study, a lot of time was consumed to verify the cause of the observed
artifacts. We believe that it would be very useful to inform about the
existence and the reason of the appearance of those artifacts in order
to avoid diagnostic pitfalls. We suggest comparing the images of SAG
FLAIR T1 with 3D reconstructions from FSPGR sequences which is
more reliable in relation with such artifacts (eg, small SNR, different
dimension of phase encoding, superior/inferior direction). Three-
Tesla (3.0 T) MRI gives the potential of improved image quality and
decreased scan times.30-32 However, in 3 T different types of artifacts
are presented, too.30 Because in FLAIR sequences in 3 T the artifacts
are more than the 1.5 T30 they may be studied retrospectively,
because we suppose that they may be more obvious and more often
appearing. In cases that we are not sure for the result, it could be use-
ful to increase the FOV with parallel cost of resolution. Alternatively,
we could apply the technique phase over wrap with cost in time,
because the FOV is not square.
Conclusions
We suggest the application of SAG Spin Echo or Turbo Spin Echo
sequences in MRI examinations of brain in addition to the use of the
T1 FLAIR, which is the standard sequence in most practices. In those
sequences, we should try to include the nose in the square of FOV. If
we do not like to change the dimension of phase encoding, we have
to check very carefully the region of the sphenoid cavity and the par-
allel axis in order to insure that there are no aliasing artifacts, which
are projected in the FOV.
Declaration of Competing Interest
The authors have declared that no competing interests exist.
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