JOURNAL OF MAGNETIC RESONANCE IMAGING 30:321–326 (2009)
Original Research
Usefulness of the Application of the BLADE
Technique to Reduce Motion Artifacts on
Navigation-Triggered Prospective Acquisition
Correction (PACE) T2-Weighted MRI (T2WI) of the
Liver
Sumire Nanko, MD,1* Hidekazu Oshima, MD, PhD,2 Takeshi Watanabe, RT,3
Shigeru Sasaki, MD, PhD,1 Masaki Hara, MD, PhD,1 and Yuta Shibamoto, MD, PhD1
Purpose: To evaluate the effects of the application of the
BLADE (Siemens, Siemens Medical Systems, Erlangen,
Germany) technique, a technique to reduce motion arti-
facts, on navigator-triggered prospective acquisition cor-
rection (PACE) T2-weighted MRI (T2WI) of the liver.
Materials and Methods: Twenty-three consecutive pa-
tients with a total of 57 localized hepatic diseases (39 ma-
lignant, 18 benign) and 57 patients without hepatic lesion
underwent MR study during eupnea. The images were as-
sessed quantitatively by calculating the liver–lesion con-
trast. Two subjective analyses were also performed. Two
observers independently assessed the image quality and
the confidence level of the detection and characterization of
hepatic nodules using a five-point scale. Statistical analysis
was performed with the Wilcoxon matched-pairs test except
for the diagnostic performance evaluated with jackknife
alternative free-response receiver operating characteristic
(JAFROC) analysis.
Results: There was no significant difference in the mean
liver–lesion contrast between the PACE T2WI with BLADE
(T2WI-BLADE) (mean ⫾ SD ⫽ 0.29 ⫾ 0.14) and that without
BLADE (0.30 ⫾ 0.14) (P ⫽ 0.39). Visual assessment of PACE
T2WI-BLADE (4.8 ⫾ 0.47) was superior to that without
BLADE (4.3 ⫾ 0.8) (P ⬍ 0.0001), although there were no
significant differences in detecting and characterizing he-
patic lesions using JAFROC analysis.
1
Department of Radiology, Nagoya City University Graduate School of
Medical Sciences, Nagoya, Japan.
2
Department of Radiology, Mie Kosei Inabe General Hospital, Mie, Ja-
pan.
3
Division of Diagnostic Imaging, Mie Kosei Inabe General Hospital, Mie,
Japan.
*Address reprint requests to: S.N., MD, Department of Radiology,
Nagoya City University Graduate School of Medical Sciences, 1 Kawa-
sumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8602 Japan.
E-mail: snankou2002@yahoo.co.jp
Received January 16, 2009; Accepted May 7, 2009.
DOI 10.1002/jmri.21855
Published online in Wiley InterScience (www.interscience.wiley.com).
© 2009 Wiley-Liss, Inc.
Conclusion: The BLADE technique could improve image
quality by reducing motion artifacts on hepatic MRI with-
out affecting the diagnostic performance.
Key Words: BLADE; PACE; motion artifacts; hepatic imag-
ing; T2-weighted imaging
J. Magn. Reson. Imaging 2009;30:321–326.
© 2009 Wiley-Liss, Inc.
ON UPPER ABDOMINAL MRI, several artifacts are ob-
served, mainly caused by respiratory motion. Respira-
tory motion causes image blurring, ghosting, loss of
signal intensity (SI), and misregistration, which might
obscure important anatomic structures and lesions.
Various techniques have been used to reduce respira-
tory artifacts. Breathhold imaging with a rapid imaging
technique and respiratory-triggered technique can re-
duce respiratory artifacts. Previous studies demon-
strated that respiratory-triggered turbo spin-echo (TSE)
could improve the detectability of focal hepatic lesions
compared to the breathhold TSE technique (1,2). More
recently, Kim et al (3) reported that the navigator-trig-
gered prospective acquisition correction (PACE) TSE se-
quence showed better diagnostic performance than
other free-breathing techniques. Most of these evalua-
tions on respiratory triggering have been performed
with T2-weighted imaging (T2WI) probably because of a
technical reason; as the repetition time (TR) of a respi-
ratory sequence is one respiratory cycle, it is technically
demanding to modify a T1-weighted sequence in a way
that it achieves T1 contrast with a long TR.
Sequences with the periodically rotated overlapping
parallel lines with enhanced reconstruction (PROPEL-
LER; General Electric Medical Systems, Milwaukee, WI,
USA) and BLADE (Siemens Medical Systems, Erlangen,
Germany) techniques, developed by Pipe (4), have also
been proposed to reduce the effects of somatic motion.
Unlike rectilinear k-space sampling, this method ac-
quires multiple echo trains with a TSE sequence in a
rotating (with respect to rectilinear k-space), partially
321
322
overlapping fashion, so-called “blades.” Its clinical ap-
plication in the field of neuroradiology (5,6) and for
unsedated pediatric patients (7,8) has already been re-
ported. Recent studies investigated its application in
abdominal multishot diffusion-weighted imaging (9)
and renal T2WI (10); however, the usefulness of the
BLADE technique in PACE has been addressed by only
one study using volunteers (11) and another on pa-
tients comparing three different conditions of echo train
length, blade width, and percent k-space coverage in
the same scanning time (12). Therefore, we carried out
this study to compare PACE T2WI of the liver with and
without the BLADE technique in a larger number of
patients with and without a hepatic lesion and to assess
the effect on diagnostic performance, with an hypothe-
sis that the PACE T2WI with BLADE (T2WI-BLADE)
sequence could replace PACE T2WI in the near future.
MATERIALS AND METHODS
Patients
All MRI was obtained using clinical cases in our insti-
tution. The institutional review board approved this
study, and oral informed consent was obtained from all
patients prior to their examination. Eighty consecutive
patients (24 female and 56 male; mean age ⫽ 56 years;
range ⫽ 22–92 years) who underwent upper abdominal
MRI between April and July 2008 were prospectively
studied. Among the 80 patients, 23 had the following
hepatic lesions; eight had 26 hepatocellular carcinoma
(HCC) lesions, four had 13 metastasis lesions, six had
10 cysts, two had five hemangioma lesions, and one
each had abscess, benign solid lesion, and biloma.
Thirteen patients had multiple lesions, and two pa-
tients had two kinds of lesions (HCC and cyst). All
lesions over 5 mm in diameter, up to a maximum nine
lesions per patient, were included in the assessment. A
total of 57 lesions were evaluated. The remaining 57
patients had confirmed or suspected extrahepatic ab-
dominal disease. The final diagnosis of hepatic lesions
was made using the following criteria.
1. Simple cysts and hemangiomas were diagnosed by
typical ultrasonography (US), computed tomogra-
phy (CT), and MR findings in 10 and 5 lesions,
respectively.
2. HCCs were diagnosed by US-guided core needle
biopsy in nine lesions, and the findings of elevated
enhancement in an early phase on dynamic CT
and/or MR images and/or follow-up studies in 17
lesions.
3. The diagnosis of metastatic lesions were made by
US-guided core needle biopsy in one lesion, and
the clinical information that multiple hepatic le-
sions increased in both size and number on serial
imaging examinations in 12 lesions. All primary
lesions were histologically confirmed (five were
colorectal cancer, three each were gastrointestinal
stromal tumor and cholangiocellular carcinoma,
and one each was breast cancer and maxillary
cancer).
4. A case of abscess was diagnosed based on the
clinical course of the decrease in size on serial
Nanko et al.
follow-up examinations after antibiotic therapy. A
case of biloma was diagnosed by characteristic CT
findings. A benign solid lesion was confirmed by
US-guided core needle biopsy.
MRI
All scans were performed using a 1.5T MR scanner
(Symphony; Siemens Medical Solutions, Erlangen, Ger-
many). The spine-array coils and the phased-array sur-
face coil were used for signal reception. The section
thickness ⫽ 5 mm with the interslice gap ⫽ 1.5mm. All
images were acquired in the axial plane without the
parallel imaging technique. The normalizing filter was
switched off. Phase encoding was performed from the
anterior to posterior direction. Fat suppression was ap-
plied.
The scan parameters for PACE T2WI were as follows:
TR/echo time (TE) ⫽ 2808 – 8945 msec/82 msec, ma-
trix size ⫽ 320 ⫻ 256 matrix, bandwidth ⫽ 260 Hz/
pixel, flip angle ⫽ 170°, and echo-train length (ETL) ⫽
19. Those for PACE T2WI-BLADE were as follows: TR/
TE ⫽ 2808 –7954 msec/88 msec, ETL ⫽ 29, echo spac-
ing ⫽ 5.84 msec, k-space coverage ⫽ 100%, matrix
size ⫽ 320 ⫻ 320; refocusing flip angle ⫽ 150°, and
bandwidth ⫽ 446 Hz/pixel; with slice thickness ⫽ 5
mm and field of view ⫽ 350 mm2 (the same as for PACE
T2WI). The mean scan time was four minutes five sec-
onds for PACE T2WI-BLADE, and three minutes 48
seconds for PACE T2WI. All scans were obtained during
eupnea.
Other sequences, such as T1-weighted images, dy-
namic contrast-enhanced images, and magnetic reso-
nance cholangiopancreatography (MRCP), were also
obtained depending on the requirements of each pa-
tient; however, these images were not evaluated in this
study, and PACE T2WI with or without BLADE was
independently evaluated without reference to other im-
ages.
Quantitative Analysis
Quantitative image analysis was performed by an ab-
dominal radiologist who measured the SI of the lesion
and the adjacent liver using operator-defined oval re-
gions-of-interest (ROIs) for each image. This radiologist
did not participate in the subsequent analysis of lesion
detection. To measure the SI of focal liver lesions, ROIs
were placed on lesions over 5 mm in diameter, thereby
avoiding necrotic foci. The SI of the hepatic parenchyma
beside the lesions was measured, avoiding large vessels
and artifacts. The size of the ROI was normalized in
both sequences, but it varied in each patient. The liver–
lesion contrast was calculated from the following equa-
tion (13):
(SI lesion ⫺ SI liver)/(SI lesion ⫹ SI liver). [1]
Qualitative Analysis
Visual Assessment of Image Quality
MR images were analyzed by two radiologists with more
than seven years of experience with abdominal MRI.
Usefulness of BLADE on PACE T2WI of the Liver 323

Table 1 difference in the mean figure of merit (FOM) value be-

Results of Quantitative Assessment of Liver–Lesion Contrast tween two pulse sequences (14,15). Medcalc version 9.6
PACE T2WI PACE T2WI-BLADE P (Medcalc software; Mariakerke, Belgium) was used to
(mean ⫾ SD) (mean ⫾ SD) value obtain weighted kappa to assess reader agreement; val-
ues ranges: 0.21– 0.40 ⫽ fair agreement; 0.41– 0.60 ⫽
Liver–lesion contrast 0.30 ⫾ 0.14 0.29 ⫾ 0.14 0.39
moderate agreement; 0.61– 0.80 ⫽ substantial agree-
PACE ⫽ prospective acquisition correction, PACE T2WI-BLADE ⫽ ment; and 0.81–1.0 ⫽ almost complete agreement.
PACE T2WI with BLADE.

RESULTS
The observers graded the overall image quality of the Quantitative Analysis
right and left hepatic lobes of both sequences using the The result of the quantitative assessment for the liver–
following five-point scale: 1 ⫽ unacceptable; 2 ⫽ poor; lesion contrast is summarized in Table 1. There was no
3 ⫽ fair; 4 ⫽ good; and 5 ⫽ excellent. The presence of significant difference between the mean liver–lesion
artifacts, such as respiratory ghosting, vascular pulsa- contrast obtained with PACE T2WI and that with PACE
tion, peristalsis, susceptibility, and cardiac motion, T2WI-BLADE (P ⫽ 0.39).
was graded as: 1 ⫽ severe; 2 ⫽ moderate; 3 ⫽ mild; 4 ⫽
minimal; and 5 ⫽ absent. The depiction of intrahepatic
Qualitative Analysis
portal veins was assessed using the following criteria:
1 ⫽ unacceptable (the main portal vein was invisible); The results of qualitative assessment of the visual im-
2 ⫽ poor (only the main portal vein was visible); 3 ⫽ fair age quality on MR images are summarized in Table 2.
(only the main branch of portal vein was visible); 4 ⫽ The mean grade of all evaluated targets with PACE
good (the peripheral portal veins were sometimes visi- T2WI-BLADE was significantly higher than with PACE
ble); and 5 ⫽ excellent (the peripheral portal veins were T2WI.
clearly visible). Image sharpness of the liver was graded The results of JAFROC analysis are summarized in
as: 1 ⫽ unacceptable; 2 ⫽ poor; 3 ⫽ fair; 4 ⫽ good; and Table 3. False positivity was found in two lesions for
5 ⫽ excellent. detection and in 10 lesions for differentiation of benign
and malignant ones. To detect all hepatic lesions and
Lesion Detection and Characterization malignant hepatic lesions, there were no significant
differences in the FOM value between PACE T2WI and
Two radiologists, with more than seven years of experi- PACE T2WI-BLADE. Kappa values for the two observers
ence with abdominal MRI, also evaluated the number of ranged from 0.48 to 0.82 (Table 4). Interobserver agree-
hepatic lesions per sequence independently. They were ment for the two reviewers was fair to almost perfect.
blinded to all patient information, including clinical
history, biopsy results, and image findings. Image in-
terpretation was separated into two sessions at more DISCUSSION
than two-week intervals. Only one of the two free- Our study proved the feasibility and usefulness of
breathing T2WI sequences was evaluated in each ses- PACE T2WI-BLADE for hepatic imaging in patients with
sion and was independently assessed. For each pulse and without liver disease. With respect to all types of
sequence, the observers marked the location of de- artifacts and image quality, PACE T2WI-BLADE was
picted abnormalities and then assigned a four-point superior to PACE T2WI using visual criteria. This supe-
confidence level scale: 1 ⫽ 1% to 49%; 2 ⫽ 50% to 74%; riority seems to be apparent in all the three figures
3 ⫽ 75% to 94%; and 4 ⫽ 95% to 100%. The observers (Figs. 1–3). Artifacts produced by physiologic motion
characterized each detected lesion using the following
five-point scale: 1 ⫽ definitely benign; 2 ⫽ probably
benign; 3 ⫽ indeterminate; 4 ⫽ probably malignant;
and 5 ⫽ definitely malignant. Table 2
Results of Qualitative Assessment of Image Quality on MRI
Images Obtained With Two Pulse Sequences
Statistical Analysis
PACE
The Wilcoxon signed rank test was performed using PACE T2WI P
T2WI-BLADE
Graph Pad Prism 5.0 (GraphPad software, CA, USA), to (mean ⫾ SD) value
(mean ⫾ SD)
compare the liver–lesion contrast, and to assess visual
image quality. P ⬍ 0.05 was considered significant. The Right lobe
Motion artifacts 4.0 ⫾ 0.5 4.9 ⫾ 0.3 ⬍0.0001
diagnostic accuracy of each pulse sequence to detect
Sharpness 4.5 ⫾ 0.7 4.8 ⫾ 0.5 ⬍0.0002
hepatic lesions and to differentiate malignant from be-
Depiction of portal vein 4.6 ⫾ 0.7 4.9 ⫾ 0.4 ⬍0.0005
nign diseases was determined using jackknife alterna- Overall image quality 4.3 ⫾ 0.8 4.8 ⫾ 0.5 ⬍0.0001
tive free-response receiver operating characteristic (JA- Left lobe
FROC) analysis, which was performed using software Motion artifacts 3.8 ⫾ 0.5 4.8 ⫾ 0.4 ⬍0.0001
JAFROC1 version 1.0 (http://devchakraborty.com). Sharpness 3.9 ⫾ 0.6 4.7 ⫾ 0.5 ⬍0.0001
The receiver operating characteristic (ROC) curve anal- Depiction of portal vein 4.5 ⫾ 0.7 4.8 ⫾ 0.4 ⬍0.0001
ysis was not appropriate for this study in patients with Overall image quality 4.3 ⫾ 0.8 4.8 ⫾ 0.5 ⬍0.0001
multiple hepatic lesions. A 95% confidence intervals PACE ⫽ prospective acquisition correction, PACE T2WI-BLADE ⫽
(CI) that did not contain a zero indicated a significant PACE T2WI with BLADE.
324 Nanko et al.

Table 3
Results of Free-Response Receiver Operating Characteristic Curve Analysis for the Detection of Focal Hepatic Lesions*
Mean figure of merit value Intermodality 95% confidence
Hepatic lesions
PACE T2WI PACE T2WI-BLADE differences intervals (CI)

All 0.95 0.95 ⬍0.01 ⫺0.29,0.28

Malignant 0.90 0.86 0.04 ⫺0.42,0.50
*Mean figure of merit value is an average of the results of two observers and was obtained from two pulse sequences for the detection and
characterization of focal hepatic lesions. If CI does not include zero, the corresponding difference is significant. CI may appear inconsistent
with the P-value, e.g., CI may just barely include 0 (i.e., no significant difference) but the P-value could be slightly smaller than 0.05 (i.e.,
significant difference).
PACE ⫽ prospective acquisition correction, PACE T2WI-BLADE ⫽ PACE T2WI with BLADE

deteriorated the image quality and decreased the diag-

nostic information. Various types of T2WI have been
developed to improve image quality. Breathhold TSE
T2WI sequences are the most common and easiest
technique because they might completely eliminate re-
spiratory motion artifacts when patients hold their
breath due to the relatively short acquisition time
(16,17). Nevertheless, patients sometimes cannot ade-
quately complete this maneuver, as patients referred
for abdominal MRI might occasionally be in poor gen-
eral condition because of underlying diseases.
The navigator-triggered PACE technique is a new
method of respiratory monitoring without additional
hardware. It is a two-dimensional (2D) navigator-based
technique in which the position of the diaphragm is
repeatedly measured. The examination is not inter-
rupted due to dislocation of the monitoring device and
is less susceptible to artifacts (18). Kim et al (3) reported
that the PACE TSE sequence had better diagnostic per-
formance for detecting and characterizing lesions than
other free-breathing techniques such as respiration-
triggered TSE and half-Fourier acquisition single-shot
turbo spin-echo (HASTE) performed with navigator-
triggered PACE. In our study, however, we experienced
pulsation artifacts that mainly originated from the
aorta, as observed with other conventional sequences.
We are familiar with this type of artifact, so we seldom
mistook the artifacts as lesions; therefore, in addition to
PACE showing good diagnostic performance, it pro-
duced few false-positive lesions and there were no sig-
nificant differences between the two pulse sequences in
lesion detection and characterization in spite of the
apparently improved image quality of PACE T2WI-
BLADE. If only solid lesions in the left hepatic lobe were
assessed, a difference in lesion detectability might be
observed between the two sequences.
BLADE and PROPELLER sequences can reduce gross
motion artifacts such as translation and rotation with
the correction techniques (5). This technique includes a

Table 4
Weighted Kappa for the Detection of Lesions and the
Differentiation of Malignant from Benign Lesions
PACE T2WI PACE T2WI-BLADE
Figure 1. An 88-year-old man with no hepatic lesions. a: MRI
Lesion detection 0.48 0.63 image obtained with PACE TSE T2WI sequence shows arti-
Lesion characterization 0.71 0.82 facts, including ghost artifacts. b: On MRI image obtained with
PACE ⫽ prospective acquisition correction, PACE T2WI-BLADE ⫽ PACE T2WI-BLADE, the ghost artifact decreases compared to
PACE T2WI with BLADE. that on PACE TSE sequence image.
Usefulness of BLADE on PACE T2WI of the Liver 325

because most motion in the abdomen might be related

to respiration and random diaphragmatic motion,
which leads to combined in-plane and through-plane
motion on axial images. In our study, PACE could cor-
rect for through-plane motion such as respiratory mo-
tion and cardiovascular pulsation. In contrast, BLADE
could correct for in-plane motion. As a result, we think
that improved image sharpness and clear depiction of
the intrahepatic portal vein could be obtained on PACE
T2WI-BLADE. In spite of the apparently improved im-
age quality, there was no significant difference in the
liver–lesion contrast; we think that this was due to the
small differences in imaging parameters between the
two sequences and that the liver–lesion contrast is not
influenced by the background noise level.

Figure 2. A 58-year-old man with hemangioma. The sharp-

ness and depiction of the intrahepatic portal vein obtained
with PACE T2WI (a) are inferior to those on PACE T2WI-BLADE
(b). With both sequences, a hyperintense benign lesion is
clearly shown in the right lobe. The contour of the mass is
clearer on PACE T2WI-BLADE than on PACE T2WI.

series of rotating blades containing phase-encoding

lines, with each blade sampling a common central k-
space data set. This enables correction for motion and
also averages motion by oversampling, thereby offering
significant advantages in terms of imaging artifacts
(11). This has been used for neuroradiology applica-
tions (5,8), particularly for noncooperative patients (7),
and its motion correction benefits were extended by
offering targeted correction for major in-plane move-
ment of translation and rotation. This technique does Figure 3. A 79-year-old man with HCC. With both sequences,
not offer through-plane motion correction (7). For ab- a hyperintense malignant lesion is also clearly shown in the
dominal imaging, this feature would be of less value right lobe. a: PACE T2WI. b: PACE T2WI-BLADE.
326
Using the BLADE sequence, motion artifacts were
significantly reduced, except for the radial lines that
appeared around the body without deteriorating image
quality. Michaely et al (10) reported that the BLADE
sequence exhibited the typical peripherally arranged
third-arm artifacts but we seldom experienced this type
of artifact in our study. We think that wraparound ar-
tifacts derived from arms outside of the field of view
could be reduced by a presaturation slab applied to
both arms. To obtain PACE T2WI-BLADE, an additional
17 seconds were required on average compared to
PACE T2WI, which we think would be acceptable in
clinical use. Better interobserver agreement was ob-
tained with PACE T2WI-BLADE, so it might be easier
even for radiologists with relatively short experience to
make confident diagnoses.
There are several potential limitations of our study.
First, we evaluated only T2WI to detect and characterize
localized hepatic lesions. In practice, we usually inter-
pret other MRI sequences simultaneously, including
dynamic contrast-enhanced T1-weighted imaging. Sec-
ond, not all of the focal hepatic lesions were pathologi-
cally confirmed in our study; however, this is an inevi-
table problem, particularly in clinical studies including
candidates with benign lesions. Third, parallel acquisi-
tion techniques were not utilized in our study, because
the employment of these techniques in MRI would re-
sult in decreasing the signal-to-noise ratio (SNR) and
because the function of the square root of the acceler-
ation factor, adequate acceleration factor, and opti-
mized scan parameters need to be determined in order
to maximize the advantages of the parallel acquisition
technique (reduced imaging time), while minimizing its
harmful effects (2). We did not calculate the SNR and
lesion–liver contrast-to-noise ratio because of the ab-
sence of an established method, especially on the addi-
tional BLADE sequence.
In conclusion, introduction of the BLADE technique
improved the visual image quality compared to PACE
T2WI only. Although no significant difference was noted
with or without the BLADE technique in liver–lesion
contrast and in detecting hepatic lesions and diagnos-
ing qualitative characteristics, our results suggest that
the BLADE technique might be a valid method to im-
prove image quality by reducing motion artifacts on
hepatic MRI without affecting the diagnostic perfor-
mance of PACE T2WI in practice.
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