CSF Susceptibility Variation in Patient With Intracranial Hemorrhage: Implications for Quantitative Susceptibility Mapping Reference Selection

Background Quantitative susceptibility mapping (QSM) is an emerging MRI technique with multiple clinical applications. As tissue susceptibility cannot be directly measured using MRI, QSM imaging techniques must indirectly compute susceptibility values, requiring regularization methods. CSF is a popular choice for regularization due to its near water susceptibility in healthy controls. However, the impact of pus, elevated protein, or blood dissolved in CSF on QSM regularization is not well defined. Objective This study aimed to investigate the effects of intracranial hemorrhage (ICH) on selecting CSF as reference for QSM imaging. Materials and Methods A total of 87 subjects, 53 with ICH (5 intraventricular, 19 subarachnoid, 27 both, and 2 intraparenchymal only) and 37 without hemorrhage (27 with MS, 10 without MS), were included in this study. Imaging was performed using 3D multiecho gradient echo, FLAIR, and multiecho complex total field inversion (mcTFI) at 3 T. McTFI with and without CSF zero-referencing regularization was generated from the 3DMEGRE data and reviewed with FLAIR images. Regions of hemorrhagic (H+) and nonhemorrhagic (H−) CSF were manually selected in reference to head CT and FLAIR images by a PGY III diagnostic radiology resident and Certificate of Added Qualification–certified neuroradiologist with 10 years' experience. Paired Student t test and one-way ANOVA were used with post hoc multicomparisons. A P value <0.05 was considered statistically significant. Results Areas of H− CSF were noted to have higher regularized QSM values in subjects with ICH relative to subjects without. Unregularized H− QSM values were also noted to have a systematically higher value in ICH subjects relative to subjects without blood. Subjects with MS and without ICH did not show significant difference in H− CSF regularized or unregularized QSM values. Conclusions QSM values of areas suggested to not have hemorrhage on other imaging showed significantly higher QSM values in ICH subjects relative to subjects without ICH. Additionally, areas of hemorrhage did not show significant QSM value difference between regularized and unregularized QSM images. These findings suggest that, in subjects with any area of ICH, QSM values for no-hemorrhagic areas may be significantly altered using CSF regularization relative to subjects without ICH, with implications for intra- and intersubject QSM value analysis.