Clinical Utility of Respiratory-Triggered 3D Turbo Spin-Echo Sequence with Improved Motion-Sensitized Driven Equilibrium for Magnetic Resonance Cholangiopancreatography: A Prospective Comparative Study

Clinical Utility of Respiratory-Triggered 3D Turbo Spin-Echo Sequence with Improved Motion-Sensitized Driven Equilibrium for Magnetic Resonance Cholangiopancreatography: A Prospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Utility of Respiratory-Triggered 3D Turbo Spin-Echo Sequence with Improved Motion-Sensitized Driven Equilibrium for Magnetic Resonance Cholangiopancreatography: A Prospective Comparative Study Tuanxin Xu, Xudong Chen, Wenyan Zhong Zhong, Xiao Liu, Qingyun Wang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8715485/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Conventional magnetic resonance cholangiopancreatography (MRCP) is often limited by moderate signal intensity from hepatic vessels, which may obscure visualization of the pancreatobiliary ducts. This study aimed to compare the clinical feasibility and image quality of a respiratory-triggered 3-dimensional (3D) turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium (RT-3D TSE iMSDE) for pancreatobiliary imaging. Methods: This prospective study enrolled 53 patients (19 men and 34 women; mean age, 51.3 ± 15.5 years) with suspected pancreatobiliary disorders between September 2024 and February 2025. All patients underwent both RT-3D TSE iMSDE MRCP and conventional RT-3D TSE MRCP at 3.0 T MRI. Two radiologists independently scored the overall image quality, background suppression, and visibility of 15 pancreaticobiliary segments using a 5-point Likert scale. Qualitative scores and quantitative parameters—signal-to-noise ratio (SNR), contrast ratio (CR), and contrast-to-noise ratio (CNR)—were compared using Wilcoxon signed-rank tests. Interobserver agreement was analyzed using weighted kappa statistics. Wilcoxon signed-rank tests were used for pairwise comparisons, and Kendall's tau-b correlation analysis and the Mann–Whitney U test were applied to evaluate the correlation between age, sex, body mass index (BMI), and subjective image scores. Results: Interobserver agreement was good for all subjective image quality assessments. Compared with conventional RT-3D TSE MRCP, RT-3D TSE iMSDE MRCP sequence demonstrated notably higher scores for overall image quality, background suppression, and visualization of all 15 pancreatobiliary segments (all p <.05). Quantitative analysis revealed significantly higher SNR, CR, and CNR values for the iMSDE sequence: SNR: 22.77 vs. 16.39; CR: 0.95 vs. 0.91; CNR: 29.47 vs. 19.95 (all p .05). Conclusion: RT-3D TSE iMSDE MRCP improves duct-to-background contrast through vascular signal suppression, enabling clearer delineation of pancreatobiliary anatomy than conventional MRCP and enhancing diagnostic confidence. Trial registration: Clinical trial number: not applicable. Black-blood imaging iMSDE magnetic resonance cholangiopancreatography pancreatobiliary system turbo spin-echo Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Highlights • Conventional RT-3D MRCP suffers from vascular contamination artifacts. • TSE iMSDE improves image quality and duct visualization. • iMSDE provides higher SNR, contrast, and contrast-to-noise ratios. • Second- and third-order ducts demonstrate visualization in patients. • Image quality improvements are robust across age and sex. Background Pancreatobiliary diseases, including cholangiolithiasis, cholangitis, pancreatic adenocarcinoma, cholangiocarcinoma, and congenital biliary tract malformations, encompass a spectrum of conditions that markedly affect the pancreas and biliary system. These disorders pose substantial diagnostic challenges and can severely impact patient outcomes and quality of life [ 1 , 2 ]. Accurate visualization of the biliary tract and its pathologic alterations is therefore essential for early diagnosis, individualized treatment strategies, and prognostic evaluation. A clear understanding of the patient’s condition enables timely intervention, leading to improved therapeutic efficacy and reduced disease-related morbidity. Respiratory-triggered 3-dimensional (3D) turbo spin-echo magnetic resonance cholangiopancreatography (RT-3D TSE MRCP) exploits the long T2 relaxation time of bile to provide high-resolution, noninvasive imaging of the pancreatobiliary system. By employing heavily T2-weighted fast spin-echo sequences with fat suppression, MRCP enables visualization of ductal structures without the need for contrast agents and allows multidirectional and multiplanar 3D reconstruction. Owing to its safety and diagnostic capability, this technique has been widely adopted for the evaluation of pancreatobiliary diseases [ 3 , 4 ]. Despite these advantages, the effectiveness of conventional MRCP is limited by overlapping high-intensity signals from the portal venous system. Turbulent blood flow, vascular bifurcations, and tortuous ductal anatomy can generate vascular artifacts, particularly on maximum intensity projection (MIP) images, thereby reducing ductal conspicuity and diagnostic confidence [ 5 , 6 ]. The improved motion-sensitized driven equilibrium (iMSDE) technique is a black-blood imaging method developed to suppress vascular signals. It uses spatially nonselective radiofrequency pulses combined with motion-sensitizing gradients to induce phase dispersion in moving protons. Because of velocity variations in blood flow, the resulting phase differences cannot be fully refocused, leading to effective signal cancellation that is largely independent of flow velocity [ 7 , 8 ]. Additionally, iMSDE incorporates an inversion recovery pulse to counteract motion-induced artifacts by reversing tissue magnetization, thereby mitigating motion-induced artifacts and enhancing tissue contrast [ 9 ]. This technique has demonstrated effective suppression of both slow and turbulent blood flow, improving image quality in motion-prone regions such as the heart and vasculature [ 10 , 11 ]. Although gradient- and spin-echo (GraSE) MRCP offers advantages such as shorter acquisition times and reduced respiratory dependence, it remains susceptible to T2 decay–related blurring, spatially heterogeneous background suppression, and reduced ductal visualization in the presence of highly concentrated bile. These limitations underscore the need for complementary imaging strategies. In contrast, the iMSDE-prepared RT-3D TSE MRCP technique suppresses background vascular signals prior to image readout, resulting in a more robust duct-to-background contrast and a higher spatial resolution, thereby addressing specific shortcomings of GraSE in clinical pancreatobiliary imaging [ 7 ]. Therefore, this study aimed to compare the clinical feasibility and image quality of RT-3D TSE iMSDE MRCP with conventional RT-3D TSE MRCP for pancreatobiliary imaging. We hypothesized that this novel RT-3D TSE iMSDE MRCP technique can substantially enhance diagnostic performance by improving ductal delineation and reducing image artifacts, thereby providing a more reliable imaging tool for the evaluation of pancreatobiliary diseases. Because the approach can be implemented on standard MR systems without additional scan sequences, it may support broader clinical adoption, particularly in patients with complex biliary anatomy or compromised respiratory control. Methods Study Population This prospective single-center study in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Dongguan Tungwah Hospital, and all participants provided written informed consent. This prospective study enrolled 56 consecutive patients who underwent MRCP between September 2024 and February 2025. The inclusion criteria were as follows: (1) no contraindications to MRI and (2) complete MRI datasets with diagnostic image quality. The exclusion criteria were as follows: (1) a history of abdominal surgery, (2) biliary stent placement, and (3) massive ascites or severe intestinal gas–related artifacts. MRCP was performed in patients with suspected biliary or pancreatic disease based on clinical manifestations, medical history, physical examination, or abdominal ultrasound findings. For patients who underwent surgery, intraoperative findings served as the reference standard. For nonsurgical patients, final diagnoses were determined by multimodal imaging consensus, which included at least 1 additional imaging modality (ultrasound or CT) performed within a standardized 7-day interval after MRI. MRI Protocols All participants fasted (including abstention from water) for at least 6 hours before MRCP. MRI examinations were performed using a 3.0-T MRI system (Ingenia Elition X; Philips Healthcare, Best, The Netherlands) equipped with a 32-channel digital body coil. Patients were scanned in the supine, head-first position with their arms placed alongside the body. The imaging protocol included: (1) an axial balanced turbo field echo (BTFE) sequence, (2) RT-3D TSE iMSDE MRCP, and (3) conventional RT-3D TSE MRCP. The axial BTFE sequence was used for anatomical localization and complementary diagnostic assessment of the upper abdomen and was not used as a reference or comparator for the RT-3D TSE MRCP or RT-3D TSE iMSDE MRCP sequences. All 3D sequences were acquired in the coronal plane. Respiratory triggering was performed using a prospective respiratory gating approach. The physiologic window was set to 10 seconds, within which the number of complete respiratory cycles was counted to determine the trigger delay. Identical respiratory-triggering parameters were applied to both MRCP sequences to ensure consistency in image acquisition. Detailed scanning parameters are provided in Table 1 . Table 1 Scanning parameters for RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP performed on 3.0-T MRI system Parameter RT-3D TSE iMSDE MRCP RT-3D TSE MRCP Repetition time (ms) 941 1000 Echo time (ms) 286 600 Echo space (ms) 7.1 5.8 Shot duration (ms) 571 644 Slice thickness (mm) 2 2 Layer spacing (mm) −1 −1 Acquired voxel size (mm 3 ) 0.99 ⋅ 1 ⋅ 2 0.99 ⋅ 1 ⋅ 2 Reconstructed voxel size (mm 3 ) 0.4 ⋅ 0.4 ⋅ 1 0.4 ⋅ 0.4 ⋅ 1 Field of view (mm 2 ) 350 ⋅ 350 350 ⋅ 350 Scan matrix 352 ⋅ 350 352 ⋅ 350 Flip angle (degrees) 90 80 Number of coronal slices 100 100 Compressed sensing factor 10 10 Bandwidth (Hz/pixel) 297.4 390.1 Number of excitations 1 1 Turbo factor 80 100 Drive balance Yes Yes BB pulse MSDE No Acquisition time (s) 153 126 BB, Black-blood; MSDE, motion-sensitized driven equilibrium; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography. Image Quality Analysis RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP images were transferred to a Philips Nebula workstation (Philips Healthcare) for MIP reconstruction. Cropping of the region of interest was performed collaboratively by 2 senior MRI technicians according to a standardized protocol. The region was defined with the upper limit at the superior margin of the liver, the lower limit at the pancreatobiliary duct junction, the left limit at the tail of the pancreatic duct, and the right limit at the right edge of the liver. High-signal regions of the gastrointestinal tract were also included. Both technicians underwent uniform training before image processing to ensure consistency and reproducibility across all cases, thereby minimizing potential bias between the 2 methods. The reconstructed images were systematically rotated along the sagittal, coronal, and axial planes; reformatted into anteroposterior, lateral, and craniocaudal orientations; and saved for subsequent evaluation. Qualitative Image Evaluation and Diagnostic Confidence In this study, 2 abdominal radiologists with 15 and 8 years of experience in hepatobiliary MRI, respectively, independently evaluated image quality. To minimize recall and expectation bias, image sets from the 2 sequences were reviewed in separate reading sessions at least 2 weeks apart. The order of image presentation was randomized, and both readers were blinded to patient information, sequence type, and clinical data. Image evaluation was performed on a standard Picture Archiving and Communication System workstation, which allowed adjustment of magnification, window width, and window level settings. Readers were also permitted to reconstruct coronal 3D MRCP images into any plane to optimize duct visualization. A validated 5-point modified Likert scale was used to assess (1) global image quality, (2) background suppression efficiency, and (3) the conspicuity of biliary and pancreatic duct segments at all anatomic levels [ 12 , 13 ] (Table 2 ). Discrepancies in scores were resolved through consensus discussions. Based on the established Likert scoring criteria, paired imaging sequences from the same patient were categorized as “increased” if scores improved with the iMSDE sequence, “no change” if scores were identical, and “degraded” if scores declined. Table 2 Likert scoring criteria for overall image quality and background assessment Score Overall image quality Background suppression effect Display of bile duct and pancreatic duct at all levels 1 Non-diagnostic image quality (undiagnosed) Strong background signal, preventing image evaluation Structure not visible 2 Poor image quality (below average) Strong background signal, hindering image evaluation Structure is barely visible 3 Moderate image quality (average water level) Background signal is obvious, which affects image observation Structure is partially visible, but with a blurred boundary 4 Good image quality Weak background signal, does not affect image observation Structure is almost completely visible, with clear boundaries 5 Excellent image quality Excellent background suppression All structures are fully visible, with adequate detail Quantitative Image Evaluation Signal-to-noise ratio (SNR), contrast ratio (CR), and contrast-to-noise ratio (CNR) were calculated to provide complementary quantitative assessments of image quality. SNR was used to characterize background noise levels, CR to evaluate signal intensity contrast between structures, and CNR to reflect the combined effects of signal and noise. Because CNR directly reflects diagnostic contrast, it was considered the primary quantitative metric for image comparison. SNR was reported as a supplementary descriptor of overall image quality and noise behavior rather than as a direct indicator of diagnostic performance. The SNR, CR, and CNR between the common bile duct (CBD) and surrounding tissues were calculated using the following formulas [ 14 ]: SNR \(\:=\:\frac{{SI}_{CBD}}{{SD}_{CBD}}\) CR \(\:=\:\frac{({SI}_{CBD}-{SI}_{tissue})}{({SI}_{CBD}+{SI}_{tissue})}\) CNR \(\:=\frac{({SI}_{CBD}-{SI}_{tissue})}{\sqrt{\left(S{D}_{CBD}^{2}+S{D}_{tissue}^{2}\right)/2}}\) Statistical Analysis Statistical analyses were performed using SPSS Statistics version 25.0 (IBM Corp., NY, USA). The normality of continuous variables was assessed using the Shapiro–Wilk test. Normally distributed data were presented as mean ± standard deviation, whereas non-normally distributed data were reported as median (interquartile range). Interobserver agreement between the 2 radiologists was evaluated using the quadratic weighted Cohen’s kappa coefficient and interpreted as follows: poor (≤ 0.40), moderate (0.41–0.60), good (0.61–0.80), and excellent (> 0.80). For qualitative (ordinal) data and quantitative parameters (SNR, CR, and CNR) from paired MRCP examinations, the Wilcoxon signed-rank test was applied. Bonferroni correction was used where appropriate to account for multiple comparisons. Besides Z and p values, paired differences with 95% confidence intervals (CIs) and effect sizes were calculated to estimate the magnitude and uncertainty of observed effects. Kendall's tau-b correlation analysis and the Mann–Whitney U test were used to evaluate the correlation between age, sex, body mass index (BMI), and subjective overall MRCP image quality scores in both groups. All statistical tests were 2-tailed, and a p value < .05 was considered statistically significant. Results Study Population Among the 56 eligible participants who met the inclusion criteria, 3 were excluded due to noncompliance with examination protocols, rendering 53 cases available for comprehensive clinical evaluation. As detailed in Fig. 1 and Table 3 , the 53 included cases comprised 44 patients with gallstones; 3 with dilatation of the common hepatic duct, CBD, and pancreatic duct; 2 with acute pancreatitis; 1 with tumor invasion of the right hepatic duct and common hepatic duct lumen; 1 with lower-end CBD obstruction; 1 with a pancreatic body mass; and 1 with ampullary lesions. Table 3 Demographic information of the included patients Feature Mean ± SD/No. (%) Age (year) 51.3 ± 15.5 Sex (male/female) 19(35.85%)/34༈64.15%༉ Height (m) 1.61 ± 0.08 Weight (kg) 63.73 ± 14.45 Body mass index (kg/m 2 ) 24.53 ± 4.78 No., Number; SD, standard deviation. Qualitative Image Evaluation Interobserver agreement between the 2 radiologists demonstrated substantial to strong agreement, with kappa coefficients ranging from 0.842 to 0.969 ( p < .05). The RT-3D TSE iMSDE MRCP protocol exhibited statistically significant improvements compared with the conventional RT-3D TSE MRCP sequence across all evaluated metrics, including overall image quality, background suppression, and subjective scores for individual anatomical structures (all p < .05) (Figs. 2 – 3 and Table 4 ). Shapiro–Wilk tests ( p < .05) depicted interobserver assessments using the Likert scoring criteria. As presented in Table 5 , the application of the iMSDE technique remarkably improved the visualization of all 3 grades of intrahepatic biliary ducts across paired MRCP examinations from the same patients, with visibility improvement rates ranging from 90% to 92%. Table 4 Qualitative image score comparison between RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP Site RT-3D TSE iMSDE MRCP RT-3D TSE MRCP Difference 95% CI Z value * p value * p adjust r Subjective scoring (score) Kappa value Subjective scoring (score) Kappa value QOI 5 (4, 5) 0.898 4 (3, 4) 0.967 1.066 (0.877–1.255) –6.061 <.001 <.001 .833 BI 5 (5, 5) 0.941 4 (4, 4) 0.959 0.896 (0.729–1.064) –5.929 <.001 <.001 .814 PCBD 5 (4.75, 5) 0.948 4 (4, 4) 0.957 0.585 (0.430–0.740) –5.170 <.001 <.001 .710 DCBD 5 (5, 5) 0.930 4 (4, 4) 0.871 0.651 (0.477–0.825) –5.075 <.001 <.001 .697 CHD 5 (5, 5) 0.941 4 (4, 4) 0.967 0.698 (0.512–0.884) –5.169 <.001 <.001 .710 CD 4 (3,4) 0.970 3 (3, 4) 0.961 0.566 (0.387–0.745) –4.666 <.001 <.001 .641 LHD (grade 1) 5 (4.75,5) 0.948 4 (3.5, 4) 0.949 0.896 (0.660–1.132) –5.265 <.001 <.001 .723 LIBD (grade 2) 5 (4,5) 0.966 3 (3, 4) 0.958 1.500 (1.198–1.802) –5.817 <.001 <.001 .799 LISBD (grade 3) 4 (4,4) 0.960 3 (2, 3) 0.952 1.387 (1.131–1.643) –6.097 <.001 <.001 .837 RHD (grade 1) 5 (5,5) 0.941 4 (3, 4) 0.950 0.972 (0.737–1.206) –5.483 <.001 <.001 .753 RIBD (grade 2) 5 (4,5) 0.967 3 (2.5, 4) 0.960 1.547 (1.246–1.849) –5.875 <.001 <.001 .807 RISBD (grade 3) 4 (4,4) 0.926 3 (2, 3) 0.895 1.396 (1.144–1.649) –6.015 <.001 <.001 .826 MPD (proximal) 5 (5,5) 0.842 4 (3, 4) 0.926 1.179 (0.956–1.402) –5.984 <.001 <.001 .822 MPD (central) 5 (4,5) 0.938 3 (2.25, 4) 0.963 1.453 (1.167–1.739) –5.938 <.001 <.001 .816 MPD (distal) 4 (4,4) 0.969 3 (2, 3) 0.917 1.359 (1.050–1.667) –5.927 <.001 <.001 .814 Data are presented as median (Q1, Q3); n = 53. BI, Background inhibition; CD, cystic duct; CHD, common hepatic bile duct; DCBD, distal common bile duct; LHD, left hepatic bile duct; LIBD, left interlobular bile duct; LISBD, left intersegmental bile duct; M, median; MPD, main pancreatic duct; PCBD, proximal common bile duct; Q1, first quartile; Q3, third quartile; QOI, quality of the overall image; r , effect sizes; RHD, right hepatic bile duct; RIBD, right interlobular bile duct; RISBD, right intersegmental bile duct; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography. Table 5 Changes in qualitative image scores using the iMSDE technique ( n = 53) Site Improved (increased score): n (%) No change: n (%) Degraded (decreased score): n (%) QOI 47 (88.68) 4 (7.55) 2 (3.77) BI 45 (84.91) 6 (11.32) 2 (3.77) PCBD 34 (64.15) 17 (32.08) 2 (3.77) DCBD 37 (69.81) 13 (24.53) 3 (5.66) CHD 33 (62.26) 18 (33.96) 2 (3.77) CD 32 (60.38) 18 (33.96) 3 (5.66) LHD (grade 1) 34 (64.15) 19 (35.85) 0 (0) LIBD (grade 2) 45 (84.91) 6 (11.32) 2 (3.77) LISBD (grade 3) 49 (92.45) 2 (3.77) 2 (3.77) RHD (grade 1) 38 (71.70) 13 (24.53) 2 (3.77) RIBD (grade 2) 46 (86.79%) 5 (9.43) 2 (3.77) RISBD (grade 3) 48 (90.57) 3 (5.66) 2 (3.77) MPD (proximal) 44 (83.02) 9 (16.98) 0 (0) MPD (central) 48 (90.57) 3 (5.66) 2 (3.77) MPD (distal) 45 (84.91) 8 (15.09) 0 (0) BI, Background inhibition; CD, cystic duct; CHD, common hepatic bile duct; DCBD, distal common bile duct; LHD, left hepatic bile duct; LIBD, left interlobular bile duct; LISBD, left intersegmental bile duct; MPD, main pancreatic duct; PCBD, proximal common bile duct; QOI, quality of the overall image; RHD, right hepatic bile duct; RIBD, right interlobular bile duct; RISBD, right intersegmental bile duct; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography. Notably, in a small subset of cases ( n = 6, 11.32%), the overall image quality or ductal visualization did not improve or was slightly degraded with RT-3D TSE iMSDE MRCP compared with the conventional sequence. Most of these cases were associated with pronounced respiratory motion, markedly dilated biliary ducts, or severe susceptibility artifacts near the hepatic hilum or duodenum. Representative examples of such cases are depicted in Figs. 4 and 5 , illustrating the potential limitations of the iMSDE technique under these conditions. For qualitative analysis, all improvements in Likert scores were statistically significant ( p < .05), with large effect sizes ( r = 0.6410.837). The 95% CIs for paired differences further confirmed the consistent advantages of RT-3D TSE iMSDE MRCP over conventional MRCP. Quantitative Image Evaluation Quantitative analysis demonstrated that the SNR, CR, and CNR values obtained with the RT-3D TSE iMSDE MRCP sequence were significantly higher than those of the conventional RT-3D TSE MRCP sequence (all p < .05), indicating improved image contrast and clarity. For quantitative parameters, the mean paired differences (95% CIs) were as follows: CNR, 9.845 (95% CI: 8.262–11.428); SNR, 6.743 (95% CI: 5.619–7.868); and CR, 0.451 (95% CI: 0.354–0.548). All comparisons remained statistically significant after Bonferroni correction (adjusted p < .05) (Fig. 6 and Table 6 ). Shapiro–Wilk tests confirmed non-normal distributions for these parameters ( p < .05). Table 6 Comparison of CNR, SNR, and CR between RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP Method Number of cases CNR SNR CR RT-3D TSE iMSDE MRCP 53 29.47 (22.40, 41.22) 22.77 (17.42, 31.72) 0.95 (0.92, 0.96) RT-3D TSE MRCP 53 19.95 (13.62, 29.43) 16.39 (11.25, 24.93) 0.91 (0.87, 0.93) difference 95% CI 9.845 (8.262–11.428) 6.743 (5.619–7.868) 0.451 (0.354–0.548) r 0.870 0.870 0.870 p value .00 * .00 * .00 * p adjust .00* .00* .00* CNR, Contrast-to-noise ratio; CR, contrast ratio; SNR, signal-to-noise ratio; r , effect sizes; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography. * p .05) (Table 7 ). Table 7 Baseline characteristics and correlations between single factors and subjective image quality scores Feature RT-3D TSE iMSDE MRCP RT-3D TSE MRCP Kendall's tau-b1/ Z p 1 value Kendall's tau-b2/ Z p 2 value Age (year) –0.057 .616 –0.116 .296 Sex (male/female) –1.693 .091 –0.526 .599 BMI (kg/m 2 ) 0.086 .446 0.111 .313 Kendall's tau-b1 and p 1 values represent correlations between the single factors and overall image quality scores for RT-3D TSE iMSDE MRCP sequences. Kendall's tau-b2 and p 2 values represent correlations between single factors and overall image quality scores for RT-3D TSE MRCP sequences. BMI, Body mass index; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography. Discussion This study demonstrated that RT-3D TSE iMSDE MRCP remarkably outperformed conventional RT-3D TSE MRCP across multiple qualitative and quantitative metrics, including overall image quality, background signal suppression, and ductal structure delineation. Notably, visualization rates for second- and third-order bile ducts exceeded 90% with the iMSDE sequence, highlighting its superior diagnostic performance. These improvements are largely attributable to the technique’s ability to effectively suppress both turbulent and slow-flowing blood signals. Considering the close anatomical relationship between intrahepatic bile ducts and hepatic vasculature, high-intensity vascular signals often obscure ductal visualization on conventional MRCP. In this study, the iMSDE module was implemented using 2 adiabatic refocusing pulses, a TE prep of 200 milliseconds, and velocity encoding ( V enc ) set to 0 in the Right-Left (RL), Anterior-Posterior (AP), and Head-Feet (FH) directions. In contrast, the original MSDE technique employs a single refocusing pulse. The additional refocusing pulse and extra gradient lobes in iMSDE improve SNR and enhance robustness of flow suppression, thereby enabling more effective background suppression and clearer duct visualization [ 15 ]. Quantitative analysis further revealed that RT-3D TSE iMSDE MRCP achieved substantially higher CNR, CR, and SNR values than the conventional sequence. Lower receiver bandwidth and longer acquisition time of the iMSDE sequence inherently contribute to increased SNR and CNR. Thus, the observed quantitative improvements reflect a combined effect of sequence parameter selection and the iMSDE preparation module. However, reduced bandwidth may increase the echo spacing, potentially leading to motion-related artifacts [ 16 ]. The implementation of motion-sensitive gradient technology in iMSDE can mitigate or prevent the occurrence of these artifacts, thereby facilitating more accurate assessment of anatomic structures and pathologic alterations within the pancreatobiliary system. These findings are consistent with those reported by De et al. [ 17 ], who demonstrated that iMSDE improves tissue contrast, reduces vascular ghosting, and enhances suppression of both arterial and venous signals. Our subgroup analysis revealed that the image quality improvements provided by iMSDE were independent of patient age and BMI. This robustness highlights its clinical applicability across diverse patient populations. Although RT-3D TSE iMSDE MRCP substantially improved the overall image quality and ductal conspicuity in most cases, a few exceptions were observed. In patients with poor respiratory control or marked susceptibility effects caused by iron deposition, iMSDE occasionally led to excessive signal attenuation or incomplete background suppression. Moreover, in markedly dilated bile ducts, velocity-sensitive gradients of iMSDE may reduce intraluminal signal intensity, resulting in unchanged or slightly degraded image quality. These findings indicate that the effectiveness of iMSDE may vary depending on respiratory motion, magnetic field homogeneity, and ductal flow characteristics. Further optimization of sequence parameters and adaptive tuning of iMSDE settings may help address these limitations. In cases of cholecystolithiasis and cholecystitis, RT-3D TSE iMSDE MRCP improved visualization of the cystic duct and its junction with the common hepatic duct. This benefit can be attributed to bile concentration and intraluminal hemorrhage associated with biliary disease, both of which shorten the T2 relaxation time of bile [ 18 ]. Conventional RT-3D TSE MRCP sequences typically use very long echo times (TEs; up to 600 milliseconds), leading to rapid signal loss in concentrated bile and poor visualization of gallbladder-related structures [ 19 ]. Previous studies have reported that concentrated bile remains visible at shorter TEs (286 milliseconds), supporting the clinical value of this approach for preoperative identification of cystic duct variants and reducing the risk of biliary injury [ 20 ]. GraSE-based MRCP can achieve a favorable resolution–SNR trade-off through appropriate parameter optimization. Its shorter echo time and inherent background suppression may help mitigate signal loss associated with concentrated bile, and GraSE remains a widely available and effective MRCP technique in clinical practice. However, GraSE relies on long echo trains, which are susceptible to T2 decay–related blurring and spatially variable background suppression, particularly in complex biliary environments. In addition, performance characteristics may vary across vendors and system configurations, and residual blurring remains a recognized limitation of the technique [ 21 ]. In contrast, the proposed iMSDE-based MRCP incorporates a motion-sensitized preparation module that introduces an additional degree of freedom beyond conventional T2-weighting. This enables more robust suppression of unwanted background signals while preserving biliary duct continuity. As a result, iMSDE provides a complementary approach in scenarios where vascular or motion-related signal contamination limits conventional MRCP techniques [ 22 ]. Furthermore, in 2 patients with irregular respiratory patterns, the iMSDE sequence provided clearer visualization of the biliary and pancreatic ducts than the conventional MRCP sequence, which was prone to ghosting and blurring artifacts. This improvement is likely related to the shorter echo train length and reduced shot duration of the iMSDE sequence (80 vs 100; 571 milliseconds vs 644 milliseconds, respectively), reducing motion sensitivity [ 23 ]. These findings are consistent with those of Chen et al. [ 24 ], who demonstrated the robustness of iMSDE against motion artifacts. Notably, despite a modest increase in the acquisition time (153 seconds vs 126 seconds), the iMSDE sequence achieved substantial improvements in image quality, outperforming traditional black-blood techniques that often compromise efficiency [ 25 ]. Although this study was performed on a 3.0-T Philips system, the iMSDE preparation itself is vendor-independent and theoretically applicable across scanners and field strengths. Previous studies have demonstrated the feasibility of MSDE-prepared MRCP at 1.5 T using optimized V enc and TE settings to balance SNR and vascular suppression [ 5 ]. Future multicenter studies across diverse vendors and field strengths will be valuable for confirming reproducibility and generalizability. Recent advances in MRCP acquisition have introduced various acceleration and reconstruction strategies such as parallel imaging, compressed sensing, and deep learning–based reconstruction. These approaches primarily improve sampling efficiency and SNR while reducing scan time [ 26 ]. However, these techniques primarily mitigate undersampling-related artifacts and do not directly address motion- or flow-related signal contamination. In contrast, the iMSDE preparation module targets intravoxel incoherent motion by dephasing spins from flowing blood, thereby suppressing vascular signals and improving duct-to-background contrast [ 27 ]. Notably, iMSDE is compatible with acceleration frameworks and can be integrated with compressed sensing or deep learning–based reconstruction to achieve both motion robustness and time efficiency. Future studies combining iMSDE with these advanced reconstruction methods may further enhance MRCP image quality and workflow efficiency. In summary, compared with GraSE-based MRCP, the iMSDE approach mitigates key limitations such as T2 decay–related blurring, variable background suppression, and reduced visualization in the presence of concentrated bile. It offers a complementary and clinically feasible strategy for robust MRCP imaging. These advantages underscore both the technical rationale and clinical value of iMSDE as a reliable method to improve diagnostic performance in challenging clinical imaging scenarios. Conclusions The RT-3D TSE iMSDE MRCP technique remarkably improves visualization of subtle ductal strictures and pancreatobiliary maljunctions by effectively suppressing confounding signals from portal venous flow and respiratory motion. By enhancing SNR, CR, and CNR, this method enables more reliable quantitative assessment of ductal anatomy and pathology. Improved delineation of pancreatobiliary structures may provide added clinical value in the evaluation of complex biliary diseases and support diagnostic confidence and clinical decision-making. Abbreviations BB, black blood BI, background inhibition CD, cystic duct CHD, common hepatic bile duct CNR, contrast-to-noise ratio CR, contrast ratio DCBD, distal common bile duct LHD, left hepatic bile duct LIBD, left interlobular bile duct LISBD, left intersegmental bile duct M, median MPD, main pancreatic duct MSDE, motion-sensitized driven equilibrium No., number PCBD, proximal common bile duct Q1, first quartile Q3, third quartile QOI, quality of the overall image r , effect sizes RHD, right hepatic bile duct RIBD, right interlobular bile duct RISBD, right intersegmental bile duct RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography SD, standard deviation SNR, signal-to-noise ratio Declarations Ethics approval and consent to participate This prospective single-center study in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Dongguan Tungwah Hospital (approval number: DHKY-2025-035-01). Written informed consent was obtained from all participants prior to enrollment. Consent for publication Written informed consent for publication of anonymized images and clinical data was obtained from all participants. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions XTX and CXD contributed to writing the original draft, data collection, data analysis, and visualization. LX and ZWY performed MRI scanning and data collection. WQY contributed to data analysis, conceptualization, and methodology. XYZ and LYT performed statistical analysis. LZY and ZGM contributed to conceptualization, supervision, project administration, and manuscript review and editing. All authors read and approved the final manuscript. Acknowledgments Not applicable. References Dar FS, Abbas Z, Ahmed I, et al. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol. 2024;30(9):1018-42. https://doi:10.3748/wjg.v30.i9.1018 Kidanemariam S, Gu J, Yoon JH, Challapalli JV, Fruh V, Sax AJ. Cholangiocarcinoma: Epidemiology and Imaging-Based Review. R I Med J (2013). 2024;107(5):43-8. Published 2024 May 2. https://pubmed.ncbi.nlm.nih.gov/38687269/ Mahalingam N, Ralli GP, Trout AT, Dillman JR. Comparison of quantitative 3D magnetic resonance cholangiography measurements obtained using three different image acquisition methods. Abdom Radiol (NY). 2022;47(1):196-208. https://doi:10.1007/s00261-021-03330-2 Itani M, Lalwani N, Anderson MA, Arif-Tiwari H, Paspulati RM, Shetty AS. Magnetic resonance cholangiopancreatography: pitfalls in interpretation. Abdom Radiol (NY). 2023;48(1):91-105. https://doi:10.1007/s00261-021-03323-1 Nakayama T, Nishie A, Yoshiura T, et al. Balanced MR cholangiopancreatography with motion-sensitized driven-equilibrium (MSDE) preparation: Feasibility and optimization of imaging parameters. Magn Reson Imaging. 2015;33(10):1219-23. https://doi:10.1016/j.mri.2015.07.003 Nakayama T, Yoshiura T, Nishie A, et al. Balanced MR cholangiopancreatography with motion-sensitised driven-equilibrium (MSDE) preparation: feasibility of Gd-EOB-DTPA-enhanced biliary examination. Clin Radiol. 2016;71(12):1284-88. https://doi:10.1016/j.crad.2016.03.019 Meng ZN, Zhu XQ. Applications and research progress of motion-sensitized driven-equilibrium[J]. Chin J Magn Reson Imaging, 2021, 12(8): 121-24. https://doi:10.12015/issn.1674-8034.2021.08.029 Hammood ER, Shirani S, Sadri A, Bahri M, Dehghani S. The Role of Improved Motion-Sensitized Driven Equilibrium Blood Suppression and Fat Saturation on T2 Relaxation Time, Using GraSE Sequence in Cardiac Magnetic Resonance Imaging. J Magn Reson Imaging. 2024;60(2):662-72. https://doi:10.1002/jmri.29079 Choi JW, Han M, Hong JM, Lee JS, Kim SY, Kim SS. Feasibility of improved motion-sensitized driven-equilibrium (iMSDE) prepared 3D T1-weighted imaging in the diagnosis of vertebrobasilar artery dissection. J Neuroradiol. 2018;45(3):186-191. https://doi:10.1016/j.neurad.2017.11.006 Koori N, Kamekawa H, Naito T, et al. Carotid and aortic plaque imaging using 3D gradient-echo imaging and the three-point Dixon method with improved motion-sensitized driven-equilibrium (iMSDE). Magn Reson Imaging. 2024;111:202-9. https://doi:10.1016/j.mri.2024.03.036 Ning Z, Zhang N, Qiao H, et al. Free-breathing three-dimensional isotropic-resolution MR sequence for simultaneous vessel wall imaging of bilateral renal arteries and abdominal aorta: Feasibility and reproducibility. Med Phys. 2022;49(2):854-64. https://doi:10.1002/mp.15436 Chevallier O, Escande H, Ambarki K, et al. Single-Breath-Hold MRI-SPACE Cholangiopancreatography with Compressed Sensing versus Conventional Respiratory-Triggered MRI-SPACE Cholangiopancreatography at 3Tesla: Comparison of Image Quality and Diagnostic Confidence. Diagnostics (Basel). 2021;11(10):1886. Published 2021 Oct 13. https://doi:10.3390/diagnostics11101886 Jin D, Li X, Qian Y, et al. Modified respiratory-triggered SPACE sequences for magnetic resonance cholangiopancreatography. Eur J Radiol Open. 2024;12:100564. Published 2024 Apr 20. https://doi:10.1016/j.ejro.2024.100564 Shiraishi K, Nakaura T, Uetani H, et al. Deep learning-based reconstruction and 3D hybrid profile order technique for MRCP at 3T: evaluation of image quality and acquisition time. EurRadiol. 2023;33(11):7585-94. https://doi:10.1007/s00330-023-09703-z Nishihara T, Nakamura Y, Yoshizawa N, et al. Nature of the Intracellular-contrast-enhancing Fat-saturated T1-weighted Gradient-echo (ICE-TIGRE) Sequence: A Fat-suppressed T1-weighted Technique with Motion-sensitised Driven-equilibrium for Improved Contrast Enhancement in Liver Imaging. Magn Reson Med Sci. 2025;24(1):133-43. https://doi:10.2463/mrms.tn.2023-0104 Dai YF, Zhang M, Zhang M, et al. Effect of bandwidth on abdominal imaging quality in 3.0 T MR. J Med Imaging,2020,30(03):441-3+452. De Paepe KN, Higgins DM, Ball I, Morgan VA, Barton DP, deSouza NM. Visualizing the autonomic and somatic innervation of the female pelvis with 3D MR neurography: a feasibility study. Acta Radiol. 2020;61(12):1668-76. https://doi:10.1177/0284185120909337 Xu YCH, Xu ZhD, Zhang JH, et al. The application of three-dimensional breath-hold gradient and spin-echo sequence in the MR cholangiopancreatography. Chin J Radiol, January, 2021, 55(1): 64-9. https://doi:10.3760/cma.j.cn112149-20200215-00160 Itatani R, Namimoto T, Takaoka H, et al. Clinical impact of 3-dimensional balanced turbo-field-echo magnetic resonance cholangiopancreatography at 3 T: prospective intraindividual comparison with 3-dimensional turbo-spin-echo magnetic resonance cholangiopancreatography. J Comput Assist Tomogr. 2015;39(1):19-24. https://doi:10.1097/RCT.0000000000000163 Ihara R, Oura D, Ichimura W, Kobayashi K. Magnetic resonance cholangiopancreatography using T2 preparation pulse: quantitative and qualitative analyses. Acta Radiol. 2023;64(12):2969-76. https://doi:10.1177/02841851231203055 Morimoto-Ishikawa D, Hyodo T, Takenaka M, et al. Comparison between gradient and spin-echo (GRASE) and compressed sensing sequences for single breath-hold three-dimensional magnetic resonance cholangiopancreatography in patients with T1 hyperintense bile. Eur J Radiol. 2022;150:110279. https://doi:10.1016/j.ejrad.2022.110279 Itatani R, Namimoto T, Kusunoki S, Mizuguchi T, Ohtsuka S, Yamashita Y. Usefulness of the Short-Echo Time Cube Sequence at 3-T Magnetic Resonance Cholangiopancreatography: Prospective Comparison With the Conventional 3-Dimensional Fast Spin-Echo Sequence. J Comput Assist Tomogr. 2016;40(4):551-6. https://doi:10.1097/RCT.0000000000000401 Isoda H, Maetani Y, Kataoka M, et al. Contrast behavior and image quality of magnetic resonance cholangiopancreatography imaging using variable echo times at 3.0 T. Clin Imaging. 2008;32(5):362-6. https://doi:10.1016/j.clinimag.2008.02.024 Jun C, Shuhua L, Xue Z, Chunqing B, Mingli H. Application of motion-sensitized driven equilibrium based black blood 3D TSE sequence in the detection of brain metastases. Magn Reson Imaging. 2022;93:145-148. https://doi:10.1016/j.mri.2022.08.010 Yang Q. Current situation and prospect of intracranial vessel wall MRI[J]. Chin J Radiol, 2024;58(11):1146-51. https://doi:10.3760/cma.j.cn112149-20240731-00448 Wu X, Yue X, Peng P, et al. Accelerated 3D whole-heart non-contrast-enhanced mDIXON coronary MR angiography using deep learning-constrained compressed sensing reconstruction. Insights Imaging. 2024;15(1):224. Published 2024 Sep 19. https://doi:10.1186/s13244-024-01797-3 Cervantes B, Kirschke JS, Klupp E, et al. Orthogonally combined motion- and diffusion-sensitized driven equilibrium (OC-MDSDE) preparation for vessel signal suppression in 3D turbo spin echo imaging of peripheral nerves in the extremities. Magn Reson Med . 2018;79(1):407-15. https://doi:10.1002/mrm.26660 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8715485","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591907592,"identity":"71879816-4fff-4703-90b6-acedd1d221bb","order_by":0,"name":"Tuanxin Xu","email":"","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tuanxin","middleName":"","lastName":"Xu","suffix":""},{"id":591907593,"identity":"2e5d5efd-d892-4956-b157-26471dce90c1","order_by":1,"name":"Xudong Chen","email":"","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xudong","middleName":"","lastName":"Chen","suffix":""},{"id":591907594,"identity":"bb9fdaae-73fe-4628-ad11-61e301cd4ca7","order_by":2,"name":"Wenyan Zhong Zhong","email":"","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wenyan","middleName":"Zhong","lastName":"Zhong","suffix":""},{"id":591907595,"identity":"dbd9f7ef-5fef-44fa-97c1-4aa4471ebf35","order_by":3,"name":"Xiao Liu","email":"","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Liu","suffix":""},{"id":591907596,"identity":"8149ee44-f8f5-40e7-8246-63e3680e4174","order_by":4,"name":"Qingyun Wang","email":"","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qingyun","middleName":"","lastName":"Wang","suffix":""},{"id":591907597,"identity":"8223bc57-82f0-4227-b7d1-cda330fad1b7","order_by":5,"name":"Yongzhou Xu","email":"","orcid":"","institution":"Philips Healthcare","correspondingAuthor":false,"prefix":"","firstName":"Yongzhou","middleName":"","lastName":"Xu","suffix":""},{"id":591907598,"identity":"e210cc93-e662-4765-b878-61e3200b7fd3","order_by":6,"name":"Yuting Liao","email":"","orcid":"","institution":"Philips Healthcare","correspondingAuthor":false,"prefix":"","firstName":"Yuting","middleName":"","lastName":"Liao","suffix":""},{"id":591907599,"identity":"c4bc5a19-4228-4678-a582-a21b2c382b30","order_by":7,"name":"Zhaoyong Li","email":"","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhaoyong","middleName":"","lastName":"Li","suffix":""},{"id":591907600,"identity":"8afc4a4e-6877-456f-b975-c9b3df2b189f","order_by":8,"name":"Gangming Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYFACxgYGhop/9fwMDAYwLjFazhxIkGwgXgtIWduBBIMDxGrhn3a47eHXtjt5xucXb93Mw2Aju+EA87MH+LRI3E5sN5Y596zY7Mazsts8DGnGGw6wmRvgteZ2Ypu0RBkz47YbZ8yAWg4nbjjAwyaBT4c8WAsbM+PmGWAt/wlrMQBqkfzQBjScvwek5QBhLYYgWxjOpBlL3GAruznHINl45mE2M7xa5G6nP5P8UWEjx99/eNuNNxV2sn3Hm5/h1QICzDwgUiKBAZIAmAmpBwLGHyCS/wARSkfBKBgFo2BEAgCD+VI+0X4eZgAAAABJRU5ErkJggg==","orcid":"","institution":"Dongguan Tungwah Hospital","correspondingAuthor":true,"prefix":"","firstName":"Gangming","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2026-01-28 02:39:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8715485/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8715485/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103165659,"identity":"03d2b2b0-7984-4f39-8ad6-904ddad1688c","added_by":"auto","created_at":"2026-02-22 12:33:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15586906,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of patient inclusion.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRT-3D TSE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8715485/v1/8e37529c496964f40154866b.png"},{"id":103165664,"identity":"b486b60b-8f75-4e0f-b6fa-ffbc7e932646","added_by":"auto","created_at":"2026-02-22 12:34:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21530087,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of MRCP sequences in a 44-year-old man diagnosed with choledocholithiasis and cholangitis.\u003c/strong\u003e(a andb) Maximum intensity projection images obtained from the 2MRCP sequences. (a) RT-3D TSE MRCP sequence revealing prominent hepatic vascular signal (white arrow), interfering with visualization of the intrahepatic bile ducts. (b) RT-3D TSE iMSDE MRCP sequence demonstrating effective suppression of hepatic vascular signals, allowing clear delineation of second- and third-order intrahepatic ducts (red arrow) and improved visualization of choledocholithiasis within the common bile duct (yellow arrow). RT-3D TSE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combinedwith improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8715485/v1/a451f8b70842d542b95b7f0d.png"},{"id":103165660,"identity":"f5fb4b96-dfe1-41aa-87cb-7ed6f7bd833c","added_by":"auto","created_at":"2026-02-22 12:34:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20722357,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImproved duct and stone visualization using RT-3D TSE iMSDE MRCP.\u003c/strong\u003e A 69-year-old woman presented with dilation of the intrahepatic and extrahepatic bile ducts and common bile ducts, accompanied by multiple stones in the biliary system and cystic duct. (a andc) Maximum intensity projection images from the 2 MRCP sequences. (a) The conventional RT-3D TSE MRCP sequence displaying severe ghosting artifacts (white arrow) caused by irregular respiratory motion, which impair visualization of the biliary ducts. (c) The RT-3D TSE iMSDE MRCP sequence demonstrating effective suppression of motion artifacts, with clear depiction of the dilated intrahepatic and extrahepatic bile ducts, biliary stones, and improved visualization of the pancreatic duct (yellow arrow). (b andd) Corresponding coronal source images from the 2 sequences. (b) Conventional RT-3D TSE MRCP sequence demonstrating poor visualization of biliary stones. (d) RT-3D TSE iMSDE MRCP sequence depicting clear delineation of the size and margins of the stones (open arrow). RT-3D TSE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combinedwith improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8715485/v1/f612fd79a674fe8a858625de.png"},{"id":103165662,"identity":"47fb7532-bd71-418c-92c8-54e24a620689","added_by":"auto","created_at":"2026-02-22 12:34:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21636859,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLimited duct visualization with RT-3D TSE iMSDE MRCP in cirrhosis. \u003c/strong\u003eA 59-year-old man presented with a history of liver cirrhosis, splenomegaly, portal hypertension, rupture of esophageal and gastric varices, cholecystitis, and gallbladder stones. The RT-3D TSE MRCP sequence (a) (white arrow) successfully revealing the left hepatic duct, whereas the RT-3D TSE iMSDE MRCP sequence (b) (white arrow) failed delineating them.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8715485/v1/64f42064b05798996ac61b28.png"},{"id":103165663,"identity":"08d66dbb-ce0c-48b7-9d7f-e356156375fb","added_by":"auto","created_at":"2026-02-22 12:34:00","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":23226530,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparable pancreatobiliary duct visualization between MRCP sequences. \u003c/strong\u003eA 52-year-old woman presented with common bile duct stones accompanied by cholangitis, as well as dilatation of the intrahepatic and extrahepatic bile ducts and the common bile duct, along with multiple stones. The RT-3D TSE MRCP sequence (a) and the RT-3D TSE iMSDE MRCP sequence (b) demonstrating a consistent depiction of the pancreatobiliary ducts. RT-3D TSE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence with improved motion-sensitized driven equilibrium.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-8715485/v1/afb530e22a85e38e6a488645.png"},{"id":103505383,"identity":"3c2be297-9bb8-4875-9c65-62d6c21f112d","added_by":"auto","created_at":"2026-02-26 13:30:32","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":18025923,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eResults of the quantitative image analysis.\u003c/strong\u003e CNR, Contrast-to-noise ratio; CR, contrast ratio; RT-3D TSE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography; SNR, signal-to-noise ratio.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8715485/v1/b777e1b1bb8fc2af15bfed1d.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Utility of Respiratory-Triggered 3D Turbo Spin-Echo Sequence with Improved Motion-Sensitized Driven Equilibrium for Magnetic Resonance Cholangiopancreatography: A Prospective Comparative Study","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; Conventional RT-3D MRCP suffers from vascular contamination artifacts.\u003c/p\u003e\u003cp\u003e\u0026bull; TSE iMSDE improves image quality and duct visualization.\u003c/p\u003e\u003cp\u003e\u0026bull; iMSDE provides higher SNR, contrast, and contrast-to-noise ratios.\u003c/p\u003e\u003cp\u003e\u0026bull; Second- and third-order ducts demonstrate visualization in patients.\u003c/p\u003e\u003cp\u003e\u0026bull; Image quality improvements are robust across age and sex.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003ePancreatobiliary diseases, including cholangiolithiasis, cholangitis, pancreatic adenocarcinoma, cholangiocarcinoma, and congenital biliary tract malformations, encompass a spectrum of conditions that markedly affect the pancreas and biliary system. These disorders pose substantial diagnostic challenges and can severely impact patient outcomes and quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Accurate visualization of the biliary tract and its pathologic alterations is therefore essential for early diagnosis, individualized treatment strategies, and prognostic evaluation. A clear understanding of the patient\u0026rsquo;s condition enables timely intervention, leading to improved therapeutic efficacy and reduced disease-related morbidity.\u003c/p\u003e \u003cp\u003eRespiratory-triggered 3-dimensional (3D) turbo spin-echo magnetic resonance cholangiopancreatography (RT-3D TSE MRCP) exploits the long T2 relaxation time of bile to provide high-resolution, noninvasive imaging of the pancreatobiliary system. By employing heavily T2-weighted fast spin-echo sequences with fat suppression, MRCP enables visualization of ductal structures without the need for contrast agents and allows multidirectional and multiplanar 3D reconstruction. Owing to its safety and diagnostic capability, this technique has been widely adopted for the evaluation of pancreatobiliary diseases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these advantages, the effectiveness of conventional MRCP is limited by overlapping high-intensity signals from the portal venous system. Turbulent blood flow, vascular bifurcations, and tortuous ductal anatomy can generate vascular artifacts, particularly on maximum intensity projection (MIP) images, thereby reducing ductal conspicuity and diagnostic confidence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe improved motion-sensitized driven equilibrium (iMSDE) technique is a black-blood imaging method developed to suppress vascular signals. It uses spatially nonselective radiofrequency pulses combined with motion-sensitizing gradients to induce phase dispersion in moving protons. Because of velocity variations in blood flow, the resulting phase differences cannot be fully refocused, leading to effective signal cancellation that is largely independent of flow velocity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, iMSDE incorporates an inversion recovery pulse to counteract motion-induced artifacts by reversing tissue magnetization, thereby mitigating motion-induced artifacts and enhancing tissue contrast [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This technique has demonstrated effective suppression of both slow and turbulent blood flow, improving image quality in motion-prone regions such as the heart and vasculature [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough gradient- and spin-echo (GraSE) MRCP offers advantages such as shorter acquisition times and reduced respiratory dependence, it remains susceptible to T2 decay\u0026ndash;related blurring, spatially heterogeneous background suppression, and reduced ductal visualization in the presence of highly concentrated bile. These limitations underscore the need for complementary imaging strategies. In contrast, the iMSDE-prepared RT-3D TSE MRCP technique suppresses background vascular signals prior to image readout, resulting in a more robust duct-to-background contrast and a higher spatial resolution, thereby addressing specific shortcomings of GraSE in clinical pancreatobiliary imaging [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, this study aimed to compare the clinical feasibility and image quality of RT-3D TSE iMSDE MRCP with conventional RT-3D TSE MRCP for pancreatobiliary imaging. We hypothesized that this novel RT-3D TSE iMSDE MRCP technique can substantially enhance diagnostic performance by improving ductal delineation and reducing image artifacts, thereby providing a more reliable imaging tool for the evaluation of pancreatobiliary diseases. Because the approach can be implemented on standard MR systems without additional scan sequences, it may support broader clinical adoption, particularly in patients with complex biliary anatomy or compromised respiratory control.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Population\u003c/p\u003e \u003cp\u003e This prospective single-center study in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Dongguan Tungwah Hospital, and all participants provided written informed consent. This prospective study enrolled 56 consecutive patients who underwent MRCP between September 2024 and February 2025. The inclusion criteria were as follows: (1) no contraindications to MRI and (2) complete MRI datasets with diagnostic image quality. The exclusion criteria were as follows: (1) a history of abdominal surgery, (2) biliary stent placement, and (3) massive ascites or severe intestinal gas\u0026ndash;related artifacts.\u003c/p\u003e \u003cp\u003eMRCP was performed in patients with suspected biliary or pancreatic disease based on clinical manifestations, medical history, physical examination, or abdominal ultrasound findings.\u003c/p\u003e \u003cp\u003eFor patients who underwent surgery, intraoperative findings served as the reference standard. For nonsurgical patients, final diagnoses were determined by multimodal imaging consensus, which included at least 1 additional imaging modality (ultrasound or CT) performed within a standardized 7-day interval after MRI.\u003c/p\u003e \u003cp\u003eMRI Protocols\u003c/p\u003e \u003cp\u003eAll participants fasted (including abstention from water) for at least 6 hours before MRCP. MRI examinations were performed using a 3.0-T MRI system (Ingenia Elition X; Philips Healthcare, Best, The Netherlands) equipped with a 32-channel digital body coil. Patients were scanned in the supine, head-first position with their arms placed alongside the body. The imaging protocol included: (1) an axial balanced turbo field echo (BTFE) sequence, (2) RT-3D TSE iMSDE MRCP, and (3) conventional RT-3D TSE MRCP. The axial BTFE sequence was used for anatomical localization and complementary diagnostic assessment of the upper abdomen and was not used as a reference or comparator for the RT-3D TSE MRCP or RT-3D TSE iMSDE MRCP sequences. All 3D sequences were acquired in the coronal plane. Respiratory triggering was performed using a prospective respiratory gating approach. The physiologic window was set to 10 seconds, within which the number of complete respiratory cycles was counted to determine the trigger delay. Identical respiratory-triggering parameters were applied to both MRCP sequences to ensure consistency in image acquisition. Detailed scanning parameters are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScanning parameters for RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP performed on 3.0-T MRI system\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRT-3D TSE iMSDE MRCP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRT-3D TSE MRCP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepetition time (ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEcho time (ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEcho space (ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShot duration (ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e644\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlice thickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLayer spacing (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcquired voxel size (mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99 \u0026sdot; 1 \u0026sdot; 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99 \u0026sdot; 1 \u0026sdot; 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReconstructed voxel size (mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.4 \u0026sdot; 0.4 \u0026sdot; 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4 \u0026sdot; 0.4 \u0026sdot; 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eField of view (mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e350 \u0026sdot; 350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e350 \u0026sdot; 350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScan matrix\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e352 \u0026sdot; 350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e352 \u0026sdot; 350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlip angle (degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of coronal slices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompressed sensing factor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBandwidth (Hz/pixel)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e297.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e390.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of excitations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurbo factor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrive balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBB pulse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMSDE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcquisition time (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eBB, Black-blood; MSDE, motion-sensitized driven equilibrium; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eImage Quality Analysis\u003c/p\u003e \u003cp\u003eRT-3D TSE iMSDE MRCP and RT-3D TSE MRCP images were transferred to a Philips Nebula workstation (Philips Healthcare) for MIP reconstruction. Cropping of the region of interest was performed collaboratively by 2 senior MRI technicians according to a standardized protocol. The region was defined with the upper limit at the superior margin of the liver, the lower limit at the pancreatobiliary duct junction, the left limit at the tail of the pancreatic duct, and the right limit at the right edge of the liver. High-signal regions of the gastrointestinal tract were also included. Both technicians underwent uniform training before image processing to ensure consistency and reproducibility across all cases, thereby minimizing potential bias between the 2 methods. The reconstructed images were systematically rotated along the sagittal, coronal, and axial planes; reformatted into anteroposterior, lateral, and craniocaudal orientations; and saved for subsequent evaluation.\u003c/p\u003e \u003cp\u003eQualitative Image Evaluation and Diagnostic Confidence\u003c/p\u003e \u003cp\u003eIn this study, 2 abdominal radiologists with 15 and 8 years of experience in hepatobiliary MRI, respectively, independently evaluated image quality. To minimize recall and expectation bias, image sets from the 2 sequences were reviewed in separate reading sessions at least 2 weeks apart. The order of image presentation was randomized, and both readers were blinded to patient information, sequence type, and clinical data. Image evaluation was performed on a standard Picture Archiving and Communication System workstation, which allowed adjustment of magnification, window width, and window level settings. Readers were also permitted to reconstruct coronal 3D MRCP images into any plane to optimize duct visualization.\u003c/p\u003e \u003cp\u003eA validated 5-point modified Likert scale was used to assess (1) global image quality, (2) background suppression efficiency, and (3) the conspicuity of biliary and pancreatic duct segments at all anatomic levels [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Discrepancies in scores were resolved through consensus discussions. Based on the established Likert scoring criteria, paired imaging sequences from the same patient were categorized as \u0026ldquo;increased\u0026rdquo; if scores improved with the iMSDE sequence, \u0026ldquo;no change\u0026rdquo; if scores were identical, and \u0026ldquo;degraded\u0026rdquo; if scores declined.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLikert scoring criteria for overall image quality and background assessment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall image quality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBackground suppression effect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisplay of bile duct and pancreatic duct at all levels\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-diagnostic image quality (undiagnosed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong background signal, preventing image evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStructure not visible\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor image quality (below average)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong background signal, hindering image evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStructure is barely visible\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate image quality (average water level)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBackground signal is obvious, which affects image observation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStructure is partially visible, but with a blurred boundary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood image quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeak background signal, does not affect image observation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStructure is almost completely visible, with clear boundaries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcellent image quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent background suppression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll structures are fully visible, with adequate detail\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eQuantitative Image Evaluation\u003c/p\u003e \u003cp\u003eSignal-to-noise ratio (SNR), contrast ratio (CR), and contrast-to-noise ratio (CNR) were calculated to provide complementary quantitative assessments of image quality. SNR was used to characterize background noise levels, CR to evaluate signal intensity contrast between structures, and CNR to reflect the combined effects of signal and noise. Because CNR directly reflects diagnostic contrast, it was considered the primary quantitative metric for image comparison. SNR was reported as a supplementary descriptor of overall image quality and noise behavior rather than as a direct indicator of diagnostic performance. The SNR, CR, and CNR between the common bile duct (CBD) and surrounding tissues were calculated using the following formulas [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]:\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSNR \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\:\\frac{{SI}_{CBD}}{{SD}_{CBD}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eCR \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\:\\frac{({SI}_{CBD}-{SI}_{tissue})}{({SI}_{CBD}+{SI}_{tissue})}\\)\u003c/span\u003e\u003c/span\u003e\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section4\"\u003e \u003ch2\u003eCNR \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:=\\frac{({SI}_{CBD}-{SI}_{tissue})}{\\sqrt{\\left(S{D}_{CBD}^{2}+S{D}_{tissue}^{2}\\right)/2}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/h2\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS Statistics version 25.0 (IBM Corp., NY, USA). The normality of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test. Normally distributed data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, whereas non-normally distributed data were reported as median (interquartile range). Interobserver agreement between the 2 radiologists was evaluated using the quadratic weighted Cohen\u0026rsquo;s kappa coefficient and interpreted as follows: poor (\u0026le;\u0026thinsp;0.40), moderate (0.41\u0026ndash;0.60), good (0.61\u0026ndash;0.80), and excellent (\u0026gt;\u0026thinsp;0.80). For qualitative (ordinal) data and quantitative parameters (SNR, CR, and CNR) from paired MRCP examinations, the Wilcoxon signed-rank test was applied. Bonferroni correction was used where appropriate to account for multiple comparisons. Besides \u003cem\u003eZ\u003c/em\u003e and \u003cem\u003ep\u003c/em\u003e values, paired differences with 95% confidence intervals (CIs) and effect sizes were calculated to estimate the magnitude and uncertainty of observed effects. Kendall's tau-b correlation analysis and the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test were used to evaluate the correlation between age, sex, body mass index (BMI), and subjective overall MRCP image quality scores in both groups. All statistical tests were 2-tailed, and a \u003cem\u003ep\u003c/em\u003e value \u0026lt;\u0026thinsp;.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eStudy Population\u003c/p\u003e \u003cp\u003eAmong the 56 eligible participants who met the inclusion criteria, 3 were excluded due to noncompliance with examination protocols, rendering 53 cases available for comprehensive clinical evaluation. As detailed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the 53 included cases comprised 44 patients with gallstones; 3 with dilatation of the common hepatic duct, CBD, and pancreatic duct; 2 with acute pancreatitis; 1 with tumor invasion of the right hepatic duct and common hepatic duct lumen; 1 with lower-end CBD obstruction; 1 with a pancreatic body mass; and 1 with ampullary lesions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic information of the included patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD/No. (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(35.85%)/34༈64.15%༉\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.73\u0026thinsp;\u0026plusmn;\u0026thinsp;14.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.53\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNo., Number; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eQualitative Image Evaluation\u003c/p\u003e \u003cp\u003eInterobserver agreement between the 2 radiologists demonstrated substantial to strong agreement, with kappa coefficients ranging from 0.842 to 0.969 (\u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05). The RT-3D TSE iMSDE MRCP protocol exhibited statistically significant improvements compared with the conventional RT-3D TSE MRCP sequence across all evaluated metrics, including overall image quality, background suppression, and subjective scores for individual anatomical structures (all \u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05) (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Shapiro\u0026ndash;Wilk tests (\u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05) depicted interobserver assessments using the Likert scoring criteria. As presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, the application of the iMSDE technique remarkably improved the visualization of all 3 grades of intrahepatic biliary ducts across paired MRCP examinations from the same patients, with visibility improvement rates ranging from 90% to 92%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQualitative image score comparison between RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRT-3D TSE iMSDE MRCP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRT-3D TSE MRCP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDifference\u003c/p\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e value\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e adjust\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubjective scoring (score)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKappa value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubjective scoring (score)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKappa value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQOI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.066 (0.877\u0026ndash;1.255)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;6.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.896 (0.729\u0026ndash;1.064)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.929\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.75, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.585 (0.430\u0026ndash;0.740)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDCBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.651 (0.477\u0026ndash;0.825)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.698 (0.512\u0026ndash;0.884)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.566 (0.387\u0026ndash;0.745)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;4.666\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLHD (grade 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.75,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3.5, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.896 (0.660\u0026ndash;1.132)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.723\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLIBD (grade 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.500 (1.198\u0026ndash;1.802)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.817\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.799\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLISBD (grade 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.387 (1.131\u0026ndash;1.643)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;6.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.837\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRHD\u003c/p\u003e \u003cp\u003e(grade 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.950\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.972 (0.737\u0026ndash;1.206)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.753\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIBD (grade 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.5, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.547 (1.246\u0026ndash;1.849)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRISBD (grade 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.396 (1.144\u0026ndash;1.649)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;6.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD (proximal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.179 (0.956\u0026ndash;1.402)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.984\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.822\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD (central)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.25, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.453 (1.167\u0026ndash;1.739)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.816\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD (distal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.359 (1.050\u0026ndash;1.667)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;5.927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eData are presented as median (Q1, Q3); \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53. BI, Background inhibition; CD, cystic duct; CHD, common hepatic bile duct; DCBD, distal common bile duct; LHD, left hepatic bile duct; LIBD, left interlobular bile duct; LISBD, left intersegmental bile duct; M, median; MPD, main pancreatic duct; PCBD, proximal common bile duct; Q1, first quartile; Q3, third quartile; QOI, quality of the overall image; \u003cem\u003er\u003c/em\u003e, effect sizes; RHD, right hepatic bile duct; RIBD, right interlobular bile duct; RISBD, right intersegmental bile duct; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in qualitative image scores using the iMSDE technique (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproved (increased score): \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo change: \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDegraded (decreased score): \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQOI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (88.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (7.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45 (84.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (11.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (64.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (32.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDCBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (69.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (24.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (62.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (33.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (60.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (33.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLHD (grade 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (64.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (35.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLIBD (grade 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45 (84.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (11.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLISBD (grade 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (92.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRHD (grade 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (71.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (24.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRIBD (grade 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (86.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (9.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRISBD (grade 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (90.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (5.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD (proximal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (83.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (16.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD (central)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (90.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (5.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD (distal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45 (84.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (15.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBI, Background inhibition; CD, cystic duct; CHD, common hepatic bile duct; DCBD, distal common bile duct; LHD, left hepatic bile duct; LIBD, left interlobular bile duct; LISBD, left intersegmental bile duct; MPD, main pancreatic duct; PCBD, proximal common bile duct; QOI, quality of the overall image; RHD, right hepatic bile duct; RIBD, right interlobular bile duct; RISBD, right intersegmental bile duct; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNotably, in a small subset of cases (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6, 11.32%), the overall image quality or ductal visualization did not improve or was slightly degraded with RT-3D TSE iMSDE MRCP compared with the conventional sequence. Most of these cases were associated with pronounced respiratory motion, markedly dilated biliary ducts, or severe susceptibility artifacts near the hepatic hilum or duodenum. Representative examples of such cases are depicted in Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, illustrating the potential limitations of the iMSDE technique under these conditions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor qualitative analysis, all improvements in Likert scores were statistically significant (\u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05), with large effect sizes (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.6410.837). The 95% CIs for paired differences further confirmed the consistent advantages of RT-3D TSE iMSDE MRCP over conventional MRCP.\u003c/p\u003e \u003cp\u003eQuantitative Image Evaluation\u003c/p\u003e \u003cp\u003eQuantitative analysis demonstrated that the SNR, CR, and CNR values obtained with the RT-3D TSE iMSDE MRCP sequence were significantly higher than those of the conventional RT-3D TSE MRCP sequence (all \u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05), indicating improved image contrast and clarity. For quantitative parameters, the mean paired differences (95% CIs) were as follows: CNR, 9.845 (95% CI: 8.262\u0026ndash;11.428); SNR, 6.743 (95% CI: 5.619\u0026ndash;7.868); and CR, 0.451 (95% CI: 0.354\u0026ndash;0.548). All comparisons remained statistically significant after Bonferroni correction (adjusted \u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Shapiro\u0026ndash;Wilk tests confirmed non-normal distributions for these parameters (\u003cem\u003ep\u003c/em\u003e \u0026lt;\u0026thinsp;.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of CNR, SNR, and CR between RT-3D TSE iMSDE MRCP and RT-3D TSE MRCP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCNR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSNR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRT-3D TSE iMSDE MRCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.47 (22.40, 41.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.77 (17.42, 31.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.95 (0.92, 0.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRT-3D TSE MRCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.95 (13.62, 29.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.39 (11.25, 24.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.91 (0.87, 0.93)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edifference\u003c/p\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.845\u003c/p\u003e \u003cp\u003e(8.262\u0026ndash;11.428)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.743\u003c/p\u003e \u003cp\u003e(5.619\u0026ndash;7.868)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.451\u003c/p\u003e \u003cp\u003e(0.354\u0026ndash;0.548)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e adjust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.00*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.00*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.00*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCNR, Contrast-to-noise ratio; CR, contrast ratio; SNR, signal-to-noise ratio; \u003cem\u003er\u003c/em\u003e, effect sizes; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e \u0026lt;.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation Analysis of Single Factors with Subjective MRCP Scores\u003c/h2\u003e \u003cp\u003eAge, sex, and BMI demonstrated no strong correlations with subjective overall MRCP image quality scores in either group (all \u003cem\u003ep\u003c/em\u003e\u0026gt;.05) (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics and correlations between single factors and subjective image quality scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRT-3D TSE iMSDE MRCP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRT-3D TSE MRCP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKendall's tau-b1/\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003csub\u003e1\u003c/sub\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKendall's tau-b2/\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003csub\u003e2\u003c/sub\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.616\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;0.116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;1.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;0.526\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.599\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eKendall's tau-b1 and \u003cem\u003ep\u003c/em\u003e\u003csub\u003e1\u003c/sub\u003e values represent correlations between the single factors and overall image quality scores for RT-3D TSE iMSDE MRCP sequences. Kendall's tau-b2 and \u003cem\u003ep\u003c/em\u003e\u003csub\u003e2\u003c/sub\u003e values represent correlations between single factors and overall image quality scores for RT-3D TSE MRCP sequences.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI, Body mass index; RT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography; RT-3D TSE iMSDE MRCP, Respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study demonstrated that RT-3D TSE iMSDE MRCP remarkably outperformed conventional RT-3D TSE MRCP across multiple qualitative and quantitative metrics, including overall image quality, background signal suppression, and ductal structure delineation. Notably, visualization rates for second- and third-order bile ducts exceeded 90% with the iMSDE sequence, highlighting its superior diagnostic performance. These improvements are largely attributable to the technique\u0026rsquo;s ability to effectively suppress both turbulent and slow-flowing blood signals. Considering the close anatomical relationship between intrahepatic bile ducts and hepatic vasculature, high-intensity vascular signals often obscure ductal visualization on conventional MRCP.\u003c/p\u003e \u003cp\u003eIn this study, the iMSDE module was implemented using 2 adiabatic refocusing pulses, a \u003cem\u003eTE\u003c/em\u003e\u003csub\u003eprep\u003c/sub\u003e of 200 milliseconds, and velocity encoding (\u003cem\u003eV\u003c/em\u003e\u003csub\u003eenc\u003c/sub\u003e) set to 0 in the Right-Left (RL), Anterior-Posterior (AP), and Head-Feet (FH) directions. In contrast, the original MSDE technique employs a single refocusing pulse. The additional refocusing pulse and extra gradient lobes in iMSDE improve SNR and enhance robustness of flow suppression, thereby enabling more effective background suppression and clearer duct visualization [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Quantitative analysis further revealed that RT-3D TSE iMSDE MRCP achieved substantially higher CNR, CR, and SNR values than the conventional sequence. Lower receiver bandwidth and longer acquisition time of the iMSDE sequence inherently contribute to increased SNR and CNR. Thus, the observed quantitative improvements reflect a combined effect of sequence parameter selection and the iMSDE preparation module. However, reduced bandwidth may increase the echo spacing, potentially leading to motion-related artifacts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The implementation of motion-sensitive gradient technology in iMSDE can mitigate or prevent the occurrence of these artifacts, thereby facilitating more accurate assessment of anatomic structures and pathologic alterations within the pancreatobiliary system. These findings are consistent with those reported by De et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], who demonstrated that iMSDE improves tissue contrast, reduces vascular ghosting, and enhances suppression of both arterial and venous signals.\u003c/p\u003e \u003cp\u003eOur subgroup analysis revealed that the image quality improvements provided by iMSDE were independent of patient age and BMI. This robustness highlights its clinical applicability across diverse patient populations. Although RT-3D TSE iMSDE MRCP substantially improved the overall image quality and ductal conspicuity in most cases, a few exceptions were observed. In patients with poor respiratory control or marked susceptibility effects caused by iron deposition, iMSDE occasionally led to excessive signal attenuation or incomplete background suppression. Moreover, in markedly dilated bile ducts, velocity-sensitive gradients of iMSDE may reduce intraluminal signal intensity, resulting in unchanged or slightly degraded image quality. These findings indicate that the effectiveness of iMSDE may vary depending on respiratory motion, magnetic field homogeneity, and ductal flow characteristics. Further optimization of sequence parameters and adaptive tuning of iMSDE settings may help address these limitations.\u003c/p\u003e \u003cp\u003eIn cases of cholecystolithiasis and cholecystitis, RT-3D TSE iMSDE MRCP improved visualization of the cystic duct and its junction with the common hepatic duct. This benefit can be attributed to bile concentration and intraluminal hemorrhage associated with biliary disease, both of which shorten the T2 relaxation time of bile [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Conventional RT-3D TSE MRCP sequences typically use very long echo times (TEs; up to 600 milliseconds), leading to rapid signal loss in concentrated bile and poor visualization of gallbladder-related structures [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Previous studies have reported that concentrated bile remains visible at shorter TEs (286 milliseconds), supporting the clinical value of this approach for preoperative identification of cystic duct variants and reducing the risk of biliary injury [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGraSE-based MRCP can achieve a favorable resolution\u0026ndash;SNR trade-off through appropriate parameter optimization. Its shorter echo time and inherent background suppression may help mitigate signal loss associated with concentrated bile, and GraSE remains a widely available and effective MRCP technique in clinical practice. However, GraSE relies on long echo trains, which are susceptible to T2 decay\u0026ndash;related blurring and spatially variable background suppression, particularly in complex biliary environments. In addition, performance characteristics may vary across vendors and system configurations, and residual blurring remains a recognized limitation of the technique [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, the proposed iMSDE-based MRCP incorporates a motion-sensitized preparation module that introduces an additional degree of freedom beyond conventional T2-weighting. This enables more robust suppression of unwanted background signals while preserving biliary duct continuity. As a result, iMSDE provides a complementary approach in scenarios where vascular or motion-related signal contamination limits conventional MRCP techniques [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, in 2 patients with irregular respiratory patterns, the iMSDE sequence provided clearer visualization of the biliary and pancreatic ducts than the conventional MRCP sequence, which was prone to ghosting and blurring artifacts. This improvement is likely related to the shorter echo train length and reduced shot duration of the iMSDE sequence (80 vs 100; 571 milliseconds vs 644 milliseconds, respectively), reducing motion sensitivity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These findings are consistent with those of Chen et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], who demonstrated the robustness of iMSDE against motion artifacts. Notably, despite a modest increase in the acquisition time (153 seconds vs 126 seconds), the iMSDE sequence achieved substantial improvements in image quality, outperforming traditional black-blood techniques that often compromise efficiency [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Although this study was performed on a 3.0-T Philips system, the iMSDE preparation itself is vendor-independent and theoretically applicable across scanners and field strengths. Previous studies have demonstrated the feasibility of MSDE-prepared MRCP at 1.5 T using optimized \u003cem\u003eV\u003c/em\u003e\u003csub\u003eenc\u003c/sub\u003e and TE settings to balance SNR and vascular suppression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Future multicenter studies across diverse vendors and field strengths will be valuable for confirming reproducibility and generalizability.\u003c/p\u003e \u003cp\u003eRecent advances in MRCP acquisition have introduced various acceleration and reconstruction strategies such as parallel imaging, compressed sensing, and deep learning\u0026ndash;based reconstruction. These approaches primarily improve sampling efficiency and SNR while reducing scan time [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, these techniques primarily mitigate undersampling-related artifacts and do not directly address motion- or flow-related signal contamination. In contrast, the iMSDE preparation module targets intravoxel incoherent motion by dephasing spins from flowing blood, thereby suppressing vascular signals and improving duct-to-background contrast [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Notably, iMSDE is compatible with acceleration frameworks and can be integrated with compressed sensing or deep learning\u0026ndash;based reconstruction to achieve both motion robustness and time efficiency. Future studies combining iMSDE with these advanced reconstruction methods may further enhance MRCP image quality and workflow efficiency.\u003c/p\u003e \u003cp\u003eIn summary, compared with GraSE-based MRCP, the iMSDE approach mitigates key limitations such as T2 decay\u0026ndash;related blurring, variable background suppression, and reduced visualization in the presence of concentrated bile. It offers a complementary and clinically feasible strategy for robust MRCP imaging. These advantages underscore both the technical rationale and clinical value of iMSDE as a reliable method to improve diagnostic performance in challenging clinical imaging scenarios.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe RT-3D TSE iMSDE MRCP technique remarkably improves visualization of subtle ductal strictures and pancreatobiliary maljunctions by effectively suppressing confounding signals from portal venous flow and respiratory motion. By enhancing SNR, CR, and CNR, this method enables more reliable quantitative assessment of ductal anatomy and pathology. Improved delineation of pancreatobiliary structures may provide added clinical value in the evaluation of complex biliary diseases and support diagnostic confidence and clinical decision-making.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBB, black blood\u003c/p\u003e\n\u003cp\u003eBI, background inhibition\u003c/p\u003e\n\u003cp\u003eCD, cystic duct\u003c/p\u003e\n\u003cp\u003eCHD, common hepatic bile duct\u003c/p\u003e\n\u003cp\u003eCNR, contrast-to-noise ratio\u003c/p\u003e\n\u003cp\u003eCR, contrast ratio\u003c/p\u003e\n\u003cp\u003eDCBD, distal common bile duct\u003c/p\u003e\n\u003cp\u003eLHD, left hepatic bile duct\u003c/p\u003e\n\u003cp\u003eLIBD, left interlobular bile duct\u003c/p\u003e\n\u003cp\u003eLISBD, left intersegmental bile duct\u003c/p\u003e\n\u003cp\u003eM, median\u003c/p\u003e\n\u003cp\u003eMPD, main pancreatic duct\u003c/p\u003e\n\u003cp\u003eMSDE, motion-sensitized driven equilibrium\u003c/p\u003e\n\u003cp\u003eNo., number\u003c/p\u003e\n\u003cp\u003ePCBD, proximal common bile duct\u003c/p\u003e\n\u003cp\u003eQ1, first quartile\u003c/p\u003e\n\u003cp\u003eQ3, third quartile\u003c/p\u003e\n\u003cp\u003eQOI, quality of the overall image\u003c/p\u003e\n\u003cp\u003e\u003cem\u003er\u003c/em\u003e, effect sizes\u003c/p\u003e\n\u003cp\u003eRHD, right hepatic bile duct\u003c/p\u003e\n\u003cp\u003eRIBD, right interlobular bile duct\u003c/p\u003e\n\u003cp\u003eRISBD, right intersegmental bile duct\u003c/p\u003e\n\u003cp\u003eRT-3D TSE iMSDE MRCP, respiratory-triggered 3-dimensional turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium technique for magnetic resonance cholangiopancreatography\u003c/p\u003e\n\u003cp\u003eRT-3D TSE MRCP, respiratory-triggered 3-dimensional turbo spin-echo magnetic resonance cholangiopancreatography\u003c/p\u003e\n\u003cp\u003eSD, standard deviation\u003c/p\u003e\n\u003cp\u003eSNR, signal-to-noise ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective single-center study in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Dongguan Tungwah Hospital (approval number: DHKY-2025-035-01). Written informed consent was obtained from all participants prior to enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of anonymized images and clinical data was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXTX and CXD contributed to writing the original draft, data collection, data analysis, and visualization. LX and ZWY performed MRI scanning and data collection. WQY contributed to data analysis, conceptualization, and methodology. XYZ and LYT performed statistical analysis. LZY and ZGM contributed to conceptualization, supervision, project administration, and manuscript review and editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDar FS, Abbas Z, Ahmed I, et al. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol. 2024;30(9):1018-42. https://doi:10.3748/wjg.v30.i9.1018\u003c/li\u003e\n \u003cli\u003eKidanemariam S, Gu J, Yoon JH, Challapalli JV, Fruh V, Sax AJ. Cholangiocarcinoma: Epidemiology and Imaging-Based Review. R I Med J (2013). 2024;107(5):43-8. 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Feasibility of improved motion-sensitized driven-equilibrium (iMSDE) prepared 3D T1-weighted imaging in the diagnosis of vertebrobasilar artery dissection. J Neuroradiol. 2018;45(3):186-191. https://doi:10.1016/j.neurad.2017.11.006\u003c/li\u003e\n \u003cli\u003eKoori N, Kamekawa H, Naito T, et al. Carotid and aortic plaque imaging using 3D gradient-echo imaging and the three-point Dixon method with improved motion-sensitized driven-equilibrium (iMSDE). Magn Reson Imaging. 2024;111:202-9. https://doi:10.1016/j.mri.2024.03.036\u003c/li\u003e\n \u003cli\u003eNing Z, Zhang N, Qiao H, et al. Free-breathing three-dimensional isotropic-resolution MR sequence for simultaneous vessel wall imaging of bilateral renal arteries and abdominal aorta: Feasibility and reproducibility. Med Phys. 2022;49(2):854-64. https://doi:10.1002/mp.15436\u003c/li\u003e\n \u003cli\u003eChevallier O, Escande H, Ambarki K, et al. Single-Breath-Hold MRI-SPACE Cholangiopancreatography with Compressed Sensing versus Conventional Respiratory-Triggered MRI-SPACE Cholangiopancreatography at 3Tesla: Comparison of Image Quality and Diagnostic Confidence. Diagnostics (Basel). 2021;11(10):1886. Published 2021 Oct 13. https://doi:10.3390/diagnostics11101886\u003c/li\u003e\n \u003cli\u003eJin D, Li X, Qian Y, et al. Modified respiratory-triggered SPACE sequences for magnetic resonance cholangiopancreatography. Eur J Radiol Open. 2024;12:100564. Published 2024 Apr 20. https://doi:10.1016/j.ejro.2024.100564\u003c/li\u003e\n \u003cli\u003eShiraishi K, Nakaura T, Uetani H, et al. Deep learning-based reconstruction and 3D hybrid profile order technique for MRCP at 3T: evaluation of image quality and acquisition time. EurRadiol. 2023;33(11):7585-94. https://doi:10.1007/s00330-023-09703-z\u003c/li\u003e\n \u003cli\u003eNishihara T, Nakamura Y, Yoshizawa N, et al. Nature of the Intracellular-contrast-enhancing Fat-saturated T1-weighted Gradient-echo (ICE-TIGRE) Sequence: A Fat-suppressed T1-weighted Technique with Motion-sensitised Driven-equilibrium for Improved Contrast Enhancement in Liver Imaging. Magn Reson Med Sci. 2025;24(1):133-43. https://doi:10.2463/mrms.tn.2023-0104\u003c/li\u003e\n \u003cli\u003eDai YF, Zhang M, Zhang M, et al. Effect of bandwidth on abdominal imaging quality in 3.0 T\u0026nbsp;MR. J Med Imaging,2020,30(03):441-3+452.\u003c/li\u003e\n \u003cli\u003eDe Paepe KN, Higgins DM, Ball I, Morgan VA, Barton DP, deSouza NM. Visualizing the autonomic and somatic innervation of the female pelvis with 3D MR neurography: a feasibility study. Acta Radiol. 2020;61(12):1668-76. https://doi:10.1177/0284185120909337\u003c/li\u003e\n \u003cli\u003eXu YCH, Xu ZhD, Zhang JH, et al.\u0026nbsp;The application of three-dimensional breath-hold gradient and spin-echo sequence in the MR cholangiopancreatography. Chin J Radiol, January, 2021, 55(1): 64-9. https://doi:10.3760/cma.j.cn112149-20200215-00160\u003c/li\u003e\n \u003cli\u003eItatani R, Namimoto T, Takaoka H, et al. Clinical impact of 3-dimensional balanced turbo-field-echo magnetic resonance cholangiopancreatography at 3 T: prospective intraindividual comparison with 3-dimensional turbo-spin-echo magnetic resonance cholangiopancreatography. J Comput Assist Tomogr. 2015;39(1):19-24. https://doi:10.1097/RCT.0000000000000163\u003c/li\u003e\n \u003cli\u003eIhara R, Oura D, Ichimura W, Kobayashi K. Magnetic resonance cholangiopancreatography using T2 preparation pulse: quantitative and qualitative analyses. Acta Radiol. 2023;64(12):2969-76. https://doi:10.1177/02841851231203055\u003c/li\u003e\n \u003cli\u003eMorimoto-Ishikawa D, Hyodo T, Takenaka M, et al. Comparison between gradient and spin-echo (GRASE) and compressed sensing sequences for single breath-hold three-dimensional magnetic resonance cholangiopancreatography in patients with T1 hyperintense bile. Eur J Radiol. 2022;150:110279. https://doi:10.1016/j.ejrad.2022.110279\u003c/li\u003e\n \u003cli\u003eItatani R, Namimoto T, Kusunoki S, Mizuguchi T, Ohtsuka S, Yamashita Y. Usefulness of the Short-Echo Time Cube Sequence at 3-T Magnetic Resonance Cholangiopancreatography: Prospective Comparison With the Conventional 3-Dimensional Fast Spin-Echo Sequence. J Comput Assist Tomogr. 2016;40(4):551-6. https://doi:10.1097/RCT.0000000000000401\u003c/li\u003e\n \u003cli\u003eIsoda H, Maetani Y, Kataoka M, et al. Contrast behavior and image quality of magnetic resonance cholangiopancreatography imaging using variable echo times at 3.0 T. Clin Imaging. 2008;32(5):362-6. https://doi:10.1016/j.clinimag.2008.02.024\u003c/li\u003e\n \u003cli\u003eJun C, Shuhua L, Xue Z, Chunqing B, Mingli H. Application of motion-sensitized driven equilibrium based black blood 3D TSE sequence in the detection of brain metastases. Magn Reson Imaging. 2022;93:145-148. https://doi:10.1016/j.mri.2022.08.010\u003c/li\u003e\n \u003cli\u003eYang Q. Current situation and prospect of intracranial vessel wall MRI[J]. Chin J Radiol, 2024;58(11):1146-51. https://doi:10.3760/cma.j.cn112149-20240731-00448\u003c/li\u003e\n \u003cli\u003eWu X, Yue X, Peng P, et al. Accelerated 3D whole-heart non-contrast-enhanced mDIXON coronary MR angiography using deep learning-constrained compressed sensing reconstruction. Insights Imaging. 2024;15(1):224. Published 2024 Sep 19. https://doi:10.1186/s13244-024-01797-3\u003c/li\u003e\n \u003cli\u003eCervantes B, Kirschke JS, Klupp E, et al. Orthogonally combined motion- and diffusion-sensitized driven equilibrium (OC-MDSDE) preparation for vessel signal suppression in 3D turbo spin echo imaging of peripheral nerves in the extremities. \u003cem\u003eMagn Reson Med\u003c/em\u003e. 2018;79(1):407-15. https://doi:10.1002/mrm.26660\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":false,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Black-blood imaging, iMSDE, magnetic resonance cholangiopancreatography, pancreatobiliary system, turbo spin-echo","lastPublishedDoi":"10.21203/rs.3.rs-8715485/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8715485/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eConventional magnetic resonance cholangiopancreatography (MRCP) is often limited by moderate signal intensity from hepatic vessels, which may obscure visualization of the pancreatobiliary ducts. This study aimed to compare the clinical feasibility and image quality of a respiratory-triggered 3-dimensional (3D) turbo spin-echo sequence combined with improved motion-sensitized driven equilibrium (RT-3D TSE iMSDE) for pancreatobiliary imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis prospective study enrolled 53 patients (19 men and 34 women; mean age, 51.3 ± 15.5 years) with suspected pancreatobiliary disorders between September 2024 and February 2025. All patients underwent both RT-3D TSE iMSDE MRCP and conventional RT-3D TSE MRCP at 3.0 T MRI. Two radiologists independently scored the overall image quality, background suppression, and visibility of 15 pancreaticobiliary segments using a 5-point Likert scale. Qualitative scores and quantitative parameters—signal-to-noise ratio (SNR), contrast ratio (CR), and contrast-to-noise ratio (CNR)—were compared using Wilcoxon signed-rank tests. Interobserver agreement was analyzed using weighted kappa statistics. Wilcoxon signed-rank tests were used for pairwise comparisons, and Kendall's tau-b correlation analysis and the Mann–Whitney \u003cem\u003eU\u003c/em\u003etest were applied to evaluate the correlation between age, sex, body mass index (BMI), and subjective image scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eInterobserver agreement was good for all subjective image quality assessments. Compared with conventional RT-3D TSE MRCP, RT-3D TSE iMSDE MRCP sequence demonstrated notably higher scores for overall image quality, background suppression, and visualization of all 15 pancreatobiliary segments (all \u003cem\u003ep \u003c/em\u003e\u0026lt;.05). Quantitative analysis revealed significantly higher SNR, CR, and CNR values for the iMSDE sequence: SNR: 22.77 vs. 16.39; CR: 0.95 vs. 0.91; CNR: 29.47 vs. 19.95 (all \u003cem\u003ep\u003c/em\u003e \u0026lt;.05). No significant correlations were observed between age, sex, or BMI and overall MRCP image quality scores in either group (all \u003cem\u003ep\u003c/em\u003e \u003cem\u003e\u0026gt;\u003c/em\u003e.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eRT-3D TSE iMSDE MRCP improves duct-to-background contrast through vascular signal suppression, enabling clearer delineation of pancreatobiliary anatomy than conventional MRCP and enhancing diagnostic confidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eClinical trial number: not applicable.\u003c/p\u003e","manuscriptTitle":"Clinical Utility of Respiratory-Triggered 3D Turbo Spin-Echo Sequence with Improved Motion-Sensitized Driven Equilibrium for Magnetic Resonance Cholangiopancreatography: A Prospective Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 12:33:54","doi":"10.21203/rs.3.rs-8715485/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"97d6c605-9927-4ca4-a313-7f9509b02238","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T06:10:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 12:33:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8715485","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8715485","identity":"rs-8715485","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}