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Evaluation of Speciﬁc Absorption Rate as a Dosimeter of MRI-Related Implant Heating
Kenneth B. Baker, PhD,1* Jean A. Tkach, PhD,2 John A. Nyenhuis, PhD,3 Michael Phillips, MD,2 Frank G. Shellock, PhD,4 Jorge Gonzalez-Martinez, MD, PhD,5 and Ali R. Rezai, MD5
Purpose: To compare the magnetic resonance imaging (MRI)-related heating per unit of whole body averaged speciﬁc absorption rate (SAR) of a conductive implant exposed to two different 1.5-Tesla/64 MHz MR systems. Materials and Methods: Temperature changes at the electrode contacts of a deep brain stimulation lead were measured using ﬂuoroptic thermometry. The leads were placed in a typical surgical implant conﬁguration within a gel-ﬁlled phantom of the human head and torso. MRI was performed using two different transmit/receive body coils on two different generation 1.5-Tesla MR systems from the same manufacturer. Temperature changes were normalized to whole body averaged SAR values and compared between the two scanners. Results: Depending on the landmark location, the normalized temperature change for the implant was signiﬁcantly higher on one MR system compared to the other (P 0.001). Conclusion: The ﬁndings revealed marked differences across two MR systems in the level of radiofrequency (RF)induced temperature changes per unit of whole body SAR for a conductive implant. Thus, these data suggest that using SAR to guide MR safety recommendations for neurostimulation systems or other similar implants across different MR systems is unreliable and, therefore, potentially dangerous. Better, more universal, measures are required in order to ensure patient safety. Key Words: magnetic resonance imaging, bioeffects; magnetic resonance imaging, safety; neurostimulation systems; implants; deep brain stimulation; speciﬁc absorption rate J. Magn. Reson. Imaging 2004;20:315–320. © 2004 Wiley-Liss, Inc.
Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio. 2 Department of Radiology, The Cleveland Clinic Foundation, Cleveland, Ohio. 3 Department of Computer and Electrical Engineering, Purdue University, West Lafayette, Indiana. 4 Keck School of Medicine, University of Southern California, Los Angeles, California. 5 Section of Stereotactic and Functional Neurosurgery, The Department of Neurosurgery, The Cleveland Clinic Foundation, Cleveland, Ohio. Contract grant sponsor: NIH; Contract grant number: NS44575-01; Contract grant sponsor: Medtronic, Inc., Minneapolis, MN. *Address reprint requests to: K.B.B, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk S-90, Cleveland, OH 44195. E-mail: firstname.lastname@example.org Received November 18, 2003; Accepted April 19, 2004. DOI 10.1002/jmri.20103 Published online in Wiley InterScience (www.interscience.wiley.com).
ONE OF THE PRIMARY safety concerns related to performing magnetic resonance imaging (MRI) on biologic tissue is heating that can occur as tissue absorbs radiofrequency (RF) energy (1,2). Speciﬁc absorption rate (SAR), deﬁned in the International Electrotechnical Commission (IEC) standard (3) as the amount of RF power absorbed per unit of mass of an object indicated in W/kg, represents the current national and international dosimetric term used to characterize the thermogenic aspects of this electromagnetic ﬁeld (3–5). Concerns over RF-induced heating are compounded by the presence of conductive implants in the body, particularly those that are electronically activated or that have an elongated conﬁguration, as they can increase the potential for RF heating in the tissue immediately surrounding the implanted device (3). For example, Achenbach et al (6) reported a temperature elevation at the tip of a pacing electrode, unattached to a cardiac pacemaker, of up to 63.1°C during 90 seconds of MRI. More recently, Rezai et al (7) reported temperature elevations at the distal end of a deep brain stimulation (DBS) electrode of 25.3°C after 15 minutes of MRI. Other than encouraging the need for diligence when implants are present, neither the IEC (3,5) nor the Food and Drug Administration (FDA) document offers particular guidance with respect to performing MR procedures on patients with conductive implants. As such, it typically falls upon the manufacturers of these devices to demonstrate MR safety data for their devices. Although it is possible simply to exclude patients with implantable devices from MRI, this approach denies access to an important diagnostic imaging modality. The need to provide reliable, safe MRI in patients with implantable devices is evident. SAR has been routinely used as an indirect quantitative measure of RF energy in the reporting of safety recommendations for clinical MRI procedures when
© 2004 Wiley-Liss, Inc.
The phantom. however. However. A single SAR parameter may not be a sufﬁciently speciﬁc predictor of device heating given the four different SAR measures deﬁned in the recent IEC standard (3). this system includes two implantable pulse generators (IPG). extensions. Therefore. and 4) at an additional reference position within 1 cm of the edge of the phantom positioned in the region of the neck of the phantom. designed to approximate the size and shape of the human head and torso. MN). and leads. Samples were digitized at a rate of ﬁve samples per second and transferred to a PC for off-line analysis.12). All hardware used was representative of the manufactured “ﬁnished” version of the implant and was not altered in any manner before testing. was the weight entered at registration to enable the MR systems to calculate the whole body averaged SARs. Inc..). etc..1 mm above the contact plates of the distal left DBS electrode (L_E0). . CA). this may not be appropriate because SAR has been applied primarily as an index of heating in biologic tissue devoid of metallic or conductive implants (10). as previously described (7). as follows: MR system 1 (Symphony. Numaris 4 VA21B) and MR system 2 (Vision. except for four contact plates at the connector end as well as four contact plates in the distal 10.1 mm above contact plate zero of the distal right DBS electrode (R_E0). Malvern. 3) at a reference position midway between contact zero of the right and left electrode tips (1. Inc. and/or the amplitudes of the RF pulses (i. The MR landmark for the scans was placed at the most distal contact (contact 0) of the DBS leads or at the pectorally-placed IPG. The distal four contacts. two quadripolar extensions. Santa Clara.. and a pair of DBS leads.27 mm in diameter. temperature measurements from those probes were redundant to the data presented here and are not included. software version.e.316 Baker et al. effective ﬂip angles) were modiﬁed to produce a range of whole body averaged SAR values. TR. Speciﬁc acquisition parameters (i. Temperature recordings were obtained during multislice fast spin echo (FSE). T1-weighted spin-echo (SE). conductive implants are present (7–9). ﬂuoroptic thermometry probes were placed 1) 0. The connector that joins the extension to the DBS lead was positioned to emulate the more common post-auricular placement. MR Systems and Imaging Sequence Ex vivo testing was performed on two different generation 1. within the phantom skull the distal ends of the two DBS leads were positioned parallel and coronally coplanar.5 mm of polyurethane material. was ﬁlled with a semi-solid aqueous gel prepared to simulate the electrical conductivity and thermal convection properties of human tissue (11.e. was used in the experiments. The phantom was placed on the MR table such that its position was consistent with that of a patient in a typical head-ﬁrst supine position. 2) 0. It should be noted that while both are considered whole body MR systems. The mass of the ﬁlled phantom. For the purpose of the experiments described. and the patient weight entered during registration. Numaris 3. Thermometry System and Placement of Temperature Probes Temperatures were recorded at multiple locations using an MR-compatible ﬂuoroptic thermometry system (Model 3100. Luxtron. The IPGs were positioned to represent subcutaneous. Minneapolis. The excess lead that exists between the burrhole and the extension wire was subsequently allowed to arrange itself in a random fashion along the surface of the phantom skull. number of slices. Finally. subclavicular placement with the attached 51-cm extension routed ipsilaterally along the neck. PA).5 mm of the lead. Additional probes were present at other electrode contacts. 30 kg.5 mm in length and 1.0 VB33G). the transmitter reference adjustment and applied voltages. the purpose of this study was to explore the validity of using SAR in making safety recommendations for patients with implanted devices by comparing the ex vivo MRI-related heating of an electronically-activated implant between two different generation commercial 1. and IPGs (Model 7426) were positioned in a manner to emulate the clinical method (7. are separated from one another by 1. echo train length [ETL]. separated by a distance of 3 cm at the distal tips (contact 0). A plastic grid frame with adjustable posts was placed at the bottom of the phantom to ensure stable positioning and support of the neurostimulators. Furthermore.5-Tesla MR systems from the same manufacturer. It was held ﬁrmly against the surface of the phantom skull by a thin piece of silicone rubber. extensions (Model 7495-51).5-Tesla/64 MHz MR systems from the same manufacturer (Siemens Medical Solutions USA.13). The bilateral DBS leads (Model 3387-40). the MR system 1 is a short-bore system and the MR system 2 is a long-bore system. The software reported values for the whole body averaged SAR based upon the MR sequence parameters. Neurostimulation System The Activa Tremor Control System (Medtronic. used for DBS. The position and routing of all hardware components was held constant throughout the experiments in order to avoid any potential geometry-based changes in the interaction between the DBS hardware and RF ﬁeld.5 cm equidistant from each). it appears that MR system manufacturers are using proprietary and evolving models of the human body upon which to base their SAR calculations. The lead was routed along a phantom skull and circled the burrhole cap one time before passing into the skull. software version. and fast spin-echo inversion recovery pulse sequences (FSE-IR). The 40-cm-long DBS lead used in the present study is insulated along its entire length.. MATERIALS AND METHODS Phantom Experiments were performed using a previously described phantom model (7). For a typical bilateral procedure. Experiments were performed using the circularly polarized (CP) transmit/receive RF body coil. each 1.
5 mm caudal to contact 0 of the DBS lead) in approximately the region of the neck (X 65.74 1.44 8.40 1. contact 0. contact 0. the absolute value then was normalized to the console-reported indices of whole body averaged SAR. Figure 3 summarizes the normalized heating data for the right and left DBS lead between the two MR systems when the landmark was placed over contact 0.0) for the right DBS lead (P 0. This approach is justiﬁed by the observed linear relationship between implant heating and whole body averaged SAR seen for each generation of MR system.73 ( 0. T 16. This was done in order to minimize the inﬂuence of any potential signal noise in the temperature recordings.38 0.12 T (° C) R E0 4. In order to control for variations in the duration of the individual MRI procedures.8 – 0.39 0. IR inversion recovery. and 3) 30 cm below the IPGs in the region of the umbilicus (X 20. The temperature change recorded was highly correlated (r 0. T 15). This suggests that. and thus represented an average of the eight samples recorded between 51. This inability was related to the values for exposed or head averaged SAR reaching the maximal allowable IEC limit on the Symphony system.86 7. Figure 1 provides a sample of the raw temperature data recorded from MR system 1 (right) and MR system 2 (left).97 1.88 1.78 0. RESULTS Twelve different pulse sequences were evaluated with the scan landmark at contact 0 of the DBS lead and eight with the landmark at the IPG.00 1.5 cm). but rapidly decreased as the landmark was moved caudally (lower values of X). N 6). Unfortunately. where appropriate. Whole body SAR (W/kg) 0.92 T (° C) L E0 6.01.07 0. N 5). Finally.06 0. R_E0 right lead. N 4).55 1. an additional 15 pulse sequences were evaluated with the scan landmark placed at locations other than the IPG and contact 0 of the DBS lead. When normalized to the whole body averaged SAR. SE spin echo.8 (range: 0. results were normalized and expressed in terms of temperature rise per unit of SAR. The normalized mean values ( SD) for MR system 1 and 2 were 4.00 0. The data shown were taken with the landmark positioned at the electrode contacts and correspond to runs S02 and V03 listed in Table 1.5 (range: 62.43 ( 0.39 0.9 (range: 1.46 1. The temperature sample at that point was eight-bin and center averaged.6 –75. The difference between the two scanners was maximal with the landmark placed at the electrodes (X 76.85 0. P 0. 2) 15 cm below the IPGs in the region of the xyphoid process (X 35.33 0.6 –97.SAR and MRI-Related Implant Heating 317 Table 1 Summary of Raw Temperature Data Sequence MR system Run no. for comparison between the two MR systems.33 0.2 and 61. respectively. This included 1) 15 cm rostral to the IPGs (11.00 2. MR system #1 symphony.8 seconds after scan initiation. The averaged value then was converted to an absolute temperature rise by subtracting the pre-sequence baseline average.4) and 0.40 2.35 2.99.79 1.03 0.68 15.66 0.34 1.72 2. as measured at the thermometry probe positioned over contact 0 of the left DBS lead. Landmarked at contact 0 FSE-T2 1 FSE-T2 1 FSE-T2 1 FSE-T2 1 Fast-IR 1 T1-SE 1 T1-SE 1 FSE-T2 2 FSE-T2 2 FSE-T2 2 FSE-IR 2 IR 2 Landmarked at the IPG FSE-T2 1 FSE-T2 1 T1-SE 1 T1-SE 1 FSE-T2 2 FSE-T2 2 FSE-T2 2 T1-SE 2 S02 S03 S04 S16 S06 S07 S08 V02 V03 V20 V05 V06 S09 S10 S11 S12 V07 V08 V11 V09 IPG implantable pulse generator. and temperature change at contact 0 of the right and left DBS lead for both MR systems.96 3.4 (range: 85. degrees of freedom [df] 6) and 0. as indexed by whole body averaged SAR. direct comparisons based on the exact whole body averaged SAR value were not possible in the current study as the two different MR systems could not be made to deliver the exact same SAR for a given imaging sequence.69 2.66 12. the median values for MR system 1 and MR system 2 were 68.13 3.58 0. T 15) and 90. L_E0 left lead.88 7.09 Data Analysis Baseline temperature recording for each experimental condition was initiated at least 20 seconds before the start of MRI.51 2.90 4.88 4.97 ( 0. Sag sagittal. df 6). 4 summarizes the normalized temperature data for sequences performed with the scanner landmark at the IPGs.77 0.45 0. Thus.9.02 2.44 0. MR system #2 vision.83 0.1.6 –2. the Mann-Whitney Rank Sum test.05 1.01.14) for the right DBS lead (P 0. Temperature changes generally were extremely rapid.08 ( 0.04 0.06 0.96 1. The results of the experiments are summarized in Table 1.27 5. Figure 5 illustrates how the magnitude of the temperature difference normalized to whole body averaged SAR between the two MR systems varied as a function of landmark position. Comparisons between the two MR systems were made using Student’s two-tailed t-test or. statistical comparisons were based on the temperature increase as recorded 60 seconds after the initiation of scanning.79 1.11 1. For this reason.14) and 0. Similarly.75 6.01.53 3.89 5.6) and 1.39) and 0. Figure 2 illustrates the relationship between RF intensity. respectively. Fig.02 0. FSE fast spin echo. with the temperature recorded at the 60-second time point typically representing 60% or more of the ﬁnal or maximum temperature recorded throughout the sequence.01) with the amount of RF power for both MR system 1 (N 7) and MR system 2 (N 5).01.9) for the left DBS lead (P 0.59 2.08 1. . within a given MR system.32 5.06) for the left DBS lead (P 0. T 6. the primary determinant of the magnitude of the temperature change for a given lead system and conﬁguration is the overall level of estimated RF power.20 22.
despite the use of different sequence types. Each plot shows the temperature change as recorded at contact 0 of the left (empty circles) and right (ﬁlled circles) DBS lead. Specifically.88 W/kg. 0. a speciﬁc scanner hardware running a speciﬁc software version) from the same manufacturer. Temperature change as recorded at contact 0 of the right and left DBS lead as a function of whole body averaged SAR. where time zero represents the onset of MRI (i. *Note that for MR system 2. Data are shown from MR system 1 (left: Run #S02) and MR system 2 (right: Run #V03) and represent temperature changes recorded at contact 0 of the left DBS lead.07 W/kg vs. Both measurements were made with the landmark position at contact 0 on the DBS electrode. two of the ﬁve data points for each lead partially overlap. the temperature change per unit whole body averaged SAR was as much as 90 times higher when using the transmit/receive RF body coil on MR system 1 as opposed to that observed on MR system 2. was profoundly different between two different generation 1. the temperature increase as recorded 60 seconds after the start of MRI is approximately nine times higher on MR system 1. start of pulsed RF). The landmark was at contact 0 on the DBS electrode. Note that. Example of the raw temperature data showing the change in temperature as function of time. .5-Tesla MR systems (i.. respectively)..318 Baker et al. Note that the temperature increase is initially quite rapid. These Figure 2. DISCUSSION The most signiﬁcant ﬁnding of this study was that the amount of heating per unit change in the calculated whole body averaged SAR. Also.e.e. as recorded at an implantable conductive device. the recorded temperature change is well correlated with the amount of RF power. within a given MR system. despite a reported whole body averaged SAR value that was less than 1/12th of what was delivered on MR system 2 (0. Figure 1.
though the relative contribution of each factor to the observed difference reported herein cannot be deﬁnitively determined. The reliability of the data presented is supported further by the consistency of the ﬁndings across all of the electrodes monitored. safety results with regard to heating for implanted devices that are determined on speciﬁc types of MR systems relying on whole body averaged SAR as the dosimetric means of characterizing RF power deposition cannot be reliably generalized to other imaging systems and software versions. That such differences do indeed exist between the methodologies employed by each of two scanners used in this study is evidenced by the terminology used to characterize the reported SAR values reported. as this would tend to exclude the possibility that the observed difference between the two Figure 5. the ﬁndings support a linear relationship between SAR and heating within a given type of MR system. any difference in the algorithm (e. Comparison of the change in temperature (T) per unit of whole body averaged SAR (W/kg) between the two MR systems for both the right and left DBS lead with the landmark set at contact 0 of the DBS electrodes..and software-related factors.” and “Whole Body” SAR values and system 2 reporting “Partial Body. *P 0.” “Exposed Body. With respect to hardware issues. spin echo vs. Figure 4. As expected. Similarly. Overall.g. it is likely a combination of hardware. While it is well known that the electric ﬁeld distribution associated with an RF resonator will vary with coil design. MR systems resulted from a change in the physical relationship between the ﬂuoroptic probes and the metal implant as the phantom was moved from one MR system to the other. this information is not available to the standard MR user. where the observed temperature change was highly correlated with whole body averaged SAR. more than 95% of the variance in temperature on a given type of MR system was accounted for by the amount of RF energy delivered. fast spin echo vs. the methodologies used to calculate SAR are not accessible to the user. The results presented in this manuscript most likely reﬂect the combined effects of these factors. with the error bars showing the standard deviation. Comparison of the change in temperature (T) per unit of whole body averaged SAR (W/kg) between the two MR systems for both the right and left DBS leads with the landmark position at the level of the IPGs.” and “Whole Body”. From the software perspective. Mean values are shown for each MR system. Finally. and hence. This difference in terminology also explains why no attempt was made to normalize the temperature data to any value other . the largest contribution probably would derive from differences in the design of the transmit RF body coils.01.SAR and MRI-Related Implant Heating 319 Figure 3. inversion recovery fast spin echo). The maximum difference is observed when the landmark position is placed at contact 0 of the DBS electrode and diminishes as the landmark positioned is placed more caudally. ﬁndings strongly suggest that calculated whole body averaged SAR is not a reliable metric for RF power irradiation across different MR systems in the presence of an electronically-activated conductive implant. the impact cannot be assessed. it is worth noting the high degree of linearity within each system that existed despite variations in the type of sequence used (i. with the error bars representing the ﬁrst and third quartile values. The effect of the landmark position on the magnitude of the difference in normalized temperature change (change in temperature [T]/whole body averaged SAR) between the two MR systems. *P 0.e. The data are plotted as the log of change in temperature (T) per unit of whole body averaged SAR.” “Local Body. with MR system 1 reporting “Head. Thus. body modeling) used to estimate whole body averaged SAR would play a large role.. Median values are shown for each MR system.01. Although the source of the discrepancy between the two MR systems is not clear.
AJNR Am J Neuroradiol 2002. Guidance for industry and FDA staff. . or at the very least the same device and software version.08 W/kg. non-gelled phantom material for measurement of MRI-induced temperature increases with bioimplants. 5. Safety aspects of radio-frequency power deposition in magnetic resonance. as it is clear that SAR estimates are not reliable as a methodology of determining power delivery across MR sys- tem types. J Magn Reson Imaging 2002. Bieberle T.5Tesla. Simon BJ. July 14. U. et al. et al. Physician and hospital staff mannual. 3. Furthermore. Finelli D. Magnetic resonance safety of a newly-developed ﬁber-optic cardiac pacing lead. FL: CRC Press. instead being speciﬁc to the performance of MRI using a transmit/receive RF head coil (9). generalization of those results to MR system 1 could be catastrophic.15:241–250. Implantable spinal fusion stimulator: assessment of MR safety and artifacts. Park SM. Radiofrequency-induced heating during MR procedures: a review. 4.16:97–103. Food and Drug Administration. In the meantime. Achenbach S. Shellock FG.6:775– 789. Neurostimulator for deep brain stimulation: ex vivo evaluation of MRI-related heating at 1. American Society for Testing and Materials. Until the manufacturers of these systems and devices solve these potential problems. Am Heart J 1997. Miller V. Medical Electrical Equipment. the investigators concluded that. Diem B. Center for Devices and Radiological Health. Standard test method for measurement of radio frequency induced heating near passive implants during magnetic resonance imaging. Greatbatch W. Boca Raton. Finelli DA. those for MR system 2 remained more or less constant. Shellock FG.134:467– 473.12:30 –36. For example. a value that is less than 1/10th of the safety limit proposed for data collected from MR system 2 (7). as for example its RMS value (B1. however. the “static” conditions within the phantom used in the present study result in more or less a worst-case scenario. editor.RMS) may be a more suitable measure than SAR for predicting the potential for RF-induced heating near an implant.S. J Magn Reson Imaging 2000. 2. 7. West Conshohocken. Moshage W. on which the imaging is to be performed. in consideration of the present ﬁndings. 2002. Bachmann K. Magn Reson Imaging Clin N Am 1998. Gelled vs. REFERENCES 1. the conservative approach would be such that MR examinations not be performed on patients with electronically-activated implants in the absence of ex vivo experimental data speciﬁc to the type of MR scanner. Ruggieri PM. the RF body coil recommendations made by Rezai et al (7) were based on the same neurostimulation system evaluated on the same MR system (MR system 2) used in the current study. et al. MR imaging related heating of deep brain stimulation electrodes: In vitro study. manufacturers of MR systems should be encouraged to adopt a universally acceptable. Effects of magnetic resonance imaging on cardiac pacemakers and electrodes. J Magn Reson Imaging 2002. 9. Schibgilla V. 6.12:214 –223. Criteria for signiﬁcant risk investigations of magnetic resonance diagnostic devices. In that study. human subject has shown that while the whole body averaged SAR values reported by MR system 1 change as a function of the landmark position. until the comparisons have been made between various types of MR systems with transmit/receive RF head coils. 14. FDA guidance for MR system safety and patient exposures: current status and future considerations. Indeed.320 Baker et al. Model 7246. It is likely that some of the observed difference arises from the different methods of SAR calculation used across the two generations of MR systems. standardized measure of RF power deposition. 2003.9 W/kg could be performed without exceeding 2°C at the tip of the electrodes. In: Shellock FG. than the reported whole body averaged SAR. Magnetic resonance procedures: health effects and safety. Minneapolis. Particular requirements for the safety of magnetic resonance equipment for medical diagnosis. Certainly. J Magn Reson Imaging 2000. Neurostimulator for Deep Brain Stimulation. Rezai AR. Radiofrequency energy-induced heating during magnetic resonance procedures: laboratory and clinical experiences. This is particularly true considering the rate at which the temperature increase occurs. it would be reasonable to carefully consider applying those guidelines. Differences across MR systems in the calculation of the whole body averaged SAR could have potentially disastrous clinical implications if that value is used as the metric for deﬁning universally safe operating conditions for patients with conductive implants.39:3367– 3371. et al. As well. but it is unlikely that cerebral blood ﬂow or other physiologic mechanisms could effectively dissipate any heating approaching that magnitude. Soletra™.9 W/kg whole body averaged SAR on that system would result in a theoretical temperature rise on the order of 90°C. Experiments on MR system 1 showed that 6°C of heating could be achieved with a whole body averaged SAR of only 0.0). p 75–95. when using the transmit/receive RF body coil. Hatﬁeld M. implant manufacturers should be encouraged to continue to pursue development of MRI compatible devices. Schaefer DJ. preliminary work in the laboratory using an adult. exposure to 0. whole body SAR exposures of up to 0. as it clearly should be possible to develop lead systems that do not conduct current at the RF used in MRI and yet allow for the conduction of appropriate stimulation (14). Nyenhuis JA. the onus for safety lies in the hands of radiologists at individual institutions. 8. International Standard IEC 60601-2-33. 13. FL: CRC Press. 11.23:1795–1802. It is important to note. 2001. PA: ASTM International. 2001. Department of Health and Human Services. Although the results of the present study are consistent with those recommendations for MR system 2 (maximum T/whole body averaged SAR on MR system 2 was 2. Boca Ration. As the maximum T/whole body averaged SAR on MR system 1 was approximately 97. International Electrotechnical Commission (IEC). A more direct measure of the RF magnetic ﬁeld. 2002. Smith CD. In: Magnetic resonance procedures: health effects and safety. 2001. IEEE Trans Magnetics 2003. Therefore. however. Nyenuis JA. 12. that the recommendations of the neurostimulation system manufacturer do not allow the use of a transmit/receive RF body coil. 10. Schaefer DJ. ASTM International. Shellock FG. MN: Medtronic. p 183–196. Zaremba L. Shellock FG. Rezai AR.
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