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MAGNETOM

Issue no. 2.2003


RSNA Edition

F L A S H

Summertime is
MAGNETOM World Meeting Time

s
medical
MAGNETOM FLASH

Content
Topic Page
EDITORIAL
Summertime is MAGNETOM World Meeting Time 4

TECHNOLOGY CORNER
iPAT Applications in Clinical Routine and Beyond:
Imaging from Head to Toe 6
Motion Under Control with Prospective Acquisition Correction
(PACE) 22
MRCP with 2D PACE 25
A Quantum Leap in MR Tomography: Tim [76x32] 32
Introducing MAGNETOM Avanto:
The Revolution Begins Now 36
Imaging the Whole Body – Viewing the Entire Person 40

MAGNETOM WORLD EVENTS MIAMI


2nd Annual MAGNETOM World Summit
September 17-19, 2003 44

SUPER TECHNOLOGISTS
Crues-Kressel Award 75
R2-HIC: A Practical Method for Measuring Liver Iron Levels 76

MRI SAFETY
Guidelines to Prevent Excessive Heating
and Burns 80
Institute for Magnetic Resonance Safety,
Education and Research 81
Guidelines for the Management
of the Post-Operative Patient 84

The information presented in MAGNETOM® Flash is for illustration only and is not intended to be relied upon by the
reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded
that they must use their own learning, training and expertise in dealing with their individual patients. This material
does not substitute for that duty and is not intended by Siemens Medical Solutions, Inc. to be used for any purpose in
that regard.

2
Topic Page
EVENTS
Annual CT/MR Users’ Seminar Review 86
Siemens Promotes a First-Ever Meeting Between
MR and CT Users within Mercosur 88
MAGNETOM World Meeting
Cardiac Imaging Symposium for Asia 96
MAGNETOM Forum 2003 –
A Norwegian MAGNETOM World Users Meeting 103
MAGNETOM World Activities in India 104
Siemens MAGNETOM User Club (SMUC) Meeting
in Ängelholm, Sweden... 108

GASTROINTESTINAL IMAGING
MR Colonography as an Interdisciplinary
Cooperative Project 110

ULTRA HIGH-FIELD
Cerebrospinal Fluid Flow Measurements –
Initial Results at 3.0 T 116
Intracranial 3D ToF MRA with Parallel Acquisition
Techniques at 1.5 T and 3.0 T 120

MAGNETOM SITE VISIT


High Workflow of Maestro Class System
at a Brazilian Clinic 122

CARDIO VASCULAR
Bilateral Four Channel Phased Array Carotid Coil
from Machnet 126
Self-Gated Cardiac Cine
Virtually Eliminates ECG Triggering 128
How to Improve your 3D ToF with
a Few Drops of Gadolinium 131

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MAGNETOM FLASH

Editorial

Summertime is
MAGNETOM World Meeting Time

Our Editorial Team decision had Cardiac MR is maybe the most


been to include a report on one or prominent aspect of Siemens MR. We
two MAGNETOM World meetings in are so far ahead of the field that
each Flash magazine. So, as we were there is scarcely any competition.
planning this latest issue of Flash, Proof of this are our CMR ambassadors
we thought that MAGNETOM World – MAGNETOM cardiac MR users and
Summit and one other meeting leaders in the scientific community in
would be covered in detail. Then my their specific cardiac imaging areas.
old friend Gustavo Gonzalves Ribeiro This year, in addition to our Miami
called from Brazil: “Nejat”, he said meeting of CMR Ambassadors, we
excitedly, “you can’t believe how also held another MAGNETOM World
enthusiastic our customers were meeting for cardiac MR users in Asia.
about the MAGNETOM World at their
meeting in Mercosur. They say they The MAGNETOM World summit in
had never seen anything like this Miami was an amazing event. Not
before, for the quality of the scientific even Hurricane Lisa could disrupt
contributions and the fun”. He sent the wonderful organization of an
me the photos and a report of the gathering that brought together
meeting. He was right. I was even people from the four corners of the
worried that we would have difficulty world. I would like to thank again
matching that level of organization Raya Dubner from US organization
with our global MAGNETOM World and team colleague Heike Schindler
Summit. for the meticulous and imaginative
organization of even the smallest
The CT/MR Users’ seminar in the US details of this meeting.
is a unique tradition and the envy of
all other medical imaging companies Do not think that we always search
and exotic New Orleans was the for sun, sea and sand when we plan
chosen location for this year’s mee- our MAGNETOM World meetings.
ting. Stimulating meetings took place this
summer in the cool and refined
countries of Sweden and Norway,
where more than 200 people gathered
to exchange information and learn
about latest developments.

The MAGNETOM World meeting in


Mumbai, India, was also an opportu-
nity to provide WIP sequences to our
customers and get valuable feedback
for optimizing our new sequences.
4
Editorial Team

Tony Enright, Ph.D.


Asia Pacific Collaboration,
Australia

Marion Hellinger, MTRA Lisa Reid,


MR Marketing- US Installed Base Manager,
Application Training, Malvern, PA
Erlangen

This is what our MAGNETOM World is


Milind Dhamankar, M.D. Michael Wendt, Ph.D.
all about: communication. We have MR Marketing- US R&D Collaborations,
the opportunity to get feedback Applications, Erlangen Malvern, PA
from a worldwide community which
can only help to get our products
ever closer to perfection.
On the theme of perfection, we have
a new MAGNETOM family member
which is probably about to revolutio-
nize the MR world: the MAGNETOM
Dagmar Thomsik- Helmuth Schultze-Haakh,
Avanto, which employs the state-of- Schröpfer, Ph.D. Ph.D.
the-art technology we have named MR Marketing-Products, US R&D Collaborations,
Erlangen Malvern, PA
as Tim (Total Imaging Matrix). Tim
is the first seamless, whole body
surface coil design that combines 76
seamlessly integrated coil elements
with up to 32 RF Channels, opening
the door to the most advanced
clinical applications available today.
Peter Kreisler, Ph.D. Judy Behrens,
With reports on 6 meetings, Tim, Collaborations & R.T. (MR) (CT)
Avanto, iPAT and much more, Flash is Applications, Erlangen Adv. Clinical Applications
Specialist
an essential source of information
and a great read.

Enjoy this issue of Flash.


Charlie Collins, B.S.R.T. Raya Dubner
Market Manager (USA), Design Editor,
Erlangen Malvern, PA

A. Nejat Bengi, M.D.


Editor in Chief
Gary R. McNeal, MS(BME) Achim Riedl
We thank Harald Werner, Antje Hellwich, Lawrence Tallentire Advanced Application Specialist Technical Support,
and Iman Staab for their editorial help. Cardiovascular MR Imaging Erlangen
Siemens Medical Solutions USA
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MAGNETOM FLASH

iPAT Applications in Clinical Routine and


Beyond: Imaging from Head to Toe
Olaf Dietrich, Ph.D. Introduction There are two groups of iPAT
Stefan O. Schoenberg, M.D. algorithms: algorithms that explicitly
Department of Clinical Radiology – With the release of syngo MR 2002B, calculate missing k-space lines before
Großhadern an important new feature has become Fourier transforming the data,
(Chairman: Maximilian F. Reiser, available for routine examination: and algorithms that first reconstruct
M.D.), Ludwig-Maximilians- integrated Parallel Acquisition images with reduced FOV for all
University of Munich, Germany Techniques (iPAT). The general idea receiver coil elements and then merge
behind iPAT is to acquire image data these different images into one with
simultaneously by two or more full FOV. syngo MR 2002B provides
receiver coils with different spatial both types of algorithms. GeneRalized
Correspondence: sensitivities. Initially, this technique Auto-calibrating Partially Parallel
was motivated by the wish to acce- Acquisition (GRAPPA) is an algorithm
Dr. Olaf Dietrich
lerate image acquisition without of the first type [1] and is based on
Ludwig-Maximilians-University of
reducing the spatial resolution of the another well-known algorithm of the
Munich
image. However, it turned out that same class called SiMultaneous
Department of Clinical Radiology –
iPAT provides several other advan- Acquisition of Spatial Harmonics
Großhadern
tages in various MR applications. (SMASH) [2]. The best-known algo-
Marchioninistraße 15
D-81377 Munich rithm of the second type has been
Germany called SENSitivity-Encoded (SENSE)
Technical background MRI [3] and a modified SENSE algo-
rithm called mSENSE is available
Acquisition of MR images works by under syngo MR 2002B. It depends
subsequently acquiring phase- on the specific application, such
encoded lines in k-space. These lines as the anatomical region and pulse
of data are finally transformed into sequence, as to which of these two
the image slice (or slab, in the case of iPAT algorithms will yield better
3D acquisitions) by a mathematical image quality.
process called Fourrier transformation.
An important property of data in Both GRAPPA and mSENSE algorithms
k-space is that the density or “distance” require some additional information
of the lines in k-space corresponds about the spatial coil sensitivities, i.e.
inversely to the field of view (FOV) of which part of the FOV is covered by
the final image, whereas the data each coil element. This information
range in k-space corresponds to the can be acquired as a separate extra
spatial resolution of the image. scan with low resolution or, typical
Therefore, reducing the line sampling for the GRAPPA and mSENSE algo-
density by a factor of 2 (by not rithm, by additionally acquiring some
acquiring every other line) leads to of the missing data lines in the center
an image with half the FOV in phase- of k-space (so-called reference lines)
encoding direction in comparison integrated into the acquisition.
with the original image. In this case,
the acquisition time is also reduced Generally, the signal-to-noise ratio
by a factor of 2 as is well known from (SNR) in iPAT images is decreased
using rectangular FOVs. iPAT methods compared to acquisitions with the
use exactly this effect to accelerate full k-space data. This is the same
image acquisition, but without effect as in conventional imaging
decreasing the FOV due to a special with rectangular FOV: acquiring
iPAT image reconstruction. Using the fewer lines in k-space decreases the
complementary data from the different SNR of the image. Additionally, iPAT
receiver coils, the “missing” lines in images suffer an SNR loss due to the
k-space can be calculated during special reconstruction scheme: this
image reconstruction. effect depends on the efficacy of the
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TECHNOLOGY CORNER

geometry of coil distribution and is is almost compensated and remaining restricted by tissue properties,
described by the so-called “geometry motion artifacts are further reduced. particularly by the cellular micro-
factor” g [3]. structure and the spatial orientation
Single-shot pulse sequences, like
of cells. Especially in fiber structures
echo-planar imaging (EPI) or half-
like muscle tissue or the cerebral
Fourier acquired single-shot turbo
Advantages and white matter, molecular motion is
spin echo (HASTE), often suffer from
disadvantages of iPAT restricted by cell membranes or
image artifacts due to their long echo
myelin sheaths, and molecules move
The obvious advantage of iPAT is the trains. EPI is especially sensitive to
preferably parallel to the fiber
acceleration of imaging due to the susceptibility artifacts, whereas
direction whereas diffusion orthogo-
reduced number of phase-encoding HASTE images often appear blurred
nal to the fiber direction is decreased.
lines to be acquired. With an accele- due to the T2-related signal decay
Thus, the resulting water diffusion is
ration factor (or PAT factor) of 2, i.e. during the readout of the echo train.
anisotropic. Information about the
acquisition of only every second line Both problems can be reduced by
diffusion strength (apparent diffusion
in k-space, the imaging time is applying iPAT to shorten the length
coefficient, ADC), diffusion anisotropy,
reduced by close to 50 % depending of the echo train without loss of
and diffusion direction are contained
on the number of reference lines. spatial resolution. In contrast to
in the so-called diffusion tensor, a
This can be used to decrease the other pulse sequences, single-shot
mathematical object (symmetric 3x3
overall examination time and thus methods can even gain SNR due to
matrix) consisting of 6 independent
improve the patient throughput and iPAT because late echoes with
numbers.
examination efficacy. Alternatively, relatively low signal intensity that are
acquired in conventional sequences The most common pulse sequences
the spatial image resolution can be
are not contained in the shortened to measure the diffusion tensor are
improved in an iPAT scan compared
iPAT echo train. diffusion-weighted EPI sequences
to a conventional scan of the same
with diffusion gradients applied in at
duration. Both shorter scan times and In conclusion, iPAT can be advan- least six different directions [4, 5].
higher resolution are especially tageous in very different applications Single-shot EPI sequences have the
important in breath-hold imaging: with very different ways of using advantage that imaging is fast (about
either breath-hold times can be iPAT. This is demonstrated in the 100 ms/image) and thus very insensi-
shortened or the spatial resolution following sections with examples tive to motion. However, EPI sequences
can be improved without prolonging ranging from clinical routine imaging are very prone to susceptibility
the breath-hold time. to advanced study protocols. Imaging artifacts manifesting as distortions in
Another important iPAT application is in all presented applications is perfor- the frontal brain and the cranial base.
dynamic imaging, such as measure- med on a 1.5 T MAGNETOM Sonata This disadvantage can be overcome
ments of perfusion or cardiac function, Maestro Class system. Standard by using iPAT sequences to shorten
because image acceleration allows sequences are used in most cases; the length of the EPI gradient echo
for a higher temporal resolution. however, some applications require train. Hence, we use a spin echo EPI
However, as mentioned above, the sequences from special “work in diffusion sequence with GRAPPA
resulting SNR will be decreased progress” (WIP) packages by Siemens reconstruction, an acceleration factor
compared to non-iPAT acquisitions, Medical Solutions*. of 2, and 24 reference lines for DTI
so iPAT is especially useful for examinations. A dedicated iPAT head
high-SNR applications like contrast- coil consisting of 8 surface coil
enhanced angiography. Diffusion tensor imaging elements (Fig. 1) provides the required
number of receiver channels.
Using iPAT to acquire more averages Diffusion tensor imaging (DTI) is an
in the same total scan time can advanced MR imaging technique for Acquisition with the 8-channel
improve image quality, particularly in measuring the strength, anisotropy, head coil results in images with an
anatomical areas that are prone to and direction of water diffusion improved SNR compared to the
motion artifacts. iPAT imaging is less in tissue. The term “water diffusion” standard quadrature head coil (Fig. 2).
sensitive to motion, because every refers to the property of all water
single acquisition is shorter than in a molecules to move stochastically due * The information about this product is
preliminary. The product is under development
conventional sequence. By averaging to their thermal energy (Brownian and is not commercially available in the U.S.,
image data, the iPAT-related SNR loss motion). The extent of this motion is and its future availability cannot be ensured.

7
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MAGNETOM FLASH

This can be explained by the smaller Figure 1 8-channel phased-array


diameter of the 8-channel head coil head coil for acquisition of iPAT data.
(24 cm vs. 26 cm) and the reduced 8 surface coil elements are located
coil size in cranio-caudal direction. cylindrically around the AP axis; the
Images were acquired with inner diameter of the coil is 24 cm.
a 128x128 matrix in 36 slices,
230x230 mm2 FOV, phase-encoding
in anterior-posterior direction, a slice
thickness of 3.6 mm, 10 averages,
and an iPAT factor of 2 (24 reference
lines); the echo time was 71 ms and
the repeat time 6000 ms. DTI with
iPAT displays less distortion artifacts
than DTI with conventional EPI
sequences (Fig. 3). Evaluating the
diffusion-weighted images, parameter
maps with the mean ADC, the diffu-
sion anisotropy, and the main direction
of diffusion can be calculated (Fig. 4).
Although an N/2 artifact in phase-
encoding direction (anterior-posterior)
is visible in some of the original EPI
images, this artifact seems not to
influence the calculated parameter Figure 2 Comparison of SNR with standard head coil (a) and 8-channel
maps. An additional advantage of head coil (b). Both images are acquired with identical sequence parameters
iPAT imaging is the reduced duration (diffusion-weighted EPI sequence, b = 1000 s/mm2, no averaging) and
of the readout that allows for the without iPAT.
acquisition of an increased number
of slices within the given repetition
time (TR) compared to conventional
sequences, e.g., 38 slices without
iPAT vs. 50 slices with iPAT given a
TR of 6000 ms.

Larynx imaging
Magnetic resonance imaging of the
larynx is difficult due to tissue motion
caused by swallowing and respiration
[6]. Generally, MR pulse sequences
with long acquisition times are more
sensitive to motion than fast imaging
sequences or even single-shot
sequences. Therefore, MRI of the
larynx at conventional speed often
leads to images with excessive
motion artifacts.

Since moving organs like the larynx Figure 3 Comparison of spin echo EPI images in two slices with (a, c) and
can be more clearly visualized by without (b, d) iPAT (GRAPPA algorithm). Some obvious susceptibility artifacts
reducing the image acquisition time, are marked with arrows in (b) and (d).
8
TECHNOLOGY CORNER

iPAT sequences can reduce the


sensitivity to motion artifacts by
accelerating image acquisition while
maintaining the same image resolu-
tion. Thus, we use T1-weighted
and T2-weighted iPAT sequences for
routine larynx imaging, e.g. in
patients suffering from suspected
laryngeal carcinoma. A pair of dedi-
cated iPAT surface coil systems with
2x6 coil elements is arranged around
the lower part of the head and neck
of the patient. To compensate for the
iPAT intrinsic SNR loss, we increase
Figure 4 Examples of DTI evaluation from diffusion- the number of acquisitions to 5
weighted iPAT images: ADC map (a, d, g) with diffusion (T1-weighted gradient echo sequence
coefficients from 0 (black) to 2.5x10 -3 mm2/s (white); with TR/TE = 176 ms/4.8 ms, 24* iPAT
fractional anisotropy (b, e, h) from 0 (black) to 1 (white);
reference lines) and 3 (T2-weighted
color-coded main diffusion direction (c, f, i),
TSE sequence with TR/TE = 3970 ms/
left-right: red, anterior-posterior: green, cranio-caudal:
blue. Note especially the high anisotropy and left-right 89 ms, echo train length 15, 45* iPAT
diffusion direction in the corpus callosum. reference lines). Both sequences
have a 512x384 matrix, a FOV of
300x281.3 mm2 and a slice thickness
of 3.5 mm. The GRAPPA algorithm is
used for iPAT reconstruction.
The acquired images show a better
delineation of tumor extent and less
motion artifacts than MRI using
non-iPAT techniques, thus allowing
accurate diagnosis of laryngeal
carcinoma (Fig. 5). In our experience,
MRI with iPAT using a flexible 12-
element phased-array coil is suitable
for reliable diagnosis when laryngeal
carcinoma is suspected. Generally, in
imaging moving tissue it appears
preferable to acquire more averages
with reduced imaging time using
iPAT and thus gain images with
identical resolution and comparable
SNR but less motion artifacts than
in conventional non-iPAT imaging.

Figure 5 Axial MRI scan through the supraglottic larynx, all images show
the same scan position. The images demonstrate a large supraglottic tumor
infiltrating the preepiglottic space, the left paraglottic space and the left
aryepiglottic fold.
(a) T1-weighted image showing muscle-isointense tumor.
(b) T1-weighted image demonstrating contrast-enhancement of the tumor. * In each case the actual number of lines
measured is half the number of reference lines
(c) T2-weighted axial image showing slightly hyperintense tumor tissue. mentioned in the text. This is due to the fact
(d) T1-weighted fatsat image demonstrating contrast enhancement of the that every other line is already part of the iPAT
tumor. Spinocellular carcinoma was found at surgery. scan.

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MAGNETOM FLASH

Lung imaging
MR screening of infiltrates
Radiological lung screening is typically
performed either by conventional
Figure 6 iPAT HASTE images of a
x-ray (CXR) examination or by high- healthy volunteer reconstructed with
resolution computed tomography GRAPPA (a) and mSENSE (b) algorithm.
(HR-CT) of the thorax and therefore Note the reconstruction artifacts
exposes patients to a considerable superimposing the spine in (b).
amount of radiation, particularly
after repeated examinations. This
radiation dose could be reduced by
using MRI as screening modality
instead of x-ray based methods.
Unfortunately, MRI of the lung is still
a technical challenge because of the
very low proton density of the lung
tissue and the strong variation of
susceptibility leading to very short
T2* relaxation times. Both factors
together are the reason for very low
MR signal intensities from lung
parenchyma and hence for a low
SNR. A further difficulty in lung MRI is
tissue motion because of respiration
and cardiac motion.
The introduction of iPAT opened new
possibilities to lung imaging with Figure 7 Ground glass infiltrate in
immunosuppressed patient.
T2-weighted HASTE sequences. The
Multi-detector HR-CT (a) and iPAT
main disadvantage of conventional HASTE MRI (b).
HASTE sequences is the blurring of
images caused by the long echo train
and the T2-related signal decay
during its readout; this effect severely
limited the actual maximum image
resolution [7]. By using iPAT, the
echo train can be reduced to half of
its original length and thus blurring
artifacts are reduced. Since late
echoes with low signal intensity are
not acquired, SNR can even improve
compared to non-iPAT sequences.
Additionally, the image acquisition is
accelerated such that more slices can
be acquired during one breath-hold Figure 8 Small irregular infiltrates
period. in immunosuppressed patient.
Multi-detector HR-CT (a) and iPAT
To evaluate the use of iPAT HASTE HASTE MRI (b).
sequences for lung screening, we
compared HR-CT and MR images in
immunosuppressed patients with
symptoms of pneumonia but normal
10
TECHNOLOGY CORNER

or unspecific CXR. After comparing


iPAT images reconstructed with the
GRAPPA and mSENSE algorithm
(Fig. 6), we decided to use the GRAPPA
algorithm because of the occurrence
of reconstruction artifacts in the
image center of the mSENSE images.
Coronal slices of the lung are acqui-
red with a FOV of 400x400 mm2 and
a resolution of 320x320 pixels; axial
slices with a FOV of 400x320 mm2
and a 320x256 matrix. The slice
thickness is 8 mm and the TE is 27 ms
in both sequences. To reduce the
echo train length as far as possible, a
Siemens WIP* sequence was used.
Examples of the findings are shown
in Figs. 7-10.
We found that lung MRI with iPAT
HASTE sequences is nearly as good as
Figure 9 Discrete atypical infiltrates HR-CT for the detection of pulmonary
in immunosuppressed patient. infiltrates with only few false-negative
Multi-detector HR-CT (a) and iPAT and false-positive cases such that
HASTE MRI (b). MRI can be recommended especially
as a follow-up tool after initial HR-CT
diagnosis.

MR angiography and perfusion


imaging
Contrast-enhanced vascular lung MRI
requires a good spatial resolution
and – especially in the case of perfu-
sion imaging – also a good temporal
resolution. Both are limited by the
breath-hold duration for the patient
rather than by SNR considerations
Figure 10 Discrete atypical infiltrates due to the high-contrast situation in
in immunosuppressed patient. contrast-enhanced MRI. Experiences
Multi-detector HR-CT (a) and iPAT on MR perfusion imaging of the lung
HASTE MRI (b). are still limited and various approa-
ches like conventional FLASH and
HASTE sequences or flow-sensitive
inversion recovery techniques are
used [8-10]. However, using iPAT
techniques, both temporal and
spatial resolution can be significantly

* The information about this product is


preliminary. The product is under development
and is not commercially available in the U.S.,
and its future availability cannot be ensured.

11
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MAGNETOM FLASH

increased compared with conventional myocardial function. There is no


imaging. doubt that MRI represents the current
standard of reference. Although
We therefore added iPAT FLASH
dataset acquisition can be performed
sequences to our protocol for 3D
in virtually any plane, the calculation
contrast-enhanced MR angiography
of functional parameters is most
(MRA) and MR perfusion imaging of
commonly based on a stack of slices
patients with primary and secondary
in double oblique short-axis orien-
pulmonary arterial hypertension.
tation. To allow for high spatial as
Using GRAPPA with the optimized
well as high temporal resolution, the
12-element iPAT coil, a temporal
current sequence techniques acquire
resolution of 1.2 seconds per phase is
a single-slice cine data set each
possible for dynamic perfusion
breath-hold. Although innovations of
imaging, acquiring 25 dynamic
recent years allowed for a speed up
phases in 30 seconds; the image
of techniques, a completion of a
resolution is 1.5x3.0x4.0 mm3 acqui-
standardized functional study still Figure 11 Dynamic pulmonary
red with a 256x128 matrix in 24
takes about 10-15 minutes including perfusion imaging using iPAT to
slices. High resolution angiograms
patient recovery periods. Real-time acquire a slab of 24 images each
can be acquired with a 512 matrix 1.2 seconds. Perfusion defects are
imaging techniques using steady-
(0.8x1.0x1.6 mm3 voxel size) in 20 shown in the left upper lobe and
state free precession (SSFP) sequences
seconds breath-hold time. For both right lower lobe.
such as TrueFISP, allow for a major
dynamic perfusion and high-resolution
speed up in data acquisition due to
angiography, an iPAT acceleration
the completion of a short-axis dataset
factor of 2 is used with 24 reference
within a single breath-hold [11, 12].
lines*.
However, this comes along with
Image examples of these sequences a restriction in spatial and temporal
are shown in Figs. 11 and 12. Using resolution. And in terms of volumetric
the parallel acquisition technique, accuracy, temporal resolution is
excellent visualization of subsegmen- far more crucial than spatial resolution
tal vessels is possible in the angio- as recently shown by Miller and
graphic images. Time-resolved co-workers [13]. The current recom-
perfusion imaging allows a reliable mendation for functional cardiac
detection of small segmental and imaging requests a temporal resolution
subsegmental perfusion defects. of 50 ms or even better.
Using non-iPAT methods, visualization
of perfusion defects and intravascular iPAT allows this criterion to be met
thrombi is generally possible as well, when implemented in conjunction
although with lower temporal and with real-time TrueFISP. Compared
spatial resolution than using iPAT to previous studies performed by
methods. In conclusion, we could Barkhausen and Lee [11, 12], the
substantially improve the temporal temporal resolution that can be
resolution as well as the spatial achieved is in the order of 45-50 ms.
resolution by using iPAT. And as most recently shown, this Figure 12 Example of an iPAT
improvement in temporal resolution high-resolution pulmonary MR
now leads to an accuracy of results angiography of the same patient as
Functional cardiac imaging comparable to that of segmented in Fig. 11. A significant reduction of
TrueFISP [14] (Figs. 13-16); the iPAT arterial enhancement can be
Global and regional cardiac images are acquired with an accele- demonstrated in the left upper lobe
function ration factor of 2 and 12 reference and right lower lobe due to central
Cardiac magnetic resonance imaging lines. Accordingly, iPAT not only thromboembolic occlusions.
has been extensively used in the allows for dramatic time savings in
assessment of global and regional cardiac function analysis without
12
TECHNOLOGY CORNER

Figure 13 Short axis view of a male Figure 14 A single slice of the


patient with impaired right ventricular multi-slice iPAT real-time cine data set
function due to pericardial disease. at exactly the same slice position as
Images acquired with a segmented in Fig. 13. Comparable time points in
TrueFISP technique showing diastole (a) diastole and (b) systole.
(a) and systole (b).

Figure 15 Patient after myocardial Figure 16 Comparison with Fig. 15


infarction with ischemic dilatating at identical slice position.
cardiomyopathy. Diastolic (a) and iPAT real-time TrueFISP shows the
systolic (b) images acquired with same marked thinning of the anterior
segmented TrueFISP show almost no wall without change within diastole
change in ventricular shape (ejection (a) and systole (b).
fraction < 25 %).

* In each case the actual number of lines


measured is half the number of reference lines
mentioned in the text. This is due to the fact
that every other line is already part of the iPAT
scan.

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MAGNETOM FLASH

losing accuracy of volumetric results, Figure 17 Combination


but even allows for a multiplanar of segmented cine TrueFISP
data acquisition within a single with iPAT. In comparison
breath-hold. to standard techniques
(a; pixel size 1.5x1.5 mm2),
Based on experiences and comparisons, the use of iPAT allows
the GRAPPA reconstruction shows a for a marked increase of
spatial resolution
more robust image quality in cardiac
(b; pixel size 1x1 mm2).
MRI than mSENSE [1]. Due to the
higher sensitivity of SENSE-related
methods to folding artifacts, these
techniques seem to be less useful
in cardiac imaging because of the Figure 18 Images of MR
necessary larger FOV that leads either perfusion data sets using a
to an additional loss of spatial resolu- saturation recovery Turbo-
tion or to loss of acquisition time FLASH technique. Compa-
when more phase-encoding lines are rison of a non-iPAT Turbo-
FLASH technique (a) with
acquired. Apart from the use of iPAT
an iPAT (GRAPPA) Turbo-
with real-time techniques, it also FLASH technique (b). There
allows for a further improvement of is considerable more noise
spatial or temporal resolution in within the iPAT image
segmented single-slice acquisitions which hampers depiction
compared to standard techniques of perfusion abnormalities
(Fig. 17). In general, when using cine based on the low SNR.
TrueFISP techniques, the loss in SNR
due to iPAT is almost negligible.

Myocardial perfusion imaging*


Myocardial perfusion imaging is a
promising and rapidly increasing field
in cardiac MRI. The rapid development
of scanner hardware allows also for
an improvement in sequence techno-
logies which has been of a major
benefit in techniques that require an
ultra-fast data acquisition such as Figure 19 Saturation recovery TrueFISP
myocardial perfusion imaging. MR perfusion images combined with iPAT
perfusion imaging has intrinsic (GRAPPA) and a high in-plane resolution of
benefits compared to routinely used 2.1x2.1 mm2. In contrast to saturation
techniques of nuclear medicine such recovery TurboFLASH, the spatial resolution
as single photon emission computed is still high enough to follow signal dynamics.
tomography (SPECT) imaging or even
positron emission tomography (PET)
which represents the current gold
standard in clinical perfusion imaging.
Apart from the higher spatial resolu-
tion and lack of radiation exposure,
myocardial MR perfusion imaging * The information about this product is
preliminary. The product is under development
has no attenuation problem related and is not commercially available in the U.S.,
to anatomical limitations. and its future availability cannot be ensured.

14
TECHNOLOGY CORNER

With the use of magnetization- holds such that the liver is examined breath-hold and respiratory-triggered
prepared TurboFLASH techniques, in several stacks of slices, may result techniques, the latter turned out to
however, such as saturation recovery in parts of the liver being missed if be more robust in patients whereas
TurboFLASH, the SNR has reached a the patient does not meet the same no difference in image quality was
limit (Fig. 18). Therefore a combina- position of the diaphragm in all observed in volunteers. An explana-
tion with iPAT techniques seems to stacks [19]. tion for this result is that patients
be of less benefit, as a further loss in have more difficulty with the breath-
The development of iPAT allows for
SNR is produced. Newly developed hold period of up to 20 seconds. In
a substantial reduction of acquisition
techniques for myocardial perfusion conclusion, iPAT liver examinations
time, and thus breath-hold sequences
imaging based on SSFP techniques with respiratory triggering appear
with improved spatial resolution
are currently under investigation to be the most robust approach for
can be used. 2D navigator-based
[15]. In comparison with TurboFLASH clinical routine examinations.
techniques, as the Prospective Acqui-
techniques, these sequences (avail-
sition Correction (PACE) technique,
able as Siemens WIP package) show
known from cardiac imaging, can
a considerable higher intrinsic SNR,
therefore allowing for a minimal to
adapt the stacks of slices according High-resolution renal
moderate loss of SNR when combi-
to the respiratory position by registe- MR angiography
ring the diaphragm position, so
ned with iPAT (Fig. 19). Three dimensional gadolinium-
that the whole liver can be covered
even if the patient does not hold his enhanced magnetic resonance
breath at the same position [21]. angiography (3D-Gd-MRA) has
Liver imaging gained high popularity as a non-
We compared four high-resolution invasive imaging alternative for
MR liver imaging is most severely T2-weighted sequences with 5 mm grading of renal artery stenosis [22].
restricted by respiratory movement. slice thickness and a 320x240-256 High accuracies of over 90 % have
Therefore, image quality was con- matrix for routine liver imaging: been reported by numerous resear-
siderably improved with the intro- a breath-hold TSE sequence with and chers in the past five years [23].
duction of T2-weighted turbo spin without iPAT and PACE (echo train Nevertheless, the technique is still
echo (TSE) and single-shot sequences. length: 27, TR = 2120 ms, TE = 87 ms, notoriously known for over-grading
With these techniques, breath-hold 4 breath-hold cycles, iPAT factor 2, high-grade renal artery stenoses and
examinations of the liver became 24 reference lines*), and a respira- missing low-grade lesions, thereby
possible, which most authors consider tory-triggered TSE sequence with and limiting its overall clinical acceptance
superior to conventional spin echo without iPAT (echo train length: 25, [24]. A recent Dutch multi-center
sequences [16-18]. Generally, a min. TR = 2680 ms, TE = 117 ms, trial presented less encouraging
maximum breath-hold time of about iPAT factor 2, 24 reference lines). results with overall accuracies of only
20 seconds, tolerable even for patients All images were acquired with a 12- 85 % compared to DSA. In addition,
in bad health condition, is a limiting element surface coil system optimized no reliable data on grading of stenoses
parameter for all sequences used for for iPAT applications. A respiration of the more distal main renal artery
liver imaging. belt was used for triggering. The aim or segmental arteries exists yet [25].
was to demonstrate the feasibility of
Respiratory-triggered T2-weighted iPAT and PACE for T2-weighted liver One major limiting factor is spatial
sequences have been studied as an imaging and to evaluate image resolution. For standard breath-hold
alternative to the breath-hold strategy quality of the different sequences. acquisitions with bolus administration
with contradictory results [16, 19, 20]. of extracellular, non-intravascular
Image examples of all sequences are
An advantage of respiratory-triggered gadolinium chelates, the maximum
shown in Figs. 20 and 21. In general,
sequences is the ability to perform achievable spatial resolution repre-
imaging with iPAT reduced the
high-resolution examinations with sents a compromise between scan
acquisition time by almost 50%
5 mm slice thickness which has not time, anatomic coverage and SNR.
without visible SNR loss. Comparing
been possible with breath-hold Current imaging protocols usually
sequences due to the limited breath- * In each case the actual number of lines obtain images with a maximum of
hold time. An attempt to overcome measured is half the number of reference lines 1.5 mm3 isotropic resolution which
mentioned in the text. This is due to the fact
this limitation of breath-hold imaging that every other line is already part of the iPAT still represents 5 to 7 fold less than
by examinations with multiple breath- scan. that of digital subtraction angiography
15
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 20 Examples of T2-weighted liver images: Figure 21 Examples of T2-weighted liver images:
Breath-hold sequence without iPAT (a) and with iPAT (b), Breath-hold sequence without iPAT (a) and with iPAT (b),
respiratory triggering without iPAT (c) and with iPAT (d). respiratory triggering without iPAT (c) and with iPAT (d).
Note the markedly reduced artifacts in the breath-hold Respiratory triggering shows less motion artifacts and
sequence with iPAT (b) of this subject, who had better delineation of the diffuse HCC due to better T2
problems holding his breath. Respiratory triggering as contrast.
well compensated this problem.

Figure 24 Comparison of propaga-


ted aliasing artifacts in the same
Figure 23 Coronal MIP image of patient using the mSENSE (a) and
high-resolution MRA with iPAT (a) GRAPPA (b) algorithm. The field of
reveals excellent agreement to view was on purpose set to only
DSA (b). Both high-grade renal artery 32 cm to enforce aliasing of the
Figure 22 Multiplanar reformats stenoses are seen including the arms. In the mSENSE images severe
of a high-resolution 3D-Gd-MRA. In residual vessel lumen. Note the artifacts occur in the center of the
the cross-sectional reformats of the absence of any major aliasing image (arrows) while these artifacts
vessel (lower image series) even artifacts in the center of the image. are virtually absent on the GRAPPA
the area of the stenotic lumen can images.
be clearly demonstrated due to the
isotropic spatial resolution.

16
TECHNOLOGY CORNER

(DSA). In a renal artery with a diame- ranging from 20 % luminal narrowing Whole-body imaging
ter of 7-8 mm, an isotropic voxel to occlusion. Image analysis of the
size of at least 1 mm3 is required for isotropic data sets consisted of multi- Because of the recent improvements
accurate depiction of a 90 % reduc- planar reformats along the vessel in hardware and software and the
tion in lumen diameter. axis to assess the degree of diameter lack of ionizing radiation, magnetic
reduction. In addition, reformats resonance imaging has become
Parallel acquisition techniques allow perpendicular to the vessel axis were a candidate for screening imaging
for improvement of spatial resolution performed to assess the degree of [28]. We have developed an MR
without prolonging data acquisition reduction of vessel area. Using examination which combines well
and are well suited for images with a multiplanar reformats the degree of established components including
high SNR such as 3D-Gd-MRA. Based stenosis was correctly assessed in 18 functional cardiac imaging together
on previous calculations, it is expected of 20 patients. In 2 cases, the degree with myocardial perfusion* imaging,
that voxel sizes of less than 1 mm3 of stenosis was overestimated. imaging of the lung, brain, an overall
are substantially limited by SNR However, when reformats were view of liver, kidneys, spleen, and
constraints [26]. Therefore, it was performed in the isotropic data sets pancreas, as well as the arterial
our aim to increase spatial resolution perpendicular to the vessel axis, all system.
to maximum values within this range. stenoses could be correctly identified The whole-body examination is
The iPAT strategy was applied on an compared to x-ray angiography performed in two parts. In the first
8-channel MAGNETOM Sonata Maestro (Figs. 22 and 23). part, the patient is in a head first
Class System in combination with a
One limitation is the propagation position; the spine array, two body
fast 3D FLASH sequence (TR = 3.79,
of aliasing artifacts into the center of arrays, and a head array are used as
TE = 1.3, Bandwidth = 350 Hz/pixel,
the image. These artifacts could be receiver coils. In the second part, the
flip angle = 25°). Nearly isotropic
theoretically avoided by extending patient is in a feet first position; the
data sets with a spatial resolution of
the FOV in the left-right direction so spine array, the large FOV adapter,
0.8x0.8x1 mm3 could be acquired
that no aliasing occurs at all. In one or two body arrays (depending
within 23 seconds [27]. For signal
clinical practice, however, this would on the height of the patient), and the
reception the 12-element array coil
mean a substantial increase in scan peripheral angio array are used as
system was used. An acceleration
time, in particular in large patients. receiver coils. iPAT with an accelera-
factor of 2 was used with 24 reference
In addition, not all patients are able tion factor of two is applied for most
lines for auto-calibration of the coils.
to put their arms over their heads. scans of the examination including
For data acquisition and reconstruc-
Therefore some degree of aliasing real-time TrueFISP imaging of the
tion, the GRAPPA and mSENSE algo-
into the margins of the FOV has to heart (Fig. 25), high-resolution
rithms were compared in terms of
be accepted. Using the GRAPPA imaging of the lung (Fig. 26) as well
artifacts. To improve the contrast-to-
algorithm, artifacts propagating from as dynamic cardiac perfusion* MRI
noise ratio, the one molar contrast
tissue outside the FOV into the with TrueFISP. In addition, iPAT of
agent gadobutrol (Gadovist®, Schering
center of the image were kept at a 3D-Gd-MRA in combination with the
AG, Germany) was administered at
minimum. Only slight ring-like large FOV adapter is performed for
a dose of 1.25 mmol/kg body weight
artifacts occurred, which did not all studies allowing a total scan time
with an injection rate of 2 ml/s.
affect the image interpretation. How- of only 62 seconds to cover the area
In the iPAT images, SNR decreased ever, when the mSENSE technique from the thoracic aorta down to
by a factor of about 1.5 compared to was alternatively used, these artifacts the toes at a spatial resolution of less
the data without iPAT. This decrease were more severe (Fig. 24). than 1.4x1.0x1.5 mm3 (Fig. 27).
in SNR could be visually noticed in By applying the GRAPPA algorithm
the source images, however the In conclusion, high-resolution renal
3D-Gd-MRA using iPAT allows for with its integrated auto-calibration
intravascular signal was still accept- scan, it is possible to use flexible
able. In the MIP images, the overall substantial improvement of spatial
resolution, thereby increasing dia- combinations of receiver coils with a
decrease in SNR was hardly detected. flexible choice of iPAT directions and
gnostic accuracy compared to digital
The high-resolution renal 3D-Gd-MRA subtraction angiography. Using
data sets were compared to selective the GRAPPA based algorithm, artifacts * The information about this product is
preliminary. The product is under development
x-ray angiography in more than propagating into the center of and is not commercially available in the U.S.,
20 patients with renal artery stenosis the FOV can be kept at a minimum. and its future availability cannot be ensured.

17
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 25 Single breath-hold


evaluation of global cardiac function
with real-time iPAT TrueFISP.

Figure 26 Imaging of the brain,


lungs, and abdomen as part of the
whole-body screening examination.

Figure 27 Example of gadolinium-


enhanced MR angiography as part of
the whole-body screening examina-
tion. Note the excellent visualization
of vessel segments down to the
pedal arch. No stenoses are present.
18
TECHNOLOGY CORNER

to move the patient table for different visualization of tumors in areas with
iPAT acquisitions. The advantage increased motion such as the larynx.
of iPAT in this kind of exam is the Higher temporal resolution improves
coverage of a large anatomic region the accuracy of cardiac real-time
and gain of time. techniques using SSFP sequences to
measure global cardiac function
In the last two months twenty indi- within a single breath-hold.
viduals, referred by their physician
while participating in a manager In addition to the general benefits
healthcare program, underwent the of parallel imaging, the iPAT methods
whole-body scan in our department. GRAPPA and mSENSE feature some
All twenty individuals tolerated the unique advantages. Artifacts in the
MR examination well. Compared to center of coronal images resulting
the conventional examination techni- from aliasing of tissue outside Co-workers on parallel
ques like ultrasound and ECG, we the FOV are substantially suppressed imaging
have established a more comprehen- using the GRAPPA algorithm. The Roger Eibel (pulmonary imaging)
sive exam within reasonable scan iPAT algorithms with auto-calibration
integrated into the individual scan Wilhelm Flatz (imaging of the larynx)
time. First results of pathologic
findings (scar in lung, aortic stenosis, are less sensitive to patient motion Peter Herzog (pulmonary imaging)
renal artery stenosis) show good than other parallel imaging techniques Armin Huber (cardiac imaging)
correlation with the gold standard with a single measurement of the Wolfgang Klinger (MR technician)
examinations. coil sensitivity profiles at the start of
the examination. In addition, the Harald Kramer (whole-body imaging
IPA™ (Integrated Panoramic Array) and screening)
allows a flexible combination of Konstantin Nikolaou (cardiac
Conclusion multiple receiver coil systems. There- imaging and pulmonary imaging)
fore, large anatomic coverage with Carola Schmid (MR technician)
This overview on applications and
various receiver coils and a flexible Frank Stadie (MR technician)
ongoing studies in different areas of
choice of the iPAT directions is
the body supports the current trend Robert Stahl (diffusion tensor
possible. This is particularly helpful
to use parallel imaging in the majority imaging)
for whole-body imaging where
of clinical scan protocols. The general Anja Struwe (MR technician)
multiple receiver coil systems are
advantages of parallel imaging are
combined to scan the entire body Bernd J. Wintersperger
now well established. This includes
with parallel imaging techniques. (cardiac imaging)
the possibility for higher spatial reso-
Scan time for a complete cardio- Christoph Zech (abdominal imaging)
lution for 3D-Gd-MRA with shorter
vascular exam is substantially reduced
breath-holds, thereby potentially
while spatial and temporal resolution
improving the accuracy of this tech-
of the individual scans are preserved.
nique for grading of renal artery Acknowledgements
stenosis. The combination of time- In conclusion, iPAT can be used to
We would like to thank the Magnetic
resolved and high-resolution 3D-Gd- improve most clinical protocols for
Resonance Development Department
MRA improves the detection and comprehensive morphologic and
of Siemens Medical Systems and
differentiation of pulmonary hyper- functional imaging. Depending on
especially Mathias Nittka, Berthold
tension. The use of shorter echo the specific application its main
Kiefer, and Rolf Sauter for their
trains for single shot HASTE or echo advantages are a decrease in imaging
technical support.
planar imaging results in less image artifacts or an increase in speed,
distortion and less signal decay. spatial, or temporal resolution.
Initial results show benefits for EPI
diffusion tensor imaging in the brain
as well as detection of early infiltrates
in the lung with HASTE imaging.
Imaging with multiple averages in
shorter acquisition times improves
19
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

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Simonetti OP, Lee P, Weinreb JC.
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MAGNETOM FLASH

Motion Under Control with Prospective


Acquisition Correction (PACE)
Michael Szimtenings, Ph.D. Figure 1 Positioning
Siemens Medical Solutions USA, of the pencil-shaped
volume across the
Inc.
diaphragm for 1D PACE
in an axial (a) and
coronal (b) plane. The
cross-section of the
pencil-shaped volume is
defined by the intersec-
tion of the two turquoise
boxes in the axial plane.
In a variety of MRI applications, The length of the pencil-
motion can adversely affect image shaped volume is
quality. Since patient motion cannot depicted in the coronal
be controlled sufficiently in all cases, plane (turquoise box).
Siemens has developed strategies
to maintain image quality despite and used for motion correction – in
motion. Correction of motion effects real time. In 2D PACE, an image is
at the post-processing stage would acquired by means of a low-resolution
be one approach. However, there is gradient echo sequence featuring
nothing better than acquiring good a low flip angle; this ensures that
data in the first place, and strategies magnetization is not saturated, so
to account for motion during acquisi- that dark lines in the image are
tion are currently offered on Siemens avoided. The user places a small box
MR scanners. These “Inline” techni- across the diaphragm on the 2D
ques for coping with motion are image (Fig. 2). The change in signal
collectively termed PACE (Prospective intensity along the axis of the box is
Acquisition CorrEction). Correspon- used to determine the position of the
ding to the spatial dimensions of diaphragm. Since a 2D image provides
the dataset used for calculating the more information than a single line,
adjustment, these techniques are this method is very robust. The time Figure 2 Selection of the 2D area
termed 1D PACE, 2D PACE, and 3D needed to acquire an image for 2D (turquoise box) used for detection of
PACE. The first two are used mainly PACE is around 100 ms. The highly the diaphragm position when using
to deal with breathing motion, while reliable 2D PACE technique is unique 2D PACE. Half the box should cover
the third one is applied for motion to Siemens. the lungs, the other half the liver.
adjustment in neurological studies. The advantages afforded by 1D ducibility of the breathhold position.
and 2D PACE can be used in a variety In this way, gaps between slices or
of ways. overlaps are avoided.
1D PACE and 2D PACE
Without PACE, the operator would
Method have to visually inspect the image-
The fastest method of detecting Application: stacks and determine if there are
motion is 1D PACE (also known as a Multiple breath-hold examinations gaps or overlaps between them – a
“navigator” technique). It typically For patients who can hold their breath tedious process that is highly opera-
requires only 30 ms and is used for only a short time, the acquisition tor-dependent. During this time the
primarily for minimizing the effects can be split up into multiple breath- patient would have to remain in the
of breathing motion in cardiac holds. The information about the scanner, since it might be necessary
exams. For this purpose, a single line diaphragm position allows the opera- to cover gaps with additional scans.
of data from a pencil-shaped volume tor to monitor the breathing pattern Therefore, a lack of PACE capabilities
that crosses the diaphragm is acquired. of the patient online. Furthermore, would cause unnecessary and costly
The volume is interactively placed acquisition of slices during different prolongation of the total exam-time,
(Fig. 1) in such a way that the position breath-holds can be aligned in order which in turn would lead to decreased
of the diaphragm can be calculated to compensate for imperfect repro- patient compliance and comfort.
22
TECHNOLOGY CORNER

Application:
Breathe freely with PACE
For some patients, even the shortest
breath-hold duration might be too
demanding; or, patients may be
unable to follow breathing commands
due to impairments in mental status.
In such cases, PACE allows for imaging
while the patient is breathing freely. Figure 3 Images of coronary arteries acquired using 1D PACE.
During a short “learning phase”, the In (a) the left coronary artery is visible brightly due to the bright-blood
breathing of the patient is analyzed contrast inherent to the TrueFISP sequence. In (b) the right coronary
and the central position of an “accep- artery is displayed as a dark line, since the black-blood contrast
tance window” is calculated auto- preparation of the TSE sequence makes the blood signal disappear.
matically. Next, the gated acquisition
begins: slices are acquired only when
the diaphragm position falls within
the acceptance window. Here, the detection, and instantaneous adjust- to be able to adjust to the movement.
slice positions of different scans can ment of the acquisition according 3D PACE is a feature unique to
also be aligned based on information to this information, are crucial. Siemens scanners. Its usefulness can
about the position of the diaphragm. Here, complete multi-slice EPI data- be seen in Fig. 4: without motion
Without PACE, it would be extremely sets of the head are acquired in rapid correction at all, or with retrospective
difficult (or even impossible) to succession during presentation of correction only, the fMRI activation
perform useful MR studies in patients various stimuli. In order for the maps are much less meaningful
who cannot hold their breath. statistical analysis to be successful, (statistically significant differences
the datasets need to be aligned are “lost” in the motion-induced
perfectly. For this purpose, each 3D “noise”). Without 3D PACE, fMRI
1D PACE or 2D PACE dataset is compared with the previous studies such as the one shown in
one and the translation as well as Fig. 5 would be much noisier and
Whether 1D PACE or 2D PACE should
the rotation of the head are calculated may even turn out to be entirely
be used depends on the application.
(and displayed) in real-time. The useless due to motion artifacts.
Cardiac exams benefit from the
software is able to compensate for
speed of 1D PACE. In order to obtain
rotations and translations in all
cine-images with high frame rates,
6 degrees of freedom. The technique
motion detection should be as fast Conclusion
can therefore account, in real time,
as possible. Also, saturation in the
for any so-called “rigid-body motion”.
pencil-shaped volume is not a problem, The essential feature of Siemens’
For acquisition of the next dataset,
since it can be placed outside the PACE technology is the prospective
slice position and orientation are
heart. Fig. 3 shows images of coronary adjustment of an acquisition’s scan
adjusted according to the altered
arteries acquired in this way. For parameters in order to minimize
position of the head.
abdominal imaging, 2D PACE is the motion artifacts. With the help of 1D
best choice, since the scan time and 2D PACE, breathing motion can
extension is not significant. On multi- For 3D PACE, no additional data be monitored and corrected, and the
breathhold exams, for example, acquisition is needed since the variability of breath-hold positions
breath-hold times are extended only detection of motion is done on the in multiple breath-hold exams can be
by a tenth of a second as a result of actual imaging data, which is typically virtually eliminated. 1D PACE takes
using 2D PACE. reacquired every 2-4 seconds. To very little extra time, making it ideal
account for potential motion effects for cardiac MR exams. 2D PACE
even within this short period of time, features small flip-angles, leaving the
3D PACE a further retrospective correction is magnetization in the volume of
applied (in realtime) to the data. The interest practically undisturbed. It is
Functional MR imaging (fMRI) is interval between acquisitions can also a very robust technique, making
another application where motion be as low as 100 ms for the hardware free-breathing abdominal MR imaging
23
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

a clinical reality. 3D PACE is capable


of detecting, and correcting for,
linear and rotational motion in
6 degrees of freedom and in real-
time – a feature found only on
Siemens MR scanners. The advanced
real-time feedback capabilities of
Siemens MR systems are fully
exploited in the three versions of
Figure 5 Activation of right and PACE to provide a more comfortable
left primary motor cortex as detected exam for patients and to produce
by fMRI on a 1.5 T MAGNETOM sharper, more meaningful diagnostic
Sonata system. The paradigm was images.
alternating (30s/30s) left- and right-
handed finger tapping. For the
functional study, which took 4.0 min
to acquire, 3D PACE real time motion
Figure 4 Activation maps of an fMRI correction was employed. An anatomi-
study, during which the volunteer cal dataset was pre-acquired in
performs nodding head motions of 6.3 min. The use of 3D PACE improves
1.5 degrees in correlation with a fMRI results by ensuring more
stimulus. Data were acquired without robust activation detection and better
motion correction at all (a), with suppression of motion artifacts.
retrospective motion correction only
(b), and with 3D PACE (c). The virtual
elimination of pixels falsely showing
activation is clearly seen in the
3D PACE image. Only the real diffe-
rences between regional activations
are shown in (c).

24
TECHNOLOGY CORNER

MRCP with 2D PACE

Wilhelm Horger ment of normal pancreatic paren- ■ motion induced artifacts


Application Development chyma with atrophy, fibrosis and (respiratory-, peristaltic-, cardiac-
MREA-Clinical calcification as well as ductal dilata- motion) or
tion, strictures and calculi) even the
■ the long measurement time for
dilated side branches of the pancreatic
Alto Stemmer obtaining high resolution.
duct can be seen.
Application Development
Pancreatic pseudocysts are encapsu-
MREA-Clinical
lated collections of pancreatic fluid
Option 1:
caused by acute/chronic pancreatitis Breath-hold technique
and they are well shown. MRCP Respiratory motion artifacts can be
This article addresses new MRCP
is far more sensitive in detection of largely eliminated to a great extent
techniques which will be implemented
pseudocysts than ERCP. by using breath-hold techniques
within syngo MR 2004A* for high
resolution imaging using free brea- A comprehensive MR imaging assess- in combination with T1-weighted
thing navigator-triggered (2D PACE) ment of the pancreatobiliary tract FLASH sequences with spectral fat
3D TSE-Restore sequences (at 1.5 T-3 T) normally includes, in addition to the saturation or in-/out-of-phase or with
or 3D HASTE with inversion recovery strong-T2-weighted Magnetic Reso- T2-weighted single shot TSE/HASTE
(at 0.2 T). nance Cholangio-Pancreatography sequences (thick slab or thin slices).
(MRCP), a (normal) T2-weighted When running T2-weighted single-
sequence (TSE), a T1-weighted FLASH shot techniques due to the measure-
Definition: with fat saturation and a dynamic ment time limited by the breath-hold
pre/post-gadolinium T1-weighted fat duration, very high resolution is not
Magnetic Resonance (MR) Cholangio- suppressed FLASH sequence. The easy to reach and the SNR is diminis-
Pancreatography (MRCP) is an imaging latter are not subjects dealt with in hed in comparison with multishot-
technique that noninvasively depicts this article. segmented TSE sequences. Further-
biliary and pancreatic ducts. This more, blurring due to T2 decay may
technique shows good correlation Strong-T2-weighted imaging display-
occur when long echo trains are
with the Endoscopic Retrograde ing selectively non-flowing fluid in
setup.
CholangioPancreatography (ERCP). the biliary and pancreatic ducts can
be done with:
(Strong)T2-weighted sequences
■ Thick slab and/or thin slices
Option 2: Free breathing
with fluid being bright allow optimal technique (2D PACE MRCP)
visualization of the anatomy and coronal/axial T2-weighted single shot
pathology of the biliary, and pancreatic TSE/HASTE Another technique which provides
ducts. Unlike other techniques like or with good image quality with free
ERCP, MRCP also allows visualizing ■ 3D TSE/HASTE techniques followed breathing is the 2D PACE MR Chol-
anatomy beyond these obstructions. by a MIP postprocessing. angiography (Available with syngo
MR 2004A). The advantages are:
Biliary and pancreatic ductal stones
Superposition of fluid-filled bowel ■ higher spatial resolution
are seen as filling defects, irregu-
larities like strictures, dilatations, portions can easily be identified by ■ better delineation of small
pancreatic cystic lesions, complex subsequently performing multiangle structures, strictures and small
peripancratic fluid collections and MIP projections or by administrating secondary ducts as well as filling
islet cell tumors can be visualized. negative contrast media. Nevertheless defects
when using 3D techniques it is very
Strong T2-weighted TSE/HASTE important also to review the original ■ reduction of motion effects in
sequences are the best to show peri- data to avoid the loss or change of patients who have difficulty or are
pancreatic edema, fluid collections. information due to postprocessing unable to breath-hold.
and to view also the conventional
With pathologic changes e.g. chronic * The information about this product is
axial T1- and T2-weighted images.
pancreatitis (an inflammatory process preliminary. The product is under development
of the pancreas with irreversible Difficulties in visualizing the and is not commercially available in the U.S.,
and its future availability cannot be ensured.
exocrine and endocrine dysfunction, pancreatico-biliary system might be The safety of imaging fetuses, infants has not
characterized by permanent replace- encountered due to either: been establised.

25
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Some image examples obtained with the new technique:

Chronic pancreatitis – secondary Subcapsular liver cyst and multiple Obstructive intrapancreatic diverticle
branches of the pancreatic duct small cysts (Courtesy Dr. Markus Henschel /
are clearly visible (Courtesy Dr. Markus Henschel / Bremen).
(Courtesy Prim.Univ.Doz. Dr. Gerd Bremen).
Reuther / Wien).

Dillated gall bladder and bile ducts Big gallstone in gall bladder Dilated biliary system. Chronic
2D PACE, free breathing (Courtesy Prof. Janisch / Erlangen). pancreatitis
(Courtesy Prof. Janisch / Erlangen). (Courtesy Prof. Janisch / Erlangen).

Dilated biliary system. Chronic pancreatitis Chronic pancreatitis –


Chronic pancreatitis (Courtesy Prof. Janisch / Erlangen). ”chain of beads” appearance of the
(Courtesy Prof. Janisch / Erlangen). pancreatic duct
(Courtesy Prof. Janisch / Erlangen).

26
TECHNOLOGY CORNER

Exam set-up

How to perform 2D PACE


MRCP?
Respiratory triggering reduces
motion artifacts by synchronizing
anatomical data acquisition with the
respiratory cycle. Navigator trigge-
ring uses a navigator (i.e. MR signals)
Cystadenocarcinoma to monitor the respiratory motion.
(Courtesy Prim.Univ.Doz. Dr. Gerd This distinguishes the new technique
Reuther / Wien). from the respiratory triggering
technique available with the product
Figure 1 Physio-PACE parameter
software, which uses a respiratory card.
belt to retrieve patient’s breathing
pattern. The respiratory belt is not
needed for navigator triggering. sition duration is n-times the time
needed to acquire a single echo train1.
Navigator triggering is available with
The respiratory period is defined as
the TSE PACE and with the HASTE
the time interval from one maximum
PACE sequence.
inspiration to next maximum inspira-
Both sequences offer the possibility tion. The respiratory period is roughly
to select a -90° RF pulse (the so called 5 seconds in healthy adults but may
‘restore pulse’) at the end of the echo be substantially shorter for children
train. This pulse flips the transverse or in the case of illness. The respiratory
magnetization back into longitudinal period can be measured in a brief
direction, which shortens the spin initial measurement. Select the ‘Scout
relaxation time. mode’ option in the Physio-PACE
parameter card and start the acquisi-
MAGNETOM Trio: volunteer with tion. After a complete respiratory
normal appearance of biliary ducts. To plan a navigator triggered interval (i.e. end inspiration has been
measurement, proceed as follows: detected at least twice) the median
■ Select the Trigger option listed respiratory period is displayed as
under Respiratory control on the ‘Respiratory cycle’ in the upper left
Physio-PACE card. corner of the image shown in the
Online display. Remember to deselect
■ Position the navigator on the the ‘Scout mode’ option prior to the
edge of the diaphragm in the coronal actual measurement.
localizer. Navigator positioning is
the same for all respiratory control The predicted total scan time shown
modes with navigator support and is in the upper left corner of the card
described in detail in the Siemens stack is the minimum possible scan
“Applications Guide”. time. The actual total scan time will
be longer, depending on the actual
■ Plan the slices as normal. Set up length of the respiratory period.
the imaging parameters (e.g. number The second line of the scan time tool
n of slices per concatenation, turbo tip provides the number of required
factor) to ensure that the acquisition respiratory cycles in the form 5+X.
duration TAcq is between one-third
and one-half of the expected average
MAGNETOM Concerto: volunteer respiratory-period. The tool tip of the 1
If a selective preparation pulse is used, the
with normal appearance of biliary measurement time provides the acquisition duration also includes the time
and pancreatic ducts. acquisition duration. In an interleaved
needed to play out the preparation pulse and
the time between the inversion pulse and the
multi-slice measurement, the acqui- 90°-excitation pulse (TI-time).

27
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

5 respiratory cycles for the learning If the standard setting is used the that the box encloses the whole
phase of the trigger algorithm plus trigger condition is: diaphragm trace during the proposed
X respiratory cycles for the imaging acquisition period. The parameter
phase. The actual total scan time will i. The series of detected diaphragm setting is fine for a certain respiratory
therefore be close to: positions must be rising; i.e. cycle, if the data are acquired in the
the patient must not breathe in. relaxed position near end expiration.
Actual total scan time ≈ (5+X) If the horizontal edge width of
ii. The latest detected diaphragm
* Average respiratory period the red boxes is comparable to, or
position must fall within a
■ Ask the patient to breathe regularly predefined acceptance window. greater than, one respiratory period
throughout the measurement and (horizontal distance from maximum
start the acquisition. The respiratory curve shown in the inspiration to next maximum inspira-
Online display during the imaging tion), the measurement must be
phase is incomplete (Fig. 3). During stopped and the acquisition duration
the anatomical data acquisition must be reduced. This is necessary
Principle of the navigator period the navigator is not played out to avoid artifacts and a low trigger
triggered sequence and therefore the respiratory trace rate. In the case of the TSE-sequence
can not be continued. As soon as the a smaller turbo factor or a reduced
The navigator-triggered sequence
system detects the onset of expira- number of slices per concatenation
can be split into two parts. The first
tion, the acceptance window is shortens the acquisition duration.
part is the initial learning phase,
shown as a yellow box in the Online In the case of the single shot HASTE
which is needed by the trigger algo-
display. The vertical edge width of sequence the base/phase resolution
rithm to ascertain the patient’s
the yellow box is equal to the value or the field of view in phase encoding
breathing pattern. The second part is
of the parameter ‘Acceptance win- direction can be reduced. In either
the imaging phase during which
dow ±’ on the Physio-PACE card. The case, increasing the bandwidth per
the imaging data are acquired which
central position of the acceptance pixel shortens the acquisition dura-
are needed to reconstruct the anato-
window (the so-called trigger level) tion.
mical images.
is either determined by the system
during the learning phase or can be
adjusted manually
Imaging phase
At the beginning of the imaging
phase, the navigator is repeated at a Learning phase
constant interval Scout-TR to track
the diaphragm position. As soon as The initial learning phase requires 5
the series of detected diaphragm respiratory cycles. The learning phase
positions fulfills the trigger condition, is needed by the triggering routine
the sequence stops repeating the to set the central position of the
navigator and executes the first bloc acceptance window during the
of the anatomical imaging sequence imaging phase2. During the learning
(see Fig. 2). In the case of the inter- phase the breathing pattern is shown
leaved TSE-sequence, a block acquires in the Online display. Beginning
n echo trains-one per slice of the with the second complete respiratory
current concatenation. In the case of cycle a red box visualizes the pro-
the single-shot HASTE-sequence the posed anatomical data acquisition
block acquires one complete slice. period. The location of these boxes is
400 ms after the anatomical data based on the parameter setting
acquisition period has finished the and the evaluation of the previous 2
Note that even if the trigger threshold is set
manually, a learning phase is needed since the
sequence plays out the navigator respiratory cycles. The horizontal central position of the acceptance window is
again, to find the next suited respira- edge width of the red boxes is deter- not the sole function of the trigger threshold.
tory phase. This cycle is repeated mined by the aforementioned acqui- The central position of the acceptance window
always depends on statistic quantities calcula-
until all anatomical data have been sition duration. The vertical position ted from the series of diaphragm positions
acquired. and edge width of each box was set measured during the learning phase.

28
TECHNOLOGY CORNER

Figure 2 Timing diagram for the imaging phase of the navigator triggered
sequence. The thin blue curve is the diaphragm position as a function of time.
The upper gray boxes visualize the acceptance window. The acceptance
window is interrupted while the patient breathes in, since the system never
triggers during inspiration. On the lower left side the navigators are shown:
these are repeated at a constant interval Scout-TR to track the diaphragm
position. As soon as the detected diaphragm position falls within the acceptance
window, the sequence stops repeating the navigator and executes the first
block of the anatomical imaging sequence. In the case of the interleaved TSE
sequence, a block acquires n echo trains – one per slice of the current concate-
nation. In the case of the single-shot HASTE sequence, the block acquires one
complete slice. Acquisition duration is the time needed to execute the block.
400 ms after the anatomical imaging block is finished, the navigators are
repeated again until the trigger condition is fulfilled within the next breathing
cycle.

Figure 3 Respiratory curve of the Trigger option. The turquoise dotted window
on the left (which shows the navigator position) marks the learning phase of
the trigger algorithm. During the learning phase red boxes visualise the propo-
sed anatomical data acquisition periods. The location of these boxes is based
on the parameter setting and the evaluation of the previous respiratory cycles.
The parameter setting is fine for a certain respiratory cycle, if the data is
acquired in the relaxed position near the end of expiration. If the horizontal
edge-width of the red boxes is comparable or greater than one respiratory
period (horizontal distance from maximum inspiration to next maximum
inspiration) the measurement must be stopped and the acquisition duration
must be reduced. On the right half of the figure, the respiratory trace during the
imaging phase is shown. As soon as the system detects rising signal (onset of
expiration), the acceptance window is shown as a yellow box. If the detected
diaphragm displacement (green curve) falls into the acceptance window, the
basic anatomical imaging block is executed. During anatomical data acquisition
the respiratory curve is not continued. The number of acquired scans in relation
to the total number of scans to be acquired is shown in the upper left corner
(here “Scan 6/34”). The trigger period is the median temporal displacement
between two trigger events. If the system triggers once per respiratory cycle,
the trigger period is equal to the respiratory period. The last image text line in
the upper left corner shows the trigger threshold.

29
www.SiemensMedical.com/MAGNETOM-World
We see a way to do whole-body imaging with MR in as little as 12 minutes

We see a way to seamlessly scan up to 205 cm with local coil quality

Tim sees all. ™

www.siemens.com/medical

Proven Outcomes in MR. while still enabling seamless, whole-body imaging with
Penetrating. Scrutinizing. Head to toe. Front a total FoV of 205 cm (6’ 9”). Tim is not just another
to back. And side to side. Tim (Total imaging matrix) round of enhancements. But a transforming technology
takes it all in. And in the process, opens up countless that does so much more. So you can, too. See for
new possibilities. Tim brings together, for the first yourself at www.Siemens.com/Tim.
time ever, 76 matrix coil elements and up to 32 RF
channels. All of which can be freely combined in any
way. The highest signal-to-noise ratio possible today, Siemens Medical Solutions that help
We see a way to evaluate systemic diseases in one MR exam without any patient or coil repositioning

We see a way to do MR imaging with an increased signal-to-noise of up to 100 %

Results may vary. Data on file.


MAGNETOM FLASH

A Quantum Leap in MR Tomography:


Tim [76x32]
MRI is about to become radically exams, as multiple channels fields of view, usually based on the
faster and more flexible, enabling allow a unique and almost unlimited specific PAT coils required, and a
entirely new applications thanks scanning flexibility. finite number of receiver channels.
to a powerful new partner: Here, Tim shows its real added value.
Tim – Total imaging matrix. It removes all those negatives by
By Carol Milano, Scan times cut in half allowing Parallel Imaging along the
Dr. Christoph Zindel, M.D. patient’s entire body in a total field of
Usually, even with the existing coil view of 205 cm. The very highest PAT
concept, only about a 150-cm field of factors are now available in all three
view could be scanned with surface dimensions: from head to feet,
This fall, Siemens will be introducing coils and a sufficient signal-to-noise anterior to posterior, and left to right.
Tim, a revolutionary new addition to ratio (SNR). For whole-body coverage, That means that the highest acquisi-
the traditional MRI process. Tim, the the patient needs to be repositioned, tion speeds and image resolutions
unique Total imaging matrix techno- i.e. the coil setup has to be reconfigu- can be achieved without the need for
logy, brings MR tomography greater red. The only alternative, up to now, any specific PAT coils.
performance than it has ever had has been to perform whole-body MR
before. imaging without surface coils, i.e.
just with the integrated body coil,
In the past, MR technology was which, however, significantly reduces Intelligent assistance
limited to array coils offering a maxi- image quality. Thus, MRI technicians
Tim goes even further to intelligently
mum of only eight receiving channels. have always had to choose in the
assist with MRIs: For the first time,
Until Siemens introduced the unique past between total body coverage
it makes Parallel Imaging easy by
IPA (Integrated Panoramic Array) and adequate image quality. Tim
recommending the maximum PAT
concept in 1997, the possibility of erases that difficult decision by
factors for whichever application is
varying the combination of coils for allowing up to 100 percent more
selected. And the Tim Assistant helps
scanning larger areas of the body has SNR. The result: up to 205 cm (6’ 9’’)
finding the selected coil elements,
been very limited or even nonexistent. can now be scanned at maximum
correct patient position, and appro-
Now, for the first time in the history SNR – requiring only 12 minutes.
priate MR protocol, assuring the
of MR, the user can individually select That’s a phenomenal time reduction
integrated Parallel Acquisition Tech-
the specific exams for the desired of more than 50 percent!
nique (iPAT) configuration for each
anatomy – and no longer has to deal Tim can help making accurate dia- particular need. Siemens continues
with patient repositioning or coil gnoses, even for extremely complex to uncompromisingly pursue its goal
reconfigurations. Tim features as imaging needs. Tim’s flexibility of truly optimizing workflow: With
many as 76 (!) seamlessly integrated means that if something unexpected Tim’s new Intelligent Coil Control,
coil elements, along with exactly is spotted, the region of interest can technicians can control all coils, both
32 independent receiver channels. be expanded instantly, without any fixed and flexible, and their corres-
These can be used flexibly in any repositioning of the patient or any ponding elements. This is all aimed at
combination to create a whole-body coil reconfigurations. making Parallel Imaging easy and
imaging matrix, supporting a total more efficient, as well as integrating
field of view of 205 cm (6’ 9’’). it into the clinical routine.
Conventional metastases evaluation
Unlimited parallel imaging
of the whole body, however, requires In addition, with iPAT, Siemens offers
changing coils and repositioning the Tim’s reach is virtually boundless. two forms of PAT: GRAPPA (Genera-
patient for each anatomical area of Today, so-called Parallel Imaging lized Autocalibrating Partial Parallel
interest, e.g. head, thoracic, abdomi- (Parallel Acquisition Technique, PAT) Acquisition) and mSENSE (modified
nal, pelvis, etc… With the introduction already allows faster acquisition with Sensitivity Encoding), thus increasing
of Tim, workflow and patient comfort high image quality. This is a distinct flexibility for the different require-
level are vastly improved by simpli- advantage, for instance, in MRIs of ments of MR applications. Thanks to
fying the MR process and shortening moving organs, because motion Tim and its broad iPAT capabilities,
examination times. Both the matrix artefacts are significantly reduced or outstanding image quality is achieved
coils and the patient need only be even eliminated. Unfortunately, the along with high-speed acquisition
positioned once for all desired disadvantages of PAT include limited performance and improved SNR.
32
TECHNOLOGY CORNER

The first MRI system equipped


with Tim Technology.
Tim redefines the term
“freedom in MRI”
by taking a quantum leap beyond
the boundaries of array coils to
a breakthrough matrix coil concept.

www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Whole-body functionality with [76 x 32]

Tim features three performance


levels: the top-of-the-line Tim [76x32]
(i.e. 76 seamlessly integrated coil
elements and 32 receiver channels),
which not only accommodates clinical
routine and demanding research,
but is also open for all future applica-
tions, such as interventional proce-
dures. Tim [76x18], with 18 anatomi-
cally optimized independent receiver
channels, provides Parallel Imaging
in the full 50-cm field of view, and
Up to 76 seamlessly integrated coil
Tim [32x8] for high-end clinical
elements and up to 32 RF channels
routine. There is a level for every
combined to create one Total imaging
need. matrix.

Tim enables MR users to freely and


World premiere
flexibly combine up to 76 seamlessly
When and where can you meet Tim? integrated coil elements and up to 32
Tim will make its debut at the 89th RF channels to one Total imaging
Scientific Assembly and Annual matrix. No manual coil reconfigura-
Meeting of the Radiology Society of tion during the exam. No patient
North America, beginning in Chicago repositioning either. Giving them
on November 30. Also in November, total, multi-channel whole-body
the first Tim systems will be installed imaging, seamlessly. If during the
at key facilities in New York and course of an exam unexpected
Tübingen, Germany. As part of a findings appear, the anatomical
special publication on science and region of interest can be expanded
health innovations, Siemens recently immediately. Tim enables streamli-
used Tim technology to perform a ned true whole-body imaging with a
whole-body scan on Hannah Stock- total field of view (FoV) of up 205 cm
bauer, one of the most successful (6’ 9’’) – in surface coil quality and
female swimmers in German history. with up to 100 percent increase in
Hannah, 21, who won three gold signal-to-noise ratio (SNR). Tim
medals this summer at the 10th FINA opens up a whole new world of
World Swimming Championships in clinical applications, from whole-
Barcelona, is currently doing an German Swim world champion body to local MRI. New approaches
internship at Siemens. 2003, Hannah Stockbauer, for cancer staging, visualization of
in a whole-body MRI scan. systemic diseases like rheumatic or
vessel diseases, or MR angiography.
Radiologists will see more than ever
before: detailed morphology, leading
to an unparalleled level of confiden-
ce in all physician’s diagnoses while
at the same time shortening exam
times and streamlining workflow.

Hannah Stockbauer
34
TECHNOLOGY CORNER

High-speed PAT Factors in all 3 dimensions Redefined and optimized Parallel


Imaging thanks to the new Total
imaging matrix technology. With
Tim, high-speed PAT factors (Parallel
Acquisition Techniques) can be
applied in all three dimensions.
Supporting the highest acquisition
speeds and image resolutions. Tim
allows full iPAT functionality including
iPAT 2 with PAT factors up to 12.
Highest image quality is provided by
up to 100 % more SNR for the most
clinically exceptional and relevant
images. And: no specific PAT coils
are required. The Tim Assistant
intelligently helps to make Parallel
Imaging easy by recommending
the appropriate PAT factors for the
selected application.

The benefits of Tim and MAGNETOM Avanto at a glance


Clinical benefits:
■ Outstanding image quality with up to 100 percent more SNR, for
whole-body and local MR imaging
■ A total FoV of 205 cm can be scanned without any coil reconfigurations
or patient repositioning
■ Excellent temporal resolution with the strongest gradients currently
available in the industry
■ Unlimited Parallel Imaging seamlessly throughout the whole-body,
and in all directions. No specific PAT coils required
■ True whole-body MR enables first-ever optimized visualization and
staging of systemic diseases

Business benefits:
■ More patients per day due to the highest workflow efficiency
Redefining the concept of time: ■ More referrals due to greatly expanded MR services and applications
With Tim, matrix coils only need to
be positioned once. This dramatically ■ Attracting more technicians due to most advanced MR system
reduces patient set-up. ■ Less siting costs due to AudioComfort and less noise damping
■ Always state-of-the-art technology with the MAGNETOM Evolve program
■ More revenue with less operating costs, powerful return on investment

Patient benefits:
■ Stress-free MRI with reduced exam time (patients need to be positioned
only once, and a high-quality whole-body MRI can take as little as
12 minutes)
■ Virtually all applications can be performed feet first, thus reducing
patient anxiety
■ Breath holding reduced by up to 50 percent

Easier for everyone: With Tim nearly ■ 97 percent less acoustic noise with AudioComfort
all MR procedures can be performed ■ Less burden due to ultralight-weighted coils
as feet-first exams.
35
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Introducing MAGNETOM Avanto:


The Revolution Begins Now
Carol Milano, Avanto not only more versatile, but both the work environment and the
Dr. Christoph Zindel, M.D. also more efficient. As a result, MRI staff more comfortable. The entire
facilities can broaden their offerings system, including hardware and
and expand into other, totally new software, together with the matrix
application areas. The state-of-the- coils and the 10 (!) table-integrated
art MAGNETOM Avanto offers perfor- plugs, are consistent with Siemens’
mance without compromises: Having commitment to ergonomic design.
to choose between high performance This design virtually eliminates many
and high acoustic noise levels or low time-consuming manual steps,
performance and quietness – this including coil reconfigurations and
True whole-body functionality is decision is no longer necessary. With patient repositioning, while signifi-
now available, thanks to Siemens’ MAGNETOM Avanto’s AudioComfort,
cantly reducing table operation.
new high-end 1.5T MRI system, the strongest and fastest gradient
The telescopic matrix patient table is
MAGNETOM Avanto – the very first systems with field strength of up to
perfectly suited for whole-body
Tim system. Harnessing the power of 45 mT/m and a slew rate of 200 T/m/s
workflow and helps to increase the
are combined, with a reduction of
Tim technology, MAGNETOM Avanto available workspace in the MR room.
acoustic noise of up to 30 dB(A),
is able to deliver faster and more Tim helps MAGNETOM Avanto to
equal to 97 percent.
precise results than ever before for accelerate patient setup, scan times
systemic diseases. This holistic and exams. Inline technology,
approach provides benefits for many enabling processing instead of post-
other examinations, such as
Workflow automation processing provides immediate
clarifications of vessel and rheumatic MAGNETOM Avanto is surprisingly clinical results – in realtime – for
diseases as well as preventional easy to use. By intelligently auto- procedures such as prospective
exams. Tim makes MAGNETOM mating the workflow path, it makes motion correction (PACE), diffusion,

Head-neck ce-MRA with excellent High-resolution 3D Time of Flight T1-weighted FLASH 2D fat
separation of the arteries from the (ToF) MR Angio with excellent visua- suppressed transverse image.
veins. lization of peripheral vasculature.

36
TECHNOLOGY CORNER

MAGNETOM Avanto is the first


perfusion, MR angiograms, and fMRI important for follow-up exams. In system with Total imaging matrix
(BOLD), supporting also fast, precise combination with Phoenix, it can be technology. It features exceptional
visualization of systemic diseases. also used to distribute predefined MR image quality by utilizing the highest
Another Siemens innovation, Phoenix, protocols from one scanner to anot- signal-to-noise ratio possible.
makes it possible to save, extract, her within the same institution. MAGNETOM Avanto has the most
comprehensive and innovative
and set up MR protocols in less than From a business perspective, application range available today.
30 seconds. With Phoenix, what you MAGNETOM Avanto allows MR labs Tim has met his match.
see is what you get: Just drag and to do more with less: more patients
drop a DICOM image and use the MR per day, more referrals due to new
protocol to reproduce it. With the new applications, and higher diagnostic
AutoAlign, using a standard adult confidence as a result of the impres-
three-dimensional brain, automatic sive image quality – all coupled with
slice positioning in the brain is possi- lower operating and siting costs.
ble for the first time ever. AutoAlign Another plus for the business side:
helps to make MR brain exams more Because Siemens has attained zero
reproducible which is especially helium boil-off, there is far less
37
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

205 cm (6’ 9’’)

MAGNETOM Avanto, the first


Tim-operated system, enables downtime for refilling the magnet, only 950 grams, they are far more
whole-body imaging of up to 205 cm and more uptime for the system. comfortable and will make a major
(6’ 9’’) – in as little as 12 minutes. difference to very ill cardiac or cancer
patients suffering from pain. For
claustrophobic patients, the fact that
Higher patient satisfaction virtually all MR exams can now be
Often, patients become anxious carried out in the feet-first position is
because of the acoustic noise during a critical factor. Most scans can easily
an MRI procedure. They will be very be performed with the head outside
grateful for MAGNETOM Avanto’s the bore.
AudioComfort concept, featuring With MAGNETOM Avanto, exam
multiple and integrated measures to times are shortened and acquisition
significantly reduce noise levels. For speed is peerless – welcome improve-
example, special casting for gradient ments for both medical staff and
coils and magnet encapsulation help patients. Frail patients will also be
to achieve reductions of up to 97 very relieved that breath-holding
percent without sacrificing the high- time is reduced by up to 50 percent.
performance gradients needed for
demanding applications. Therefore, MAGNETOM Avanto’s examination
ear protection or headphones are table can be lowered down to just
no longer mandatory. Patient comfort 47 cm (18.5 inches), making it
is also enhanced due to ultra-light- accessible to virtually any patient,
weight Body Matrix coils. Weighing even children and the elderly.
38
TECHNOLOGY CORNER

Without any movement restrictions,


the table also supports obese patients
weighing up to 200 kilograms
(400 lbs).

The exciting future of MR


With MAGNETOM Evolve, the easy
upgrade program from Siemens,
MRI facilities will be able to keep up
with any future changes in MR. And
Siemens’ integrated customer care
program Life will be available to
meet each customer’s evolving needs.
Evolution – and revolution – are
what Tim is all about. The powerful,
cutting-edge abilities of Tim and
MAGNETOM Avanto are vanguards of
change, integrating state-of-the-art
medical technology, information
technology, and clinical services to
increase efficiency, satisfy patients,
ease pressures on staff, and streng-
then any facility’s position in the
medical sector. Tim has launched a
new era, pushing MR to new limits
while opening the door to an exciting
world of possibilities beyond.

Author: New York-based medical writer Carol


Milano has contributed to the New York Daily
News, Los Angeles Times, Science and Health,
and Woman’s Day, as well as numerous
trade publications and online magazines for
the medical profession. She is also a longtime
adjunct professor at New York University and
Flexible combination of seamlessly integrated coil elements for coverage the author of two business books.
of large anatomical areas. This entire CNS was imaged without patient
repositioning or coil reconfiguration. Author: Dr. Christoph Zindel, M.D., is Director
of Segment Management at Siemens Medical
Solutions’ MR division.

39
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MAGNETOM FLASH

Imaging the Whole Body –


Viewing the Entire Person
Tim – Total imaging matrix – One can see the Swabian Alps from with conventional solutions is that
offers exactly what Tübingen the top of the Schnarrenberg, the site various regions of the body have to
radiologist Claus Claussen wants: of the Tübingen University Hospital. be examined in sequence using
magnetic resonance imaging When autumn fog clouds the view, different local coils. To evaluate the
of the entire body in a single Claus Claussen, director of the radio- entire body, the individual images
examination – faster, simpler, logy department, takes it in stride. had to be arranged in order. He calls
and quieter than ever before. The radiologist has had many years it “patchwork”, in the truest sense of
By Dr. Martina Lenzen-Schulte, of success in his field, and now it the word. For example, two examina-
M.D. appears as though the last mists that tions are required just to obtain the
had prevented full views into the pelvis and knee. This means that the
human body are dissipating. In patient has to be repositioned, which
November, the first Tim system was is cumbersome. For older and frail
installed at the well-equipped persons, accident victims, or the
Tübingen University Hospital. Besides most seriously ill, repositioning may
Tübingen, New York University is the be stressful, sometimes troublesome,
only other hospital currently evalua- or in the worst case even painful.
ting this groundbreaking technology. Additionally, the physician has to
Tim opens new horizons in every look for the appropriate local coil and
sense of the word. Tim, which stands position it on the patient – a continu-
for Total imaging matrix, is more ous loss of time. The speed Tim uses
than just a new development; it is a to display the entire body simplifies
revolution in magnetic resonance the examination for more than just
imaging. “76 seamlessly integrated the patient. “Tim helps the physician
matrix coil elements and signals and hospital personnel to save a lot
derived across 32 receiver channels of time,” says Claussen, the depart-
builds the technical framework for mental director, who cannot ignore

»Tim simplifies
the examination for
more than just
the patient.«
this new system,” stated Claussen in the question of efficiency within
an interview prior to the system’s his department. “Tim enables us to
premiere at his hospital. It was clear forget about all the intricacies. This
that he wanted to provide additional significantly improves clinical work-
details on what was behind these flow and enables us to dramatically
indicators. increase patient throughput, all
with excellent image resolution and
“For the first time since the introduc-
the best possible image quality.”
tion of magnetic resonance imaging,
Tim enables us to create a seamless MAGNETOM Avanto is the name of
image of the entire human body – up the first MRI system to use the
to a total of 205 centimeters.” revolutionary Tim technology; it also
Why is this important, and for whom? provides many additional advantages.
“Primarily for the patient,” says “Again and again,” said Claussen,
Claussen, the physician. The problem “we as physicians have emphasized
40
TECHNOLOGY CORNER

Dr. Claus D. Claussen


is the Director of the
Diagnostic Radiology
Department
at Tübingen University
Hospital as well as
Professor of Radiology
at the Eberhard Karl
University in Tübingen,
Germany.

www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Dr. Claus D. Claussen, a champion


of interdisciplinary perspectives, how greatly noise affects the patient This is only one example for a philo-
works in close cooperation during an MR examination. The sophy of developing products by the
with medical solution providers. constrictive nature of conventional customer for the customer. Physicians
systems, especially when performing at the radiology department in
head examinations, is very uncom- Tübingen, working in a team with
fortable for claustrophobic patients.” Siemens, proposed suggestions on
what they felt was most important.
Siemens has implemented these
“This type of cooperation is much
requests: “Faster and quieter” became
more than an exchange of know-
the watchword. A 97 percent reduc-
ledge,” says Claussen, a driving force
tion in noise while retaining the most
behind this long-term partnership,
powerful gradient system enables
“it is based on understanding and
new real-time applications in MR and
trust between people.”
results in significantly higher patient
comfort.

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TECHNOLOGY CORNER

If Tim and MAGNETOM Avanto finally


present the solution for seamlessly Professor Dr. Claus D. Claussen
imaging the entire human body, it
Director of the Diagnostic Radiology Department
means that Claussen, the diagnosti-
cian, will finally be able to obtain at Tübingen University Hospital:
a single view of the entire person: From 1966 to 1971, Professor Claussen studied medicine in Erlangen
“There is a reason we speak of a and Heidelberg, Germany. From 1973 through 1978, he trained in radiology
vascular system, a nervous system.
at Heidelberg, and then served as Senior Physician at the Hospital of the
It is not a single blood vessel that
becomes diseased and is detected Free University of Berlin (now Charite Hospital at Humboldt University).
due to localized changes in the heart, In 1988, Claussen was named C-4 Professor of Radiology at the Eberhard Karl
carotid artery, or the brain. Vascular University in Tübingen, and became Director of the Diagnostic Radiology
disease occurs everywhere, is syste- Department.
mic, from head to toe throughout the
entire organism.” In light of all the He has been a member of the Tübingen University Senate since 1998,
tangible changes to the associated and in 2000 was elected Dean of the Medical Faculty. Professor Claussen is
system, a whole-body examination a member of many national and international professional organizations.
provides far better diagnostic results From 2001 through 2003, he was President of the German Radiological
for local medical pathologies than
Society, and will serve as its vice president from 2003 through 2005.
in the past – and with no additional
He is the editor and associate editor of significant professional journals,
system expense. Otherwise, the
ability to image the entire body in a and is a subject matter expert for the German Research Society.
single examination will drastically As Chairman of the Supervisory Board for the “University of Tübingen
simplify the search for metastases in Clinical Studies (KKS)” coordinating center, he is actively involved in
cancer patients. implementing quality standards for clinical research.

As a researcher, Claussen sees far


beyond the diagnoses currently
available. “We are already past the than simply implementing techno-
point of imaging morphology, the logy. “If we can obtain an image of
mere anatomy of the body. We can the entire human body using Tim, we
already display functions, the physio- also have to merge the various
logy of organs.” In addition to the technical disciplines. Arteriosclerosis
shape of the heart, the muscle’s is not limited to the heart, and there-
vitality and the blood flow can be fore its diagnosis should not be
determined from the image. limited to a single organ.” In Tübingen,
The consistent use of integrated research on cardiac diseases has seen
Parallel Acquisition Techniques (iPAT) cardiologists and radiologists working
enables Tim to bring together speed together for quite some time, to the
and image quality within seamless benefit of both. Claussen sees him-
whole-body imaging, and there is self as the representative of this
reason to believe that much more cross-departmental group, an ideal
will be achieved. “We hope to pene- platform for the integration of the
trate the metabolic level of the individual disciplines. And Tim
organ. While it may appear to be a symbolizes interdisciplinary approach,
utopian dream, our goal is to display which goes beyond stereotypical
cellular activity down to the molecular in-the-box thinking and views the
level of detail.” Claussen intends to patient as a whole. For this reason,
follow his vision, which is beyond looking back at these ancient medical
what is possible today. As a scientist traditions may be permitted – no Author: Dr. Martina Lenzen-Schulte is a
physician. As a medical journalist, she has
and dean of faculty, he knows only matter how innovative the techno- published articles in many well-known scientific
too well that these goals require more logy. collections and magazines.

43
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MAGNETOM FLASH

2nd Annual MAGNETOM World Summit


September 17-19, 2003

44
MAGNETOM WORLD EVENTS

th
18 Thursday
Dr. Heinrich Kolem, President of
Siemens MR opened the meeting by
describing MAGNETOM World sum-
mit as a communication platform
where customers create a network in
which they can learn from each other
about clinical routine applications.
It was also a great opportunity for Vice-President of Strategic Accounts
Siemens to understand the needs of in USA, Les Friend, presented an
customers and use this opportunity outline of business at Siemens and
as requirement engineering Siemens Medical Solutions, demon-
for future product development. strating the evolution from past to
present, as well as the future direc-
tion. He stressed the innovation and
financial strengths of the company,
defining it as a competitive global
partner bringing cutting-edge tech-
nology to its customers. The US is

Miami
the largest market for Siemens
and Siemens has around 70,000
employees involved in many produc-
tion and service areas, from electronics
and IT to medical devices. Siemens
is the third largest R&D spender in
the world. Medical Systems is the
number one solutions provider in
the world, boasting a full spectrum
product portfolio and workflow
resolution images in the same time enhancement tools like syngo,
frame. Professor Otto uses iPAT to Soarian and Sienet.
improve the spatial resolution in
breast imaging. “iPAT is the future of
breast MR” was his final verdict.

Prof. Heinz Otto from Evangelische


Clinic in Gelsenkirchen provided
theoretical information and also case
reports from daily routine MR imaging
of the breast. He started with
explaining the indications for breast
MR imaging. He added that the
superiority of MR lied in the capability
of combining the morphological
information and temporal informa-
tion. He stressed the vital importance
of iPAT in breast imaging which can Multiple fibroadenomas
improve the diagnosis due to the T2 iPAT images without and with
fact that it provides higher spatial fat suppression.
45
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MAGNETOM FLASH

3D Flair Isotropic 1mm. 3D TSE Isotropic 1mm.

MR Application Business Development


Manager, Abe Padua, talked about
the clinical applications for 3 Tesla.
He showed impressive results
obtained with MAGNETOM Trio
systems for advanced and routine
neuro, vascular, body, orthopedic
applications. He also stressed the
importance of iPAT with 3 Tesla.
He concluded by stating his belief 512 matrix at 0.8 mm slice
that the Siemens ultra high-field 4 slabs 6 minutes.
system MAGNETOM Trio had become Tractography
a clinical system in an environment
where 3T systems are still perceived
as a research tool.

Allegra T1 contrast.

C-Spine using Neurovascular Coil.

L-spine imaging.

46
MAGNETOM WORLD EVENTS

3T Knee imaging.

3T Shoulder imaging.

3T 3D Shoulder imaging and MPR. 3T Elbow imaging.

3T Wrist imaging.
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MAGNETOM FLASH

3T Ankle imaging. 3T Head-neck MRA.

3T Circle of Willis MRA.

3T T1 Abdomen
In-phase Out-of-phase

Dark Blood Technique.

3D FLASH with fatsat


TR/TE 112/1.5 ms, Pixelsize: 0.9 x 0.9 x 1.2 mm.
48
MAGNETOM WORLD EVENTS

Dynamic “VIEWS”:
MAGNETOM Harmony with
Quantum gradient system (1.0 T):
Dynamic: high temporal- and high
spatial-resolution.
Enhancement kinetics; CAD analysis.
Near-isotropic voxels:
High quality 3-D MIP and MPR.

Infiltrating ductal carcinoma:


Dr. Bruce Porter from First Hill
Diagnostics talked about the rapidly high-resolution VIEWS
growing and clinically unique area (0.8 x 0.8 x 0.6 mm).
of breast MR imaging, providing an
excellent summary of Siemens breast
MR solutions. The recent sequence
techniques like “views” have improved
the diagnostic efficiency in his clinic.
He mentioned the different approaches
of researchers and clinical radiologists
in terms of choosing between higher
temporal or spatial resolution. He
said that he preferred bilateral exami-
nation of the breast with images
having isotropic voxels. Dynamic
breast MR is a technique to see and Pre-chemo
evaluate angiogenesis. Quantum
gradient upgrade has brought advan-
tages in imaging performance
capabilities of the system. Maestro
class and iPAT brought tremendous
work flow and image quality improve-
ments*. He also stressed the impor-
tance of computer-aided diagnosis Post-chemo
using the temporal resolution
information helping the differential Occult Ca:
diagnosis between malignant and
benign lesions. His choice of biopsy Malignant adenopathy,
method was for high-resolution negative ultrasound.
ultrasound guidance following an
MR in which he had obtained the
necessary information regarding the
location and perfusion characteristics
of the lesion. Significantly, STIR
sequence could be used to detect
lymph node pathologies. For breast ■ Breast MR is a powerful diagnostic tool and is increasingly available.
imaging, MR is one of the most power- ■ Current technology allows a near-ideal exam:
ful recent diagnostic tools, which is high spatial- & high temporal-resolution.
becoming increasingly available.
■ CAD facilitates breast MR interpretation and improves detection of
* The information about this product is subtle lesions, exam reproducibility, and image quality.
preliminary. The product is under development
and is not commercially available in the U.S., ■ Breast MR will become a standard, frequently used,
and its future availability cannot be ensured. clinical study in the near future.
49
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MAGNETOM FLASH

High-Field Imaging Protocols


■ Routine Brain ■ T1 SE (post Gado – Gated)
■ MPRAGE (axial acquisition) ■ 20 5 mm slices
■ Reformatted in Ax & Sag ■ 210 FOV
■ Axial FLAIR ■ 512 matrix (interpolated)
■ Axial T2
■ Axial T2
■ Axial Trace Diffusion
■ 20 5 mm slices
■ Contrast Brain ■ 210 FOV
■ Medical ■ 512 matrix (interpolated)
■ Sagittal T1
■ Standard dose Gadolinium ■ Axial FLAIR
■ Axial T1 – Gated ■ 20 5 mm slices
■ Axial FLAIR ■ 210 FOV
■ Axial T2
■ 768 matrix (interpolated)
Dr. Ed Knopp, from New York Uni- ■ Axial Trace Diffusion
versity Hospital, presented trends in ■ T2 TSE Hi Res
■ Contrast Brain
neuro-imaging and clinical use of 3 T. ■ 13 Slices
■ “Surgical”
He said that 3 T enhances spatial ■ Sagittal T1 ■ 180 FOV
resolution and does it in a clinically ■ Standard dose Gadolinium ■ 640 matrix (interpolated)
acceptable time. He introduced the ■ Axial T1 – Gated
clinical protocols he uses with 3 T ■ T1 TSE Dynamic
■ MPRAGE (axial acquisition)
MAGNETOM Allegra system and gave - Reformatted in Ax & Sag ■ 8 slices
detailed explanation of clinical use ■ Axial FLAIR ■ 200 FOV
of the protocols and sequences. In ■ Axial T2
spectroscopy, smaller voxel size was ■ 512 matrix (interpolated)
■ Axial Trace Diffusion
an additional result achieved by the ■ 44 sec scan time
3T systems, as was minimized ■ IAC
■ 3D TOF MRA
susceptibility artifacts with diffusion- ■ Coronal T1
weighted sequences. Dr Knopp also ■ 3 overlapping slabs
■ Half Dose Gadolinium
talked about advanced imaging ■ 220 FOV
techniques such as fractional iniso- ■ FS Ax T1
■ 1024 matrix (interpolated)
tropic map, tractography with 3 T, ■ Cor T1
perfusion maps, and spectroscopy ■ Diffusion (Trace & ADC)
■ Ax FLAIR
with small voxels. He ended with the ■ 20 Slices
■ Ax T2
observation that “3 T is a practical ■ 210 FOV
clinical reality in our center with ■ Axial Diffusion
■ 256 matrix (interpolated)
18-20 cases per day”. ■ Pituitary – Dynamic
■ B: 0, 500, 1000
■ Sagittal T1
■ Perfusion
■ Coronal T1
■ 1 second temporal resolution
■ Dyn Cor T1
■ Whole brain coverage
■ Half dose Gadolinium
(if needed)
■ Dyn T1’s (5 sets)
■ 256 matrix (interpolated)
■ Cor T1
■ Spectroscopy
■ T1 MPRAGE
■ Small voxel size (0.5mm)
■ 224 mm Slab (1mm partitions)
■ Long and short TE
Axial
■ 210 FOV
■ 512 matrix (interpolated)

50
MAGNETOM WORLD EVENTS

Post-op T2.

Normal Control FA map ADC map

MS Patient Diffusion Tensor


in MS.

3 T diffusion imaging.

Ultra High-Field spectroscopy.

Diffusion Tensor Imaging


Fiber Tracking. 3 Tesla MAGNETOM Allegra Higher SNR.
CSI-STEAM, TE = 20 ms,
Improved Quantification.
TA = 3’ 12 s.
Higher Spectral Resolution.
Higher Spatial/Temporal
Resolution.

51
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MAGNETOM FLASH

Fetal imaging* – MRI


Dr. Robert Zimmerman, from the 32 weeks gestation.
Children’s Hospital of Philadelphia,
Brain development.
introduced his talk with reference to
the unique character of pediatric
imaging with the patient population
ranging from a premature 14 ounce
fetus* to a 400-pound adolescent.
He surveyed the large spectrum of
diseases from metabolic diseases to
white matter diseases and developing
brain changes. SAR issues, he stated,
were one of the major problems in
pediatric MR imaging. Dr. Zimmer-
mann showed some pathological
cases with the protocols used and
sequence details for pediatric imaging.
Coronal T2 Coronal T2
He added that the image quality was
32 week fetus. 6 week infant.
continuously improving with MR.
For cerebro-vascular diseases in the Hypoglycemic brain injury
pediatric population, which differs acute – 3 day female
from the adult in terms of etiology,
he said that MR had revolutionized
the diagnosis of diseases with diffu-
sion and ADC maps. He also described
his experience with arterial spin
labeling and diagnosis of tumors with
MR. Here the use of spectroscopy
was invaluable, in his experience. The
combination of imaging and spectros-
copy would increase specificity. The
last topic he covered was metabolic
Axial T2. Axial Diffusion. Axial ADC.
diseases. He concluded his talk by
saying that the intention was to
move to 3 Tesla from 1.5 Tesla, with
the hope, of course, that SAR issues
are resolved, as this was the most
important obstacle in pediatric
* The information about this product is
imaging. preliminary. The product is under development
and is not commercially available in the U.S.,
and its future availability cannot be ensured.
The safety of imaging fetuses, infants has not
been establised.

52
MAGNETOM WORLD EVENTS

Child vs. Adult perfusion images.

Application in neonates with Arterial spin labeling


congenital heart disease

Neonatal perfusion (5 days) pre and Acute infarction.


post hypercapnia.

Proton spectroscopy Clinical indications


Primitive neuroectodermal tumor Pediatric proton spectroscopy

Metabolic disease
abnormal metabolites.
T2 5 year old
female.

single voxel
TE 135 msec
choline
taurine
Naa lactate

53
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MAGNETOM FLASH

CSI of Gliobastome multiforme.

Choline map.
Dr. Lester Kwock, from University of
North Carolina Hospital, has 20 years
of experience in spectroscopy, mostly
in neurological patients. “Siemens
has done a good job in recent years
particularly with syngo in creating
the tools to observe patterns of
Gliobastome multiforme.
diseases with spectroscopy”. He
explained the use of short and long
echo time examinations. He defined
the tendency in spectroscopy
towards multi-voxel examinations
rather than single voxel. He showed
some examples that made the advan- Myoinositol map.
tages of spectroscopy clear, such as
differentiating between primary
and metastatic lesions, diagnosis of
recurrent tumors and differentiation
of radiation changes or reactive
Choline map.
changes. He also showed some
examples of prostate spectroscopy.
He was very happy with his
MAGNETOM Sonata system and
highlighted that 3D CSI with Sonata
would take less time than with
other scanners and provide useful,
Low Grade Glioma.
reliable information with good
spectral results. A further interesting
contribution he made was the
addition of perfusion measurements
to his examinations, which improved
diagnostic certainty. A very interesting
approach was the prostate examina-
Myoinositol map.
tion he had been trying to implement
in his clinic without endorectal coils.

54
MAGNETOM WORLD EVENTS

Treated
non-small
cell lung ca
metastasis.

Dr. Frank Shellock, University of


Southern California, discussed the
safety issues with MR and with
3 Tesla systems in particular, provi-
ding specific information on acoustic
noise, RF fields, RF heating, MR
incidents and accidents. He stressed
Normal Prostate. the importance of screening in MR
environment. Dr. Shellock also
detailed several examples of implants
and devices, ranging from neuro-
stimulators and orthopedic implants
to pacemakers. “Ensure you obtain
information about the implants and
devices before commencing the
Prostate Cancer. exams” was his important advice to
all users, offering an example of the
difference between short bore and
long bore 3 Tesla systems in terms of
safety: an implant which is deemed
safe for long bore systems, need not
necessarily be safe for short bore.
He concluded with the topic of post-
operative patient handling.

55
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MAGNETOM FLASH

MRA with MAGNETOM Concerto.

James Stupino BS, RT R, from Valley Prof. Vincent Dor, a world-renowned


Advanced Imaging, talked about cardiothoracic surgeon, shared his
improving the clinical throughput in experience with MAGNETOM Sonata
Open Systems. His talk included system at the imaging center in
topics such as organizing the facility, Monaco Cardio Thoracic Center,
patient preparation, imaging which is dedicated solely to cardio-
techniques, coil selection and posi- vascular patients. He began his talk
tioning, sedation. He also offered by showing the advantages of CMR
the audience useful tips for obtaining over conventional angiography and
the best image quality especially echocardiography. His case reports
with heavy patients and in the area from the clinic showed the clear
of cervical spine imaging. 295 lbs male. benefits of CMR in daily practice for
even surgical patients, especially the
use of late enhancement viability*
imaging and functional cine visuali-
zation of the heart for surgical deci-
sions. He believed that CMR could
have a revolutionary effect in the
follow-up of infarct patients with
today’s results of left ventricular
function evaluation with cine MR and
late enhancement viability scanning,
providing the exact area of scar
Patient weight 360 lbs. formation.

* The information about this product is


preliminary. The product is under development
Cardiac MR with and is not commercially available in the U.S.,
MAGNETOM Concerto. and its future availability cannot be ensured.

56
MAGNETOM WORLD EVENTS

Sub Endocardial Infarct.

EDVI: 121 ml/m2 EDVI: 54 ml/m2


ESVI: 95 ml/m2 ESVI: 25 ml/m2
LVEF: 22 % LVEF: 53 %

57
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MAGNETOM FLASH

No iPAT Grappa

Margaret King (RT R MR) gave a


comprehensive talk about increasing
the throughput in high field systems,
starting with the ‘user interface’ and
then moving to syngo specific improve-
ments like image stamps, inline
movie, inline subtraction and off-line Sagittal T2 PAT factor 2
reconstruction. She emphasized the 3:12 minutes. Sagittal T2
importance of IPA™, saying that it 1:48 minutes.
had increased remarkably the num-
ber of patients that can be scanned in
one day. Phoenix was Margaret’s
favorite: it allowed the extraction of
sequence details from the images,
thereby enabling exact replication of
sequences and protocols. She stated
that iPAT was another useful appli-
cation either for faster imaging or
higher resolution in the same imaging
time. 2D PACE was another very
important improvement in the new
syngo based systems, improving
the daily clinical MR in abdomen
imaging. No iPAT Grappa

25 sec 14 sec
Clearly the “Imaging of the future!”

58
MAGNETOM WORLD EVENTS

Phoenix:
Drag & drop from browser to exam card.

Phoenix: Revolutionary way to exchange MR data


■ Images available through Internet, CD or floppy.
■ Easy protocol exchange (gradient strength not an issue).
■ Improves study reproducibility for follow-up and research.
■ Supports multi-center protocol standardization.
■ Helps to establish new applications.

Angiography / Inline Subtraction

Raw Data Subtracted


Data

Quick Quick
MIP MIP
Sagittal Coronal

59
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MAGNETOM FLASH

Köln/Cologne

Dr. Bernhard Schulte introduced his


clinic as representative of a business
model combining the radiologists’
and cardiologists’ efforts to one
common goal. “MR is providing not
only morphological but also physio-
logical information which is very Kardio MR/CT Team
important in the evaluation of Cologne
patients,” said Dr. Schulte. He detailed
the use of stress MR, viability imaging*,
cine MR for wall motion analysis and
ejection fraction calculation, and
said that the use of these methods
with MR is expanding the services of
cardiologists. Radiologists’ expertise
in imaging and cardiologists’ expertise
in cardiology should be combined
for expanding the use of cardiac MR
rather than getting involved in turf
battles. Köln Cardiac MR Center is a
center for collaboration where there
is one CT and 2 MR units to which
more than 80 private cardiologists
are sending their patients for further
evaluation. There are also educatio-
nal courses in the center available to
referring cardiologists in the Köln
Cardiac Center.

■ Radiologic-cardiologic joint effort.


■ One of the very first radiologic-cardiologic collaborative MR
Centers in Germany specifically focused on cardiovascular MRI.

* The information about this product is ■ Development and clinical application of MR imaging to
preliminary. The product is under development the cardiovascular system.
and is not commercially available in the U.S.,
and its future availability cannot be ensured.

60
MAGNETOM WORLD EVENTS

60 Minute
MR Prevention Protocol
Cerebral morphology
(ischemia imaging) 10 min
Arterial vascular tree from
Milestones in the formation of head to ankle 10 min
Kardio MR Köln/Bonn
Cardiac morphology and
■ Spring 2000
function / lungs 20 min
8 cardiologists in private practice
decided to be involved in Cardiac Virtual endoscopy of
MRI. the colon for polyps and
colorectal cancer 20 min
■ 2000
Formal talks culminated in 60 min
a cooperation between this
group of cardiologists and the Cerebrovascular MRI
Department of Radiology. ➔ T1-w SE
■ Mid 2000 ➔ T2-w TSE
Installation of Multislice CT and ➔ FLAIR
Dr. Stefan Ruehm, from Essen
Cardiac MRI units.
University, emphasized the impor- ➔ 3D ToF
Clinical fellowship of radiologists tance of prevention in medicine.
in other specialized Departments He said MR was very suitable for early ➔ No i.v. contrast
of Cardiology diagnostic purposes as it was non- ➔ Exam time 10 min
(Dortmund, Essen, Bad Nauheim). invasive, without any x-ray and
known side effects and was highly
■ Autumn 2003
accurate. He provided the protocols
Since 3 years they have been and sequence details for the exami-
developing a great working nation of the whole body including
relationship with more than neurovascular examination, cardiac
80 privat cardiologists and examination, thoracic examination,
3 Departments of Cardiology MR colonography and metastasis
in other hospitals. detection. His final comment was
succinct and clear: “Multi-organ
screening with MR appears feasible”.

67 year old male:


systemic manifestation of
atherosclerosis.
WB MRA; TA: 72 sec.

61
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MAGNETOM FLASH

Cardiac MRI
➔ i.v. contrast of MRA used for late
enhancement*
➔ CINE short and long axes
➔ Exam time 20 min

MR-Colonography
Dr. Stefan Schoenberg, from Ludwig-
➔ Rectal enema: 2.500 ml water
Maximilians-University of Munich,
➔ 0.1 mmol / kg BW Gd-BOPTA Germany, gave an excellent summary
of iPAT and its clinical use ranging
➔ 3D VIBE – delay 75 sec
from head to toe. The details of this
➔ Exam time 10 min topic can be seen in the article from
him on pages 6-20.

Visualization of Metastases
➔ Implemention of whole-body
MRI examination for detection /
staging of metastases.
➔ Whole body MRI using 3D-VIBE.
➔ Fast & nearly isotropic resolution.

* The information about this product is


preliminary. The product is under development
and is not commercially available in the U.S.,
and its future availability cannot be ensured.

62
MAGNETOM WORLD EVENTS

HR-CT MRI

The first day ended with a talk by


Atypical pneumonia: Scott McPherson VP, from a private
coronal images. out-patient center called “Open
System Imaging”. This was a very
interesting talk about the MR market
and current dynamics. He said that
the out-patient market was totally
different from the in-patient one and
his observation was that market-
oriented centers did well compared
to only marketing-oriented ones,
which had disappeared from the
market. The other topics he covered
were changes occurring in referral
7 month-old premature newborn: patterns and decreasing reimburse-
MRA with GRAPPA, 1.0x0.8x1.0 mm isotropic ment. His interesting observation
spatial resolution, 8 seconds acquisition time.
was that the market was reaching
maturity and MRI was becoming a
commodity service. “Profit lowering
is a reality in the market today” he
said. He defined today’s market as
more or less a “high-field market”. He
stressed the importance of the
quality perception of the customer.
Price leadership, he stated, was
becoming a major issue in the market.

Value of isotropic spatial resolution.

Choledocholithiasis DDX
endoluminal tumor.
63
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MAGNETOM FLASH

Mi
Coffee Break MAGNETOM World Summit

The coffee breaks between sessions


were good opportunities for partici-
pants to visit the demo workstations
and discuss the new developments
by Siemens MR.

64
ami MAGNETOM WORLD EVENTS

65
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MAGNETOM FLASH

nd
Mi
2 Annual MAGNETOM World Summit
September 17-19, 2003

66
ami 18th Thursday – Evening
MAGNETOM WORLD EVENTS

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MAGNETOM FLASH

Spinal canal imaging:


no PAT mSENSE GRAPPA

Dr. Pierre Brugieres, from Henri


Mondor Hospital, talked about the
use of iPAT in clinical neuro-radiology.
His presentation included examples
ranging from clinical neuro to advan-
ced neuro applications. He presen-
ted results with both techniques of
mSENSE & GRAPPA showing the
advantages, disadvantages and
artifacts related with both techniques.
His talk ended with the wish for
more coil elements, channels and Spinal imaging.
increased S/N ratio.

Turbo-FLAIR imaging:
No PAT mSENSE GRAPPA

T1w-gradient Echo imaging:


No PAT mSENSE GRAPPA
TA = 1’18 TA = 0’55 TA = 0’55
68
MAGNETOM WORLD EVENTS

TR = 4090 ms, TE = 101 ms, nex = 1, 20 slices, ToF of the circle of Willis
T2-TSE imaging: TA: 7’35
No PAT: mSENSE GRAPPA GRAPPA: PAT factor 2.
TA = 0’55 TA: 0’34 TA: 0’34

2D ToF Venous MR Angiography 3D Gd Venous MR Angiography 3D-Gd-enhanced MRA.


TA: 3’30 3D MPRAGE (sl. thick. = 1.6 mm)
GRAPPA: PAT factor 2. GRAPPA (PAT factor 2), water
excitation 10 cc DOTA-Gd, TA = 1’35.

Diffusion weighted imaging:


No PAT mSENSE GRAPPA

DWI with high b-factor values:


Stroke imaging.

Diffusion weighted imaging:


No PAT mSENSE GRAPPA
69
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MAGNETOM FLASH

Dr. Vamsi Narra, from Mallinckrodt


Institute of Radiology, concentrated
on 3D imaging of the liver, and
shared his clinical experience with
Christine Harris, RT R MR, from the other users. 3D imaging with VIBE
Children’s Hospital of Philadelphia, provides angiography information
introduced the clinic where she is and parenchymal information simul-
working – one of the biggest referral taneously with thin slices and no
centers in pediatrics and pediatric slice gap. According to Dr. Narra, it
imaging in the world. The clinic Improvement of gray/white was more advantageous to use
performs about 15,000 MR examina- matter contrast 3D than 2D. He provided technical
tions per year. Her talk focused on 1000 TR vs. 650 TR. details of the VIBE sequence. He
optimizing the clinical throughput in showed the parameters he preferred
a busy practice. She introduced the with this sequence. He also introduced
challenges of pediatric imaging Neuro Imaging Protocol setup
the workflow in his clinic regarding
ranging from sedation to examina- ■ Routine brain under 6 months post-processing, distribution of
tion room surroundings, scanning images with PACS. 3D biliary anatomy
■ Routine brain 6 months to 1 year
techniques, protocols and application evaluation after contrast injection
tips. ■ Routine brain 1 year to 2 years was an interesting application that
■ Routine brain 2 year and up showed impressive results, as he
demonstrated. He stressed the
■ Scout
parallel imaging iPAT, which he said
■ Basic brain was similar to multi-slice CT and
■ Basic brain post contrast possibly the future for MR.
■ Midline infratentorial
■ Pathology
■ Seizure
■ Seizure post contrast
■ Trauma/Stroke
■ Developmental delay
■ Orbits
■ Orbits post contrast

Sag_T1
Axial_T2
Axial_FLAIR
Axial_MT when giving contrast
Axial_SE not giving contrast
Diffusion
Cor_T2
Cor_FLAIR
Cor_STIR
Cor_T2

70
MAGNETOM WORLD EVENTS

3D imaging with VIBE.

Hepatocellular carcinoma evaluation with VIBE.

Splenorenal shunt.
Portal vein thrombosis.

71
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MAGNETOM FLASH

Dr. Charles Ho, from National


Orthopedic Imaging Associates,
shared his experience in MR ortho-
pedics imaging with the audience.
He focused especially on elbow
imaging.
Dr. Scott Pereles, from Northwestern
University, talked about MR Angio-
graphy in clinical practice. He said
that MRA was quite a mature appli-
cation for most anatomical areas.
He drew the attention of the audience
to the advantages of MAGNETOM
systems, especially Sonata, with the
lowest TRs and TEs in the industry.
He gave very useful application tips
for state of the art MRA covering all Dr. Frank Miller, from Northwestern
anatomical areas of the body inclu- University, talked about 2D liver
ding the peripheral MRA examination imaging. “Abdominal MR should be
with moving table. He also showed short and breath-hold is the way to
different imaging techniques like go,” said Dr. Miller. He prefers the
freeze frame MRA and advanced one-stop approach in upper abdomen
post-processing techniques like imaging to detect and analyze the
volume rendering. He added that lesion in the liver and evaluate the
iPAT brought significant advantages biliary system. He introduced the
to MRA. abdominal imaging protocols in his
clinic and explained the use of
different sequences for different
applications and for different patho-
logies. SHARP is one of their favorite
sequences for liver imaging – a 2D
fat-sat gradient echo with some
modifications. He provided the
audience with clinical examples in
abdomen imaging.

72
MAGNETOM WORLD EVENTS

Dr. Diego Martin, from West Virginia


University, talked about improve-
ments in MR imaging of the bowel.
He observed that imaging of the
bowel, which had previously been
thought to be unsuitable for MR, was
being used with increasing frequency. Dr. Guenter Layer, from Ludwigs-
He talked about dark and bright hafen Clinic, showed extremely
lumen imaging techniques and impressive results form his center,
showed some experimental results where there is good cooperation
using different techniques and their between the radiology and gastro-
impact in imaging. He stated that enterology departments. The MR
water and TrueFISP combination colonoscopy topic and the indications
provided the best results in these results from Ludwigshafen Clinic
experiments, with VIBE also having can be seen in this issue of Flash on
other advantages. He also shared pages 110-115. Dr. Layer’s interesting
his clinical experience in colon MR view was that MR would become the
imaging, from patient preparation to screening method of choice in the
the examination details. future and conventional colonoscopy
and sigmoidoscopy would be kept
only for therapeutic reasons.

73
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MAGNETOM FLASH

Voxel size: 3.4x0.7 mm3


with iPAT GRAPPA +
MAGNETOM Sonata.
In his second talk in two days,
Dr. Schoenberg discussed the
burden of renovascular diseases in
the community and why MR could be
useful in alleviating this problem.
He believed that we should move
from pure morphology to function in
evaluation of renovascular diseases.
He first talked about flow evaluation
of the renal artery pathologies, then
moved to the topic of renal perfusion Chronic thromboembolic disease:
MR perfusion.
– the perfusion of the kidneys to be
able to get functional information 0% 5% 10% 15% 20% 25%
related with the renovascular patho-
logies. He proved his experience with
quantitative perfusion measurements.
The second part of his talk was dedi-
cated to lung perfusion measure-
ments, the clinical need for this evalu-
ation technique and some clinical
examples, and he stressed the value
of this application in particularly
thromboembolic diseases.
O2 imaging:
Ventilation defect.

After Dr. Schoenberg’s talk, Dr. Bengi from MR Marketing thanked all the
speakers and attendees for making the 2nd MAGNETOM World Summit such a
rich experience. He said that the three communication platforms for this global
network – the Internet (with Phoenix), MAGNETOM World meetings and Flash
Magazine – would continue to develop and grow richer with more contributions
from the MAGNETOM World. He reminded everybody to contribute to this
biggest community in the medical imaging world. “See you all next year in
Europe at the 3rd MAGNETOM World Summit” he ended, as a reminder to the
audience to note their diaries for another scientific meeting full of information,
advice, fun and excitement in 2004.
74
SUPER TECHNOLOGISTS

Crues-Kressel Award

This year the Crues-Kressel Award


has been bestowed upon Greg
Brown, Senior Radiographer MR,
Royal Adelaide Hospital. The Crues-
Kressel Award is conferred by the
SMRT (the MR technologists Section)
of the International Society for
Magnetic Resonance in Medicine
(ISMRM). The citation reads “for
outstanding contributions to the
education of Magnetic Resonance Greg Brown: ping close informal contacts with the
Technologists”. designers and engineers in Erlangen
Greg’s passion for MRI has always and around the Siemens MR commu-
It is the only SMRT award decided
been matched by the desire to share nity, and Greg attributes much of his
by the membership. A ballot is held
information as well as keeping perspective on current MR to these
citing two or three candidates
Australian MR Radiographers connec- initial contacts. In 1997, after
approved by the SMRT policy board,
ted to the world scene. He believes the R.A.H. decided on a Siemens
and the award is given to the ballot
strongly that well educated MR MAGNETOM Vision, Greg returned to
winner only if more than 50% of the
radiographers play a pivotal role in Erlangen to undertake the PARGEN
SMRT membership vote. In a real
delivery of quality MR services for the Pulse programming course, trying to
sense it is an award made by one’s
patient. They create the link between gain a better understanding of how
professional peers.
the physics and engineering of the scanners work.
2003 is the 11th time the award scanner designs with the questions
has been made in the past 13 years. of radiologists and clinicians to Using the MAGNETOM Vision, Greg
Previous Crues-Kressel awardees provide answers for the patients, at emphasised 3D T1 imaging with
include educators and safety experts the same time as managing the MP-RAGE, adopted CE-MRA after
Dr. Emanuel Kanal, and Dr. Frank patients’ experience of the examina- exploring the role of stepping 2D
Shellock, Christine Harris (currently tion. ToF MRA, undertook cardiac MR
an active MAGNETOM World parti- exams in the late 90’s, and in the past
cipant in paediatric imaging), Candi For several years he distributed few years introduced regular MR
Roth, Kelly Barron (instigator of the a handmade MR newsletter to about Spectroscopy examinations of brain
SMRT Home Studies Program), and thirty sites around the region. Since tumors. His current interest is in
Anne Sawyer-Glover of Stanford meeting Michael Kean in 1991, rolling out a technique, developed by
University California. Greg has participated as faculty at the University of Western Australia
Greg is the first non-U.S. recipient many Australian MR user meetings. and possible on all Siemens 1.5 T
of the Crues-Kressel award, gaining He assisted with organisation of scanners, to monitor and better
recognition for his local and SMRT the 1998 ISMRM/SMRT meetings in manage iron overload, improving the
related work, but probably most Sydney under the chair of Dr .Carolyn quality of life for Thallassaemia
particularly for his global presence Mountford, wrote course material patients, and sufferers of Genetic
through the Adelaide MR web site for post graduate students at Sydney Haemochromatosis.
(www.users.on.net/vision) and University and Charles Sturt Univer-
sity, and lectured at the University Greg hopes to continue in MRI,
several years of active participation in sharing his perspective and learning
the MRI Technologists’ list initiated of South Australia. Greg continues to
work as an on-line tutor with the from the Australian and international
from Duke University by Richard community of MR radiographers.
Helsper, and now managed by the RMIT.
SMRT office. Greg now commences a 3 year term
Greg has a long close association
on the Policy Board of the SMRT,
with Siemens MRI beginning in 1986
and is the Chair of the Publications
with a factory visit after the Royal
committee as well as working on
Adelaide Hospital’s decision to
the programme for the next SMRT
purchase a 1Tesla MAGNETOM GBS2
meeting in Kyoto, Japan, May 15-21
system. Getting the most out of
2004.
these early systems relied on develo-
75
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MAGNETOM FLASH

R2-HIC: A Practical Method for


Measuring Liver Iron Levels*
Greg Brown Genetic haemochromatosis (GH from a method that will frequently
Senior Radiographer MR or HH) is an autosomal recessive and accurately measure HIC, without
Royal Adelaide Hospital genetic condition affecting about complications [5].
four people in every thousand of U.K. Liver biopsy is the common method
or Northern European ancestry and of measuring HIC. The procedure
carried by one in ten [3], making it is invasive and subject to significant
the most common genetic disorder procedural, performance, and
in the Australian community [4]. sampling errors. While the results are
Patients usually present later in life reliable, about one in five procedures
displaying liver failure, cirrhosis, yield an inadequate tissue sample [6].
Introduction diabetes, hepato-cellular carcinoma, Liver cirrhosis, commonly associated
or cardiac failure, which are the with chronic iron overload, will
The Royal Adelaide Hospital has consequences of prolonged iron further decrease the accuracy of liver
added quantitative liver iron measure- accumulation in the liver, endocrine biopsy because of the chance of
ment into its Radiology services to systems and heart. It is increasingly sampling fibrotic tissue regions [7].
provide critical information for recognised that GH is under-diagno- Liver biopsy on children usually
clinicians managing iron overload sed, so regular testing of iron storage requires anaesthetics and admission,
(haemochromatosis) patients. The levels is recommended for all siblings introducing more complications and
R2-MRI Hepatic Iron Concentration with genetic testing if high results expense.
method was developed by the are found. Treatment regimes of
Biophysics Research team of the venesection (controlled bleeding or Many clinical centres accept these
University of Western Australia (Prof. donation) will minimise iron accumu- performance limitations, and
Dr. Tim St. Pierre, Dr. Wanida Chua- lation and avoid serious complica- perform biopsy annually. Others use
anusorn and Mr. Paul Clark) [1] with tions. biopsy less frequently to reduce
the assistance of Radiologist Dr. Jay morbidity or expense, relying on
Ives and Radiographer Erin Robins combinations of the less reliable
Acquired haemochromatosis (AH)
of SKG Radiology, Perth Western serum ferritin test, iron loading
affects people undergoing repeated
Australia. calculations, and clinical signs.
transfusions for inherited anaemias
By combining prescribed techniques, such as beta-thallasaemia, and sickle
a simple calibration scan, and central cell. These conditions affect people
data analysis, R2-HIC delivers a precise of African and Mediterranean descent, MR assessment of liver
liver iron assay based on extensive and while rare, a recent W.H.O. review iron concentration
validation work. This method is predicted over 3.5 million new
MR is particularly well suited to
machine independent and reproducible sufferers will be born each year in
detecting tissue iron concentration.
without local validation experiments, Africa, Southern Europe, the Middle
Iron is stored in the liver as two
offering a unique opportunity to East, India, South East Asia, and
paramagnetic proteins, ferritin and
introduce an important diagnostic Southern China. The diseases are also
haemosiderin [8] [9]. These com-
test quickly and globally. present in countries with significant
pounds shorten T1 and T2 in propor-
ethnic communities from these
tion to the local concentration. Many
pan-equatorial regions. Managing
groups use the signal intensity ratios
patients with acquired haemochro-
(SIR), of liver and skeletal muscle in a
Iron overload matosis is more complex and expen-
simple single sequence protocol [10]
sive, relying on iron chelation drugs
Iron overload is a serious condition, [11] to assess the level of tissue iron.
to remove excess iron form the body.
affecting patients all over the world. Others use multiple sequences,
Untreated, it will cause cardiac altering only the echo time, then use
In both groups, accurate management
failure, liver failure, diabetes, or the signal intensity values to plot
depends heavily on accurate quanti-
hepatocellular carcinoma. [2] the signal decay curve to find a value
fication of iron concentration in the
for T2. Similar approaches have been
liver (HIC), to monitor the total body
* The information about this product is
made looking at T2* decay.
iron burden. A single measure of HIC
preliminary. The product is under development
and is not commercially available in the U.S., will not ensure effective clinical Iron loaded tissues exhibit T2 values
and its future availability cannot be ensured. management. These patients benefit of around 5 msec. resulting in signal
76
SUPER TECHNOLOGISTS

Figure 1
Steps in R2-MRI Image Analysis.

Liver Iron Vs Time


50
TH 1
40
TH 2
Mg/g Fe

30 TH 3
TH 4
20
TH 5
10 TH 6

0
0 8 13 14

Months

Figure 2

77
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MAGNETOM FLASH

levels very close to noise floors. evaluation and reporting. Pixel values results are plotted in Fig. 2. The initial
This emphasises the need to collect are processed to determine the noise R2-MRI examinations showed four
data early and close in the echo time floor, and signal offsets, then filte- thalassaemia patients with HIC
domain, and on the development ring to address motion artefacts [12] values higher than the therapeutic
of sophisticated mathematical algo- [13] [14]. The values from each echo target of 7 mg/g. Serial studies show
rithms to perform accurate curve time are fitted to a bi-exponential falling HIC levels for three of the
fitting in the presence of low SNR. decay curve to determine the T2 elevated group, and one yet to have
value for each pixel. The transverse a follow up scan.
Relaxometry and ratio methods have relaxivity value (R2) is simply the
delivered reliable assays of liver iron HIC levels were elevated, but accept-
inverse of T2; this term is used
in their original institutions but the able, in the other anaemia patients.
because R2 is proportional to iron
work is not propagated because of R2-MRI will be used annually to
concentration. The R2 values are
the need for time-consuming verifi- monitor their treatment as maintaining
correlated to iron concentrations
cation studies to calibrate machine low levels of iron loading.
using data previously verified against
specific techniques and their results biopsy data [15], yielding a measure
with objective liver iron assays. of iron concentration in every pixel
throughout the liver. Summary
R2-MRI offers a simple, reliable,
The R2-MRI analysis service reports
R2-MRI method non-invasive measure of liver iron
(usually in digital form via e-mail)
concentration that can be performed
Following some basic instruction and to the referring clinician. The report
on virtually any Siemens 1.5 T scanner.
calibration using a custom phantom, includes the average hepatic iron
The centralised data analysis model
the method can be performed on concentration, the hepatic iron index,
is well validated, offering immediate
any MAGNETOM Vision, Symphony and map and histogram of R2 values
clinical utility and avoiding the need
or Sonata scanners using standard through the largest part of the liver
for substantial local testing and
image sequences and the CP body to demonstrate heterogeneity of iron
expertise. The pixel-map approach is
array coil. concentration.
not subject to the spatial sampling
Six spin echo acquisitions (TR 2500 The method is currently used at errors that affect biopsy or large ROI
msec. TE 6,7,8,9,12 &15 msec), are about 15 scanners through Australia, MR approaches.
obtained with fixed receiver gain Asia, Europe and North America,
factors. 19 axial slices 5 mm thick although it could be rolled out
and 5 mm apart, with typical pixel to literally thousands of 1.5 Tesla Acknowledgments
dimensions of 1.4x1.4 mm cover the scanners with reliability.
Dr. Wanida Chua-anusorn for
whole liver. Close clustering short comments and encouragement.
TE acquisitions maximises SNR, and is
necessary to accurately estimate the Clinical experience
very short T2 values associated with
elevated iron levels. A container of Since December 2001, Royal Adelaide
Hartmann’s solution or saline is Hospital has conducted sixteen R2-
included in the image adjacent to HIC examinations for 10 children
provide a constant signal region, aid aged 9 to 16 years. Six have thalas-
in calibration, and assess instrument saemia, four exhibit other anaemias
drift. Total examination time is requiring repeated infusions.
approximately 35 minutes. R2-MRI Satisfactory scan data was obtained
can be performed in conjunction in 14 examinations without sedation,
with conventional liver MRI as long as while two patients (ages 7 & 9)
contrast agents are not used prior to required examination with general
the R2-MRI measurements. anaesthesia. The patients were
previously managed with a single
Scan data is sent via the Internet or liver biopsy, and serial serum ferritin
CD to the University of Western tests. They are now monitored with
Australia R2-MRI analysis service for serial R2-MRI. Their R2-MRI HIC
78
SUPER TECHNOLOGISTS

January 2002 HIC 17.2 mg/g dry August 2002 HIC 14.2 mg/g dry March 2003 HIC 8.8 mg/g dry

Figure 3 Draft appearance Frequency histograms of R2 values in the mid liver slice. The R2 value is
Thalassaemia. Changing HIC with proportional to the iron concentration in each voxel. As treatment is optimised,
DFO treatment (patient TH2). the mean R2 values fall reflecting the progressive reduction in liver iron
concentrations. This is matched by an increasingly uniform distribution of R2
values in the slice suggesting the concentration of remaining iron stores
become uniform throughout the liver.

References [ 6 ] Angelucci E, Baronciani D, Lucarelli G et al.


Needle liver biopsy in thalassaemia:
[ 11 ] Bonkovsky HL, Rubin RB, Cable EE,
Davidoff A, Rijcken TH, Stark DD.
[ 1 ] Clark PR, St. Pierre TG. analysis of diagnostic accuracy and safety in Hepatic iron concentration: non-invasive
Quantitative mapping of transverse relaxivity 1184 consecutive biopsies. estimation by means of MR imaging
(1/T2) in hepatic iron overload: British Journal of Haematology 1995; techniques.
a single spin-echo imaging methodology. 89: 757-761 Radiology 1999; 212(1): 227-234
Magnetic Resonance Imaging 2000;
18: 431-438 [ 7 ] Porter JB, Davis BA. Monitoring chelation [ 12 ] Clark PR, Chua-anusorn W, St. Pierre TG.
therapy to achieve optimal outcome in the Reduction of respiratory motion artifacts in
[ 2 ] Powell L, Isselbacher K. in Harrison’s treatment of thalassaemia. in Best Practice & transverse relaxation rate (R2) images of the
Principles of Internal Medicine 11th edition. Research Clinical Haematology 15:2, 2002 liver. Computerised Medical Imaging and
McGraw-Hill Book Company New York 1987 p.335 Graphic, submitted February 2003
p 1635
[ 8 ] Stark DD. Hepatic iron overload: [ 13 ] Clark PR, Chua-anusorn W, St. Pierre TG.
[ 3 ] Jones G. Genetic Haemochromatosis. paramagnetic pathology. Proton transverse relaxation rate (R2) images of
Sydpath. URL www.sydpath.stvincents.com. Radiology 1991; 179: 333-335 liver tissue: mapping local tissue iron concen-
au/tests/geneticheamochromatosis.htm trations with MRI. Magnetic Resonance in
accessed 14 Sep 2003 [ 9 ] Brown DW, Henkelman RM, Poon PY, Medicine 2003; 49: 572 –575.
Fischer MM.
[ 4 ] Feder JN, Gnirke A, Thomas W, et al. Nuclear magnetic resonance study of iron [ 14 ] Clark PR, Chua-anusorn W, St. Pierre TG.
A novel MHC class I-like gene is mutated in overload in liver tissue. Bi-exponential proton transverse relaxation
patients with hereditary haemochromatosis. Magnetic Resonance Imaging 1985; rate (R2) image analysis using RF field intensity-
Nature Genetics 1996; 13: 399-408 3: 275-282 weighted spin density projection: potential for
R2 measurement of iron-loaded liver.
[ 5 ] Porter JB, Davis BA op cit p 338 [ 10 ] Jensen PD, Jensen FT, Christensen T, Magnetic Resonance Imaging 2003;
Ellegaard J. 21: 519-530.
Non-invasive assessment of tissue iron overload
by magnetic resonance imaging.
British Journal of Haematology 1994;
84: 171-184

79
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Guidelines to Prevent Excessive


Heating and Burns
IMRSER damage. The nature of high frequency
electromagnetic fields is such that
the energy can be transmitted across
open space and through insulators.
Therefore, only devices with carefully
designed current paths can be made
safe for use during MR procedures.
Simply insulating conductive material
Figure 1 Third-degree burn such as wires or leads, or separating
experienced by a patient during an it from the patient, may not be
Magnetic resonance (MR) imaging is MR procedure. This burn was sufficient to prevent excessive heating
generally considered to be a relatively unrelated to equipment malfunction or burns from occurring.
or the presence of internal or
safe diagnostic modality. However,
external conductive materials. Furthermore, certain geometrical
the use of radiofrequency coils,
shapes exhibit the phenomenon of
physiologic monitors, electronically-
“resonance” which increases their
activated devices, and external Notably, more than 30 incidents of
propensity to concentrate RF currents.
accessories or objects made from excessive heating have been reported
At the operating frequencies of
conductive materials has caused in patients undergoing MR procedures
present day MR systems, conducting
excessive heating, resulting in burn in the United States that were unre-
loops of tens of centimeters in
injuries to patients undergoing MR lated to equipment problems or the
size may create problems and must
procedures. Heating of implants and presence of conductive external or
therefore be avoided, unless high
similar devices may also occur in internal implants or materials
impedance is used to limit RF current.
association with MR procedures, but [review of data files from U.S. Food
Importantly, even loops that include
this tends to be problematic primarily and Drug Administration, Center for
small gaps separated by insulation
for objects made from conductive Devices and Radiological Health,
may still conduct current.
materials with elongated shapes such Manufacturer and User Facility
as leads, guidewires, and certain Device Experience Database, MAUDE, To prevent patients from experien-
types of catheters (e.g. catheters http://www.fda.gov/cdrh/maude.html cing excessive heating and possible
with thermistors or other conducting and U.S. Food and Drug Administra- burns in association with MR proce-
components). tion, Center for Devices and Radio- dures, the following guidelines are
logical Health, Medical Device Report, recommended:
(http://www.fda.gov/CDRH/mdrfile.
html)]. These incidents included first,
second, and third degree burns
sustained patients (Fig. 1). In many of
these cases, the reports indicated
1 Prepare the patient for the
MR procedure by:
a. ensuring that there are no
parts of the patients’ bodies were
unnecessary metallic objects in
in direct contact with body radiofre-
contact with the patient’s skin,
quency (RF) coils or other RF transmit
such as metallic drug delivery
coils of the MR systems or there were
patches, jewelry, necklaces,
skin-to-skin contact points suspected
bracelets and key chains.
to be responsible for these injuries.
b. using insulation material, such
MR systems require the use of RF as appropriate padding, to prevent
pulses to create the MR signal. This skin-to-skin contact points and
RF energy is transmitted readily the formation of “closed-loops”
through free space from the transmit from touching body parts.
RF coil to the patient. When conduc-
ting materials are placed within the
RF field, the result may be a concen-
tration of electrical currents sufficient
to cause excessive heating and tissue
2 Insulating material (minimum
recommended thickness, 1 cm)
should be placed between the
80
MRI SAFETY

patient’s skin and the transmit RF coil


used for the MR procedure, or alter-
natively, the RF coil itself should be
3 Use only electrically conductive
devices, equipment, accessories,
such as ECG leads and electrodes,
5 Before using electrical equip-
ment, check the integrity of the
insulation and/or housing of all
padded. For example, position the and materials that have been components including surface RF
patient so that there is no direct thoroughly tested and determined coils, monitoring leads, cables, and
contact between the patient’s skin to be safe and compatible for MR wires. Preventive maintenance
and the body RF coil of the MR procedures. should be practiced routinely for
system, by having the patient place such equipment.
his/her arms over his/her head or by
using elbow pads or foam padding
between the patient’s tissue and the
body RF coil of the MR system.
This is especially important for those
4 Carefully follow specific MR
safety criteria and recommen-
dations for implants made from 6 Remove all non-essential
electrically conductive materials
MR examinations that use the body electrically-conductive materials, from the MR system (i.e. unused
coil or other large RF coils for trans- such as bone fusion stimulators and surface RF coils, ECG leads, cables,
mission of RF energy. neurostimulation systems. wires, etc.).

Institute for Magnetic Resonance


Safety, Education and Research
The Institute for Magnetic Resonance
Safety, Education, and Research
(IMRSER) is an independent, multidis-
IMRSER
The Medical, Scientific, and Techno-
logy Advisory Board is comprised of
recognized leaders in the field of
Magnetic Resonance in Medicine
(ISMRM), the American College of
Radiology (ACR), the Food and Drug
ciplinary, professional organization magnetic resonance (MR), including Administration (FDA), the National
devoted to promoting awareness, diagnostic radiologists, clinicians, Electrical Manufacturers Association
understanding, and communication research scientists, physicists, MRI (NEMA), the Medical Devices Agency
of magnetic resonance (MR) safety technologists, MR facility managers, (MDA), and the International Electro-
issues through education and and other allied healthcare professio- technical Commission (IEC).
research. nals involved in MR technology and
The IMRSER’s rigorous development
safety. In addition, the Food and
and review process for MRI safety
Drug Administration has assigned a
One of the functions of IMRSER is guidelines ensures that authoritative
Federal Liaison to the IMRSER’s
to develop MRI safety guidelines and and relevant information is produced
Medical, Scientific, and Technology
to disseminate this information to in a timely manner for rapid dissemi-
Advisory Board. The Corporate
the MR community in order to help nation to the MR community.
Advisory Board is comprised of
ensure safety for patients, healthcare representatives from the MR industry It should be noted that the MRI
workers, and other individuals in the including MR system manufacturers, safety guidelines developed by the
MR environment. This is achieved by contrast agent pharmaceutical IMRSER are educational in nature
the Medical, Scientific, and Technology companies, RF coil manufacturers, and not specifically intended to
Advisory Board and the Corporate MR accessory vendors, medical be legal standards of care. Accor-
Advisory Board of the IMRSER, product manufacturers, and other dingly, these MRI safety guidelines
utilizing pertinent peer-reviewed, related corporate organizations. may be modified as determined by
evidence-based literature and by Significantly, MRI safety guidelines individual circumstances, currently
relying on each member’s extensive developed by the IMRSER consider available resources, differences or
clinical, research, or other appropriate and incorporate information provided changes in technology, and other
experience. by the International Society for relevant information.
81
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

References
7 Keep electrically conductive
materials that must remain in the
MR system from direct contact with
12 Allow only properly trained
individuals to operate devices
such as monitoring equipment in
Bashein G, Syrory G.
Burns associated with pulse oximetry during
the patient by placing thermal and/or the MR environment. magnetic resonance imaging.
Anesthesiology 1991;75:382-3.
electrical insulation between the
conductive material and the patient. Brown TR, Goldstein B, Little J.
Severe burns resulting from magnetic resonance

13 Follow all manufacturer


instructions for the proper
operation and maintenance of physio-
imaging with cardiopulmonary monitoring.
Risks and relevant safety precautions.
Am J Phys Med Rehabil 1993;72:166-7.

8 Keep electrically conductive


materials that must remain
within the body RF coil or other
logic monitoring or other similar
electronic equipment intended for
Chou C-K, McDougall JA, Chan KW.
Absence of radiofrequency heating from
auditory implants during magnetic resonance
use during MR procedures. imaging.
transmit RF coil of the MR system Bioelectromagnetics 1997;44:367-372.
from forming conductive loops.
Dempsey MF, Condon B.
Note: The patient’s tissue is conduc-
14 Electrical devices that do Thermal injuries associated with MRI.
tive and may therefore be involved in Clin Radiol 2001;56:457-65.
not appear to be operating
the formation of a conductive loop, Dempsey MF, Condon B, Hadley DM.
properly during the MR procedure
which can be circular, U-shaped, Investigation of the factors responsible for
should be removed from the patient burns during MRI.
or S-shaped.
immediately. J Magn Reson Imaging 2001;13:627-631.
ECRI, Health Devices Alert.
A new MRI complication? Health Devices Alert.
May 27, pp. 1, 1988.

9 Position electrically conductive


materials to prevent “cross points”,
which occur, for example, at the
15 Closely monitor the patient
during the MR procedure.
If the patient reports sensations of
ECRI.
Thermal injuries and patient monitoring during
MRI studies.
point where a cable crosses another heating or other unusual sensation, Health Devices Alert. 1991;20:362-363.
cable, where a cable loops across discontinue the MR procedure Finelli DA, Rezai AR, Ruggieri PM, Tkach JA,
itself, or where a cable touches either immediately and perform a thorough Nyenhuis JA, Hrdlicka G, Sharan A, Gonzalez-
the patient or the sides of the trans- assessment of the situation. Martinez J, Stypulkowski PH, Shellock FG.
MR imaging-related heating of deep brain
mit RF coil more than once. Notably, stimulation electrodes: In vitro study.
even the close proximity of conduc- Am J Neuroradiol 2002;23:1795-1802.
tive materials with each other should
be avoided because some cables and
RF coils can capacitively-couple
16 RF surface coil decoupling
failures can cause localized RF
power deposition levels to reach
Hall SC, Stevenson GW, Suresh S.
Burn associated with temperature monitoring
during magnetic resonance imaging.
Anesthesiology 1992;76:152.
(without any contact or crossover) excessive levels. The MR system
when placed close together. operator will recognize such a failure Heinz W, Frohlich E, Stork T.
Burns following magnetic resonance
as a set of concentric semicircles in tomography study. (German)
the tissue on the associated MR Z Gastroenterol 1999;37:31-2.
image or as an unusual amount of http://www.MRIsafety.com

10 Position electrically conductive


materials to exit down the
center of the MR system, i.e. not
image non-uniformity related to the
position of the RF coil.
International Electrotechnical Commission

along the side of the MR system or


close to the body RF coil or other
The adoption of these guidelines
transmit RF coil.
will help to ensure that patient
safety is maintained, especially as
more conductive materials and

11 Do not position electrically


conductive materials across an
external metallic prosthesis, e.g.
electronically-activated devices are
used in association with MR proce-
dures.
external fixation device, cervical
fixation device or similar device that
is in direct contact with the patient.
82
MRI SAFETY

(IEC), Medical Electrical Equipment, Particular Considerations for Physicians, Physicists, and
requirements for the safety of magnetic Technologists, Syllabus, 87th Scientific of the
resonance equipment for medical diagnosis, Radiological Society of North America, Chicago,
International Standard IEC 60601-2-33, 2002. pp 111-123, 2001.

Jones S, Jaffe W, Alvi R. Shellock FG.


Burns associated with electrocardiographic Magnetic Resonance Procedures:
monitoring during magnetic resonance Health Effects and Safety.
imaging. CRC Press, LLC, Boca Raton, FL, 2001.
Burns 1996;22:420-1.
Shellock FG.
Kanal E, Shellock FG. MR safety update 2002: Implants and devices.
Burns associated with clinical MR examinations. Journal of Magnetic Resonance Imaging
Radiology 1990;175: 585. 2002;16:485-496.

Kanal E, Shellock FG. Shellock FG. Radiofrequency-induced heating


Policies, guidelines, and recommendations for during MR procedures: A review.
MR imaging safety and patient management. Journal of Magnetic Resonance Imaging
J Magn Reson Imaging 1992;2:247-248. 2000;12: 30-36.

Keens SJ, Laurence AS. Shellock FG.


Burns caused by ECG monitoring during MRI Reference Manual for Magnetic Resonance
imaging. Safety: 2003 Edition, Amirsys, Inc., 2003.
Anaesthesia 1996;51:1188-9.
Shellock FG, Slimp G.
Knopp MV, Essig M, Debus J, Zabel HJ, van Severe burn of the finger caused by using
Kaick G. a pulse oximeter during MRI.
Unusual burns of the lower extremities American Journal of Roentgenology
caused by a closed conducting loop in a patient 1989;153:1105.
at MR imaging.
Shellock FG, Hatfield M, Simon BJ, Block S,
Radiology 1996;200:572-5.
Wamboldt J, Starewicz PM, Punchard WFB.
Knopp MV, Metzner R, Brix G, van Kaick G. Implantable spinal fusion stimulator:
Safety considerations to avoid current-induced assessment of MRI safety.
skin burns in MRI procedures. (German) Journal of Magnetic Resonance Imaging
Radiologe 199838:759-63. 2000;12:214-223.

Kugel H, Bremer C, Puschel M, Fischbach R, Smith CD, Nyenhuis JA, Kildishev AV.
Lenzen H, Tombach B, Van Aken H, Heindel W. Health effects of induced electrical fields:
Hazardous situation in the MR bore: implications for metallic implants.
induction in ECG leads causes fire. In: Shellock FG, ed. Magnetic resonance
Eur Radiol 2003;13:690-694. procedure: health effects and safety.
Boca Raton, FL: CRC Press, 2001; 393-414.
Nakamura T, Fukuda K, Hayakawa K, Aoki I,
Matsumoto K, Sekine T, Ueda H, Shimizu Y. U.S. Food and Drug Administration,
Mechanism of burn injury during magnetic Center for Devices and Radiological Health
resonance imaging (MRI)-simple loops can (CDRH), Medical Device Report (MDR)
induce heat injury. (http://www.fda.gov/CDRH/mdrfile.html). The
Front Med Biol Eng 2001;11:117-29 files contain information from CDRH’s device
experience reports on devices which may have
Nyenhuis JA, Kildishev AV, Foster KS, malfunctioned or caused a death or serious
Graber G, Athey W. injury. The files contain reports received under
Heating near implanted medical devices by both the mandatory Medical Device Reporting
the MRI RF-magnetic field. Program (MDR) from 1984-1996, and the
IEEE Trans Magn 1999;35:4133-4135. voluntary reports up to June 1993. The database
currently contains over 600,000 reports.
Rezai AR, Finelli D, Nyenhuis JA, Hrdlick G,
Tkach J, Ruggieri P, Stypulkowski PH, Sharan A, U.S. Food and Drug Administration,
Shellock FG. Center for Devices and Radiological Health
Neurostimulator for deep brain stimulation: (CDRH), Manufacturer and User Facility Device
Ex vivo evaluation of MRI-related heating Experience Database, MAUDE,
at 1.5 Tesla. (http://www.fda.gov/cdrh/maude.html).
Journal of Magnetic Resonance Imaging MAUDE data represents reports of adverse
2002;15:241-250. events involving medical devices.
The data consists of all voluntary reports since
Schaefer DJ. June, 1993, user facility reports since 1991,
Safety Aspects of radio-frequency power distributor reports since 1993, and manufacturer
deposition in magnetic resonance. reports since August, 1996.A
MRI Clinics of North America 1998;6:775-789.

Schaefer DJ, Felmlee JP.


Radio-frequency safety in MR examinations,
Special Cross-Specialty Categorical Course in
Diagnostic Radiology: Practical MR Safety
83
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Guidelines for the Management


of the Post-Operative Patient
IMRSER less. This is because certain intravas- Shellock FG.
MRI and post-op patients.
cular and intracavitary coils, stents, Signals, No. 34, Issue 3, p. 8, 2000.
filters, and cardiac occluders, desig-
Shellock FG.
nated as being “weakly” ferromagne- MR safety update 2002:
tic, become firmly incorporated into Implants and devices.
tissue six to eight weeks following J Magn Reson Imaging 2002;16:485-496.
placement. Retentive or counter- Shellock FG.
forces provided by tissue ingrowth, Magnetic Resonance Procedures:
Health Effects and Safety.
scarring, or granulation essentially CRC Press, LLC, Boca Raton, FL, 2001.
serve to prevent these objects from
Shellock FG.
There is controversy and confusion presenting risks or hazards to such Reference Manual for Magnetic Resonance
regarding the performance of a individuals in the MR environment. Safety: 2003 Edition, Amirsys, Inc., Salt Lake
City, UT, 2003.
magnetic resonance (MR) procedure Implants or devices that may be
in a patient with a metallic implant “weakly magnetic” but are rigidly Spuentrup E, et al.
Magnetic resonance-guided coronary artery
or device during the post-operative fixed in the body, such as a bone stent placement in a swine model.
period. Studies in the peer-reviewed screw, may be studied immediately Circulation 2002;105:874-879.
literature have supported an MR after implantation. Specific informa- Teitelbaum GP, Bradley WG, Klein BD.
procedure using an MR system tion pertaining to the recommended MR imaging artifacts, ferromagnetism, and
operating at 1.5 Tesla or less, imme- post-operative waiting period may magnetic torque of intravascular filters,
stents, and coils.
diately after implantation, if a metallic be found in the labeling or product Radiology 1988;166:657-664.
object is a “passive implant” (i.e. insert for a “weakly magnetic”
Teitelbaum GP, Lin MCW, Watanabe AT, et al.
there is no electronically- or magneti- implant or device. Ferromagnetism and MR imaging:
cally-activated component associated safety of cartoid vascular clamps.
Special Note: If there is any concern Am J Neuroradiol 1990;11:267-272.
with the operation of the device) and
regarding the integrity of the tissue
it is made from a non-ferromagnetic Teitelbaum GP, Ortega HV, Vinitski S, et al.
with respect to its ability to retain Low artifact intravascular devices:
material, such as titanium, titanium
the implant or object in place or the MR imaging evaluation.
alloy or nitinol. In fact, there are Radiology 1988;168:713-719.
implant cannot be properly identified,
several reports that describe placement Teitelbaum GP, Raney M, Carvlin MJ, et al.
the individual should not be exposed
of vascular stents and other implants Evaluation of ferromagnetism and magnetic
to the MR environment. resonance imaging artifacts of the Strecker
using MR-guided procedures that
tantalum vascular stent.
include the use of high-field-strength Cardiovasc Intervent Radiol 1989;12:125-127.
(1.5 Tesla) MR systems. Someone
with a non-ferromagnetic, passive
References
implant is allowed to enter the MR Ahmed S, Shellock FG.
Magnetic resonance imaging safety:
environment of a 1.5 Tesla or less, implications for cardiovascular patients.
immediately after its implantation. Journal of Cardiovascular Magnetic Resonance
Currently, there is little data to provide 2001;3:171-181.

guidelines for MR environments Bueker A, et al.


using scanners operating at Real-time MR fluoroscopy for MR-guided iliac
artery stent placement.
3 Tesla or higher. J Magn Reson Imaging 2000;12:616-622.

Manke C, Nitz WR, Djavidani B, et al.


For an implant or device that exhibits MR imaging-guided stent placement in iliac
“weakly magnetic” properties, such arterial stenoses: A feasibility study.
Radiology 2001;219:527-534.
as certain stents, atrial septal defect
occluders, ventricular septal defect Rutledge JM, Vick GW, Mullins CE, Grifka RG.
Safety of magnetic resonance immediately
occluders, patent ductus and arterio- following Palmaz stent implant:
sus occluders, it is typically necessary a report of three cases.
to wait for six to eight weeks after Catheter Cardiovasc Interv 2001;53:519-523.
implantation before performing an Sawyer-Glover A, Shellock FG.
MR procedure or allowing the person Pre-MRI procedure screening:
recommendations and safety considerations for
to enter the MR environment of biomedical implants and devices.
a scanner operating at 1.5 Tesla or J Magn Reson Imaging 2000;12:92-106.
84
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Siemens Medical Solutions that help


MAGNETOM FLASH

Annual CT/MR Users’ Seminar Review

Barbara Cammisa It was our pleasure to have several The MR and CT Divisions from the US
National Manager, of our Siemens customers speak sponsored the surprise Friday night
US MR Applications at our seminar. Margaret King, from event that consisted of a genuine
Raleigh MRI in North Carolina, Marti Gras parade including floats,
consistently delivers invaluable tips beads and music. At the end of the
for the technologists, which can be parade a private riverboat ride on the
implemented immediately upon their Creole Queen was waiting to meet all
return to their workplace. We asked the participants for a night of food,
Margaret to extend her usual one- fun and entertainment. It will be
hour lecture to two hours this year difficult to top this next year but we
In June 2003, the CT and MR Appli- since she never seems to have already have some great ideas in
cations groups from the US had the enough time to answer all the ques- the pipeline!
pleasure of sponsoring our annual tions or address the topics raised
Our annual user seminar demonstrates
dual-modality users seminar for our by the audience. As in the previous
Siemens ongoing commitment to
global MAGNETOM and SOMATOM two years, Margaret’s lecture was
educating our MAGNETOM users in
customers. again the highest rated lecture of
a variety of different platforms.
the seminar from the attendees.
The MR group had a grand turnout We are in the midst of planning our
of 125 MR customers from the US as Among our faculty was Tamara Lee seminar for next year. Once finalized,
well as our friends from Canada, from the Children’s Hospital of the information will be posted on
Germany and other international Philadelphia. Tamara presented a the MAGNETOM World website at
patrons. It was a wonderful forum for Pediatric Cardiac Imaging lecture, SiemensMedical.com/MAGNETOM-
our MAGNETOM users to share their which gave our users insight into the World as well as in the MAGNETOM
experiences with their MAGNETOM challenging task of imaging pediatric Flash. We hope you will join us for
friends. patients. Dr. Vamsi Narra from the another exciting seminar next year!
Mallinkrodt Institute of Radiology
The two-and-a-half day seminar
expanded our knowledge of contrast
took place in the entertaining and
enhanced MRA studies as well as
fun-filled city of New Orleans. Nancy
VIBE imaging. Dr. Meng Law from
Gillen, Vice President – US MR Divi-
New York University contributed to
sion, kicked off with an invigorating
the subject of Spectroscopy along
presentation providing insight
with Sheila Bero, one of our Advanced
into what the future holds for MR.
MR Applications Specialists.
This fueled the excitement of our
attendees who chose a profession in Of course, our users seminar would
Magnetic Resonance Imaging. not be complete without contributions
from our talented and dedicated
internal faculty of MR Applications

New Orlean
Specialists, the MR R & D group, the
Uptime Service Center and the MR
Division. The topics of discussion
from our internal staff ranged from
Cardiac MRI to ACR Accreditation
to “Pet Imaging”. We also offered
one-on-one Leonardo demonstrations
(our multi modality workstation) to
our attendees who were interested
in learning about the Leonardo’s
post-processing capabilities.

86
EVENTS

New Orlean
ns
87
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Siemens Promotes a First-Ever Meeting


Between MR and CT Users within Mercosur
By: Alessandra Wasilenko for
Siemens Medical Solutions Brazil

From June 6-8 in Angra dos Reis (RJ),


Brazil, Siemens Medical held a first-
ever meeting within Mercosur between
radiology experts in the areas of
Magnetic Resonance (MR) and
Computerized Tomography (CT).
Renowned users of Siemens equip-
ment from Brazil and elsewhere had
the opportunity to meet together
and learn from each other. “The
objective was to exchange experien-
ces and update these professionals
on diagnostic solutions and the
latest trends in CT and MR in terms of
advanced techniques and applica-
tions for post-processing procedures
and studies”, said Gustavo Ribeiro,
Siemens Medical’s Magnetic Reso-
nance Modality Manager-Mercosur.
who spoke about screening techni- as the merger potential and protocols
ques using a 32 row/second Multi- for PET, CT and MR images.
Twenty-three lecturers presented
slice computerized tomography to
questions in the following areas: Roughly 70 % of Siemens’ users offer
Neurology Program; News and New perform virtual colonoscopy; and their patients both diagnostic modes,
Technologies; Screening and Ortho- also about non-invasive angiography which fact explains the union of
pedics Program; Thorax, Abdomen for treating coronary artery diseases CT and MR at the event. The presen-
and Pelvis Program; Angiography and and neurovascular applications. tations were directed towards the
Cardiology Program, and Case Reports. Lecturers from the Mercosur region analysis of illnesses in which there
One such lecturer was Dr. Filippo discussed such themes as neurologi- exist experiences using both techni-
Cadermartini, from the Radiology cal applications in open systems, ques. The idea of the meeting grew
and Research Department of the latest news in high field MR, multi- from Siemens Medical’s awareness
Erasmus Medical Center, Amsterdam, slice computed tomography, as well that there lacked uniformity of

88
EVENTS

Brasil

information among users regarding beginning of a series that will promote Computed Tomography Business
similar equipment. The proposal further interaction between the Manager – Latin America. On Sunday,
received support from Siemens’ company and users. After all, it is by June 8, the event program offered a
international programs: MAGNETOM understanding and anticipating user free day allowing participants
World, in the Magnetic Resonance needs that new solutions are develo- to enjoy one of the most fascinating
area; and SOMATOM Life in the ped. By uniting more than 100 users ecological sites in Brazil.
Computed Tomography area. These of similar equipment, the consider-
programs aim to disseminate able interaction during and especially
information and develop loyalty after the event was only to be expec-
among users. The number of partici- ted – the networking of these pro-
pants was limited to the first 120 fessionals was multiplied”, explains
applicants. “This event marked the Paulo Gropp, Siemens Medical’s

89
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

“I thought this was an extremely


important initiative on the part of
Siemens, for we had the opportunity
to exchange experiences with other
colleagues and also learn a lot,
not only as a lecturer. We see the
work other people are doing in other
cities; and each one has a different
experience in a given area, pushing
the discussion towards a more
specific subject. So we exchange a “I focused on citing cases from the
lot of experiences not only in the Symphony Maestro Class because
scientific area, but also in the Siemens developed an equipment
administrative field, which is very easy to work with. I can perform a
important. In addition to this scientific complete neurological examination.
and administrative aspect, it is The equipment is fantastic and can
also very good to get together with execute very thorough examinations:
Dr. Romeu Cortes Domin- colleagues on a social level. Siemens diffusion, perfusion, spectroscopy
Brasil is experiencing a very positive and tractography. Tractography is
gues, director of the CDPI period, both commercially as well a diffusion-based image that Ameri-
and Multi-Imagem (RJ) as in services. As a result, what we cans call tensor image. And we can
clinics. Neurology Program. see is considerable satisfaction from do all this much faster and easier
Lecture: “Functional MR the radiology area towards the than in days gone by. (...) The equip-
technology and services of Siemens. ment today is much quicker and
in brain tumors (Diffusion, It is interesting and positive to see a easier to work with. Consequently,
Perfusion, Spectroscopy, company sponsoring an event such I can offer a complete exam and
Tractography and BOLD)”. as this – which requires such invest- provide a better diagnosis to neuro-
ment of time and money – in a time surgeons and neurologists. I possess
of crisis. In hard times, nobody wants more tools so that my diagnosis as
to invest; everybody is forced to cut between a tumor or an inflammatory
costs. However, Siemens proves process is always accurate. So I tried
that it is prospering and believes that to show in practice, with an example,
the country’s economy is going to how it has become easier to provide
improve and people will begin a diagnosis, giving us a lot more
buying again. This is why it is getting assurance. I want to show how these
a head start. I think this is a vision new techniques represent a major
of the future (...). Paulo Gropp and advancement. I believe there was
Gustavo Ribeiro deserve to be even interaction between Siemens
congratulated, as does the company. and certain key centers in the United
(...) And it is nice to see that the States, such as Harvard University.
people using Siemens equipment We know that various software
here in Brazil are doing a great job. applications of theirs, such as for
In watching the heart classes, as well perfusion and tractography, resulted
as the tomography, neurology and from our joint efforts. With these
that of other groups, we see that the new techniques, Siemens has taken
company has sold to opinion-forming a significant leap forward (...).”
centers and that is good, for both
the company and local specialists.”

90
EVENTS

“The event was marvellous and very


Dr. Martín Eleta, from the well organized. The lectures were
Hospital Italiano in Argentina good. The contacts were excellent.
The lectures were top notch with
and Radiology professor
outstanding image quality. I also
at the Federal University think that the topics were well-
of Buenos Aires (AR). divided: the mix was ideal. All imaging
News and New Technologies Dr. Paulo Schwartzman, areas were discussed. I thought they
were very good. (...) I work in the
Program. Lecture: Cardiology professor at the
cardiovascular imaging area: I want
“Experiences with PET, Federal University of to discuss my area of interest and I
combining CT and MR”. Rio Grande do Sul, former- want others to see what I do. I want
fellow of the Cardiovas- others to be able to carry out these
exams. Likewise, there are people
cular Imaging Service at from the abdomen area and some
Cleveland Clinic, Head doctors from the neurological area.
“The event was very useful and Physician responsible for In summary, this mixture is interesting
interesting. We witnessed many new Cardiac Resonance at and informative for all groups.
technologies that are being introdu- “My objective was to show that it is
Hospital Mãe de Deus Cen- possible to conduct cardiac magnetic
ced at the centers. We were given the
opportunity to see the clinical featu-
ter (RS) and Clínica X-Leme resonance using Siemens equipment.
res of these new techniques. (...). (PR). Angiography and The examination is quick. I want to
This will be useful given the interac- Cardiology Program. take the mystery out of the exam for
tion we will have with potential people who think cardiac MR exams
Lecture: “Clinical applica- are too lengthy. Cardiac MR resonance
contacts to take mutual advantage
of what each one currently deve-
tions of Cardiac Magnetic as a whole can be a long exam, but
lops”. Resonance”. I wanted to show the reality, that
“My objective was to demonstrate with Siemens equipment, especially,
the progress in Positron Emission it is possible to run a thoroughly
Tomography using fusion images of complete exam in just 30-35 minutes.
PET, MR and CT and the utility of I can therefore debunk the myth
this method especially in oncology, that cardiac MR takes up too much
cardiology and neurology. The machine time and show where this
diagnostic feature of the new method examination stands in today’s cardio-
exhibits the complete anatomy and logy area and what its applications

Brasil
morphology together with meta- are.”
bolism, thereby making available a
lot of information. (...)”

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MAGNETOM FLASH

Dr. Renato Mendonça, “ (...) I was very impressed by the


space in which the event took place.
responsible for Medi-
It was very well organized, well
magem’s neuroradiology decorated. Lots of screens.
area at Beneficência I think the company outdid itself.
Portuguesa Hospital; former I hereby congratulate all those
responsible for having offered so
President of the São Paulo many classes in such a breathtaking
Radiology Society; current place. It is impossible to keep every-
President of the São Paulo one in the rooms the entire time.
Radiology Society’s I believe they obtained record
Dr. Pedro Guedes, Radio- audiences, because the majority of
Scientific Commission (SP). people that came attended the
logist of Hospital Real
classes, in spite of the potential
Português and Serviço distraction of such beautiful surroun-
Real Imagem (PE). Thorax, dings. The level of presentations was
Abdomen and Pelvis very good. First world quality. (...).
Program. Lecture: “MR and We can see that the quality of work
Brazilian physicians are doing is on a
Endorectal Spectroscopy par with our foreign colleagues. (...)
of the Prostrate Gland, how I think Siemens deserves to be con-
I do it”. gratulated. The event was perfect,
impeccable. (...) Believe me, I have
participated in events held by other
companies, but nothing comes even
close to this one. It included examples
from all over Brazil. I know a lot of
“The event was outstanding not
people here; there are individuals
only in terms of people it reached,
from the northeast, the north, the
but also for the quality level of the
southeast. There are people from the
lecturers, the large number of parti-
midwest. Siemens gathered a very
cipants and the professionalism with
representative sample of experts
which Siemens organized the event.
from all over Brazil. The event was
Gustavo Ribeiro and Paulo Gropp
represented in the way the company
deserve the special congratulations
is represented throughout Brazil.
and I truly hope this event is repeated
This, to me, comes as a surprise;
every year. The important thing in
witness so many well-established
an event like this is not only to praise
bases. Everything – and everyone –
the good things being done, but also
was catered for. The company even
to deal with the problems we have
took the caution of hiring an emer-
with our equipment. That is, exchange
gency rescue service in the event any
experiences about our problems.
‘oldies’ had a stroke during the event.
To try and correct a problem with a
I appreciated this special attention
solution that another colleague may
given to us ‘oldies’. We thank you.”
perhaps have found. (...). After all,
everyone here is a loyal Siemens
customer. We all have similar
Siemens equipment. Therefore, this
interaction is what really counts.”

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EVENTS

Dr. Carlos Jader Feldman,


Radiologist of the Diagnostic
Investigation Service at
Hospital Ernesto Dornelles
and Instituto de Cardio-
logia, in Porto Alegre (RS).

“It was an excellent opportunity to


participate in this new idea in Brazil.
The event format was compact,
we had interesting themes and the
discussions were in-depth.”

Arnaldo Lobo, Radiologist


at Clínica Lobo, in Belém do
Pará (PA).

“I was very enthusiastic about this


initiative from Siemens. Firstly,
because it was my first experience of
this kind of event. Secondly, because
of how I experienced the event, not
only in terms of the presentation
of technological progress, but also
the quality of people invited to parti-
cipate in the course. I believe that
the exchange of information was
very good and the future very
promising. There should be at least
one of these events every alternate
year.”

Brasil
www.SiemensMedical.com/MAGNETOM-World
93
MAGNETOM FLASH

“With such a successful event,


Siemens Medical Mercosur proved
beyond all doubt the pride and
confidence which we all share in the
strengths of our South American
continent. We were delighted with
the outcome of the meeting:
our main objective to promote and
exchange knowledge between our
customers exceeded our expec-
tations. Much of the success was
due to the invaluable contributions
by some eminent radiologists who
promoted some very stimulating
discussions. One thing is for sure:
we now have more ideas and
opportunities to enable us to stay
ahead of the field in the healthcare
sector, which is exactly where we
belong.”
Carlos Vallejos
Marketing Manager

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EVENTS

Brasil
www.SiemensMedical.com/MAGNETOM-World
95
MAGNETOM FLASH

MAGNETOM World Meeting


Cardiac Imaging Symposium for Asia
Tony Enright, Ph.D.
Clinical Marketing and
Collaboration Manager
MR Asia Pacific

Singapore, July 5, 2003 tions, such as our speakers from


Wakefield Hospital in Australia and
Cardiac MR (CMR) is of growing Sir Run Run Shaw Heart Centre in
importance to diagnostic and inter- Hong Kong (SRRSHC). Both institutes
ventional healthcare workers for chose their MRI system for their
cardiology services within the Asia cardiology needs, Siemens Maestro
region. Siemens recognises the Class MAGNETOM Sonata.
needs and interests of this community
in continuing education on the Participants heard from Dr. Stephen
utilisation of CMR. This was the aim Worthley, an interventional cardio-
of MAGNETOM World’s Cardiac logist located at Wakefield Hospital,
symposium located in the beautiful and Dr. Ching Hon Luk, a consultant
city of Singapore. Participants from cardiologist from SRRSHC. Dr. Brett
throughout the Asia region joined Cowan from the University of Auck-
the symposium to hear clinicians from land and Greenlane Hospital in New
within their region who are involved Zealand is involved at the forefront
of rapid and advanced reporting

MAGNETOM
in the state-of-the-art application
of CMR techniques. techniques for cardiology. Dr. Renate
Jerecic from Siemens Medical Solutions
The meeting was jointly organised in Germany introduced the latest
with the Singapore Chapter of Radio- groundbreaking technologies in use
logists, Academy of Medicine, and by frontline researchers and clinicians
the Singapore Radiological Society alike, such as self-gated cardiac
and Singapore Cardiac Society. “With imaging*. “The ECG gating informa-
the involvement of these societies tion is determined directly from the
this educational symposium was able Siemens images, there are no wires
to reach out to a wider community attached to the patient for gating.
of cardiology, radiology, allied This is outstanding technology
healthcare workers and the research reducing patient setup and removing
community.” Dr. Kevin Chen of the dependence on the ECG when
Singapore General Hospital and Tan patients have poor ECG signal. It also
Ru San from the National Heart offers a solution for ultra-high field
Center were joint chairpersons for cardiac imaging where at clinical
the symposium. 3 T the magneto hydrodynamic effect
A special focus of this symposium can be more disruptive to the ECG
was to examine CMR from the measured by MRI scanners.”
perspective of cardiology experience
from within the Asia region. Siemens
collaborates with institutes in the * The information about this product is
preliminary. The product is under development
Asia region where cardiology does and is not commercially available in the U.S.,
play a strong role in CMR examina- and its future availability cannot be ensured.

96
EVENTS

M World
Singapore
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MAGNETOM FLASH

a b a b
Figure 1 a) 2D conventional heart Figure 2 a) 3D cardiac model of left
model constructed from separate ventricle, wire mesh for epicardium
slices, and b) 3D heart model. and surface for endocaridum,
b) model fit to dynamic (cine) images.

logy requires quantities such as end epicardium shown as a wire mesh


diastolic volume (EDV), end systolic and the endocardium shown as
volume (ESV), and myocardial mass. a surface display. “This sets a new
MR can also provide information on standard in the way the global func-
regional wall motion, wall thickening tion of the left ventricle is measured.”
and mass. But MR needs rapid
In addition to the advantages in
and accurate image analysis for
reporting the heart’s global function,
Dr. Brett Cowan reporting.”
now that the position of the endo-
Cardiac MR Research Group Dr. Cowan described the issues asso- cardium and epicardium through the
University of Auckland, ciated with the image analysis based cardiac cycle is known, it is also
New Zealand on the conventional 2D approaches possible and even convenient to
such as those shown in figure 1a: perform any kind of regional analysis
The Cardiac MRI Research Group on the heart. Since these regions
■ Contouring the endocardium and can be mathematically traced though
lead by Dr. Brett Cowan and Dr. Alistair
epicardium is time consuming the cardiac cycle, an EDV, ESV, stroke
Young work in the area of rapid
clinical analysis of MRI images and ■ All images from a short axis stack volume, mass and ejection fraction
are well established as a core lab for must be contoured can be calculated for each separate
large international pharmaceutical ■ The ventricle is not composed of region.
trials. They have a depth of expertise a series of disks In the example of figure 3, a patient
in both clinical imaging and high-
■ Wall thickening can only be who has had an infarct, the ejection
tech mathematical modeling of the
measured in the available slices fraction in the infero-lateral region
heart. Their work was recognized in
■ Volume in the most basal slice is is 24.7 % and the time-volume curve
July of this year with the awarding of
difficult to calculate is shown in green. In contrast, the
the 2003 Computerworld Excellence
anterior and antero-lateral regions
in IT in Biotechnology prize. Additionally, failure to account for which were unaffected by the infarct
the through plane motion of the base have local ejection fractions of 71.6
of the heart can lead to a significant and 73.1 % respectively as are shown
Ejection fraction in error in volumetric changes. on the bottom two time-volume
5 mins – rapid reporting curves.
These issues are addressed by a
of function – latest “fully beating” 3D model of the heart
techniques (Fig. 1b). Siemens is collaborating
The focus of Dr. Cowan’s lecture was with the Auckland group to realise
on the reporting needs of cardiology the power of a 3D analysis of cardiac
and radiology, when working with function in the ARGUS product.
MR images of the heart – “a rapid Developed by the Auckland group,
software analysis which quantifies the 3D model* has a finite element
global function and other diagnostic computer representation of the heart
quantities with a high degree of dividing the ventricle into a patch-
accuracy”. work of small surfaces which can
deform to match a patient’s heart
“MRI now delivers superb quality shape throughout the cardiac cycle.
cardiac imaging that is rapid, with Figure 2a shows the model for the
real-time imaging a reality. However, left ventricle, here demonstrating the Figure 3 Regional Analysis and
the needs of cardiology extend Reporting – volumetric changes from
beyond the high resolution anato- * The information about this product is
preliminary. The product is under development
infero-lateral region shown in green
mical images from MR. For patient and is not commercially available in the U.S., annotation, and antero-lateral
management and prognosis cardio- and its future availability cannot be ensured. shown in purple.
98
EVENTS

based techniques – the resolution


from CMR allows one to evaluate a b
transmural effects of ischemia. Figure 1 Late enhancement
viability imaging* for assessment of
Most exciting from CMR is myocardial hypertropic cardiomyopathy
viability. Assessed with the late patient treated with Percutaneous
enhancement technique, presently Transluminal Septal Myocardial
there is no comparison in terms of Ablation (PTSMA) – a) initial viability
spatial resolution. The superior imaging showing rim enhancement
resolution afforded by MR allows delineating boundaries of infarct
accurate evaluation of the transmural region, and b) final viability images
extent of myocardial scarring, and confirming infarct.
Dr. Stephen Worthley
results are obtained within 15-20
Director of Cardiovascular Imaging
minutes of contrast administration. successful combination of PTSMA
Wakefield Hospital, Adelaide,
and CMR for therapeutic intervention
Australia Viability imaging from CMR has a
in patients with hypertrophic cardio-
contribution to make to Dr. Worthley’s
myopathy.
Dr. Worthley’s initial address entitled recent interventional work using
“Non-invasive Myocardial Imaging Percutaneous Transluminal Septal
with MRI” was the first in a series of Myocardial Ablation (PTSMA). Patients
with thickening of the septum / Non-invasive coronary and
lectures for the symposium – “MR in
myocardium (“hypertrophic cardio- plaque imaging
Cardiovascular Diagnosis”.
myopathy”) may have problems with This second lecture was directed at
obstruction to the ejection of blood some of the most challenging areas
into the aorta due to this thickened of CMR – coronary artery magnetic
Non-invasive myocardial region of muscle. Here alcohol serves
imaging with MRI resonance angiography (CMRA) and
to occlude the selected arterial branch, the characterisation of atherosclerotic
Participants were presented a causing a localised infarction, redu- plaque.
“potpourri” of clinical examples from cing this obstruction. MRI is used to
Wakefield Hospital which served assess the extent of localised infarc- A review of the techniques used
to demonstrate and introduce cardio- tion and the resulting changes to left in CMRA are:
vascular magnetic resonance imaging ventricular function. Perfusion MRI ■ Breath-hold versus navigator
(CMR) for anatomy and morphology, enables an assessment of the extent techniques
cardiac masses, structural abnorma- of perfusion disruption to the myo- ■ Contrast versus non-contrast
lities, viability, ischemia and valve cardium, and the late enhancement
“In many cases the breath-hold
abnormalities. technique for viability demonstrates
examination is sufficient for evalua-
the extent of the localised infarction.
Dr. Worthley highlighted the diagnostic tion of the coronaries and the longer
A practical note to the late enhance-
strengths that CMR offers cardiologists, examination using navigator is not
ment technique for this procedure is
and in context with existing and required. This is certainly an advantage
that the infarction may not be shown
conventional imaging techniques in time saving and rapid review of
hyperintense immediately following
that are routinely applied today to the positioning results – capturing
the PTSMA procedure as the occluded
a range of cardiac diseases – for the coronary segments of interest. In
artery prevents the contrast agent
instance difficult cases where breath-hold is
gadolinium from entering the area.
“In pericardial disease MR is probably not possible the navigator technique
However, a rim enhancement of the
the modality of choice for pericardial offers another solution.”
infarct region can be observed thereby
constriction where echocardiography delineating the boundaries (see For CMRA Dr. Worthley highlighted
doesn’t always provide the amount of example in figure 1a. Dr. Worthley that current clinical studies have
structural and functional information demonstrated cases highlighting the largely concluded MR is sensitive to
often required for diagnosis.” stenosis but its major limitation
In imaging of myocardial perfusion* * The information about this product is remains the specificity of the techni-
preliminary. The product is under development
the resolution offered by CMR is and is not commercially available in the U.S., que for routine use. Dr. Worthley’s
superior to that offered by SPECT and its future availability cannot be ensured. institution also utiliseses 16-slice
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MAGNETOM FLASH

multi-detector CT (MDCT). The


participants were able to see a com-
parison between high resolution
CMRA and the MDCT for coronary
artery imaging, such as shown in
figure 2.
A particular focus of research for
Dr. Worthley has been imaging of
atherosclerotic plaque for which he
completed his PhD at Mt Sinai in New
York. “Often the severity of stenosis Dr. Ching Hon Luk
is a poor predictor for risk of myo-
Sir Run Run Shaw Heart Centre
cardial infarction. This has led to the
St Teresa’s Hospial, Hong Kong
necessity for lesion characterisation
to identify plaque vulnerability. MRI
can characterise the plaque compo-
nents – fibrous cap, lipid pool, calcifi- Sir Run Run Shaw Heart and Diagnostic
cations … and it is these components Centre (SRRSHC) is one of the earliest
of the atherosclerotic plaque that are heart centers located in the Kowloon
better predictors for myocardial peninsula, founded by Sir Run Run
infarction.” Shaw through a generous donation.
It is operated and run through St
While the routine use of MRI for high Teresa’s Hospital, located in Kowloon
resolution imaging of coronary Peninsula, Hong Kong. Sir Run Run
arteries still poses challenges, plaque Shaw Heart and Diagnostic Center is
composition in carotid arteries is unique in that cardiology plays an
already feasible. Dr. Worthley utilises important role in cardiac MR imaging.
a specialised RF coil on Siemens The MR is situated within the Heart
MAGNETOM Sonata for bilateral Center and is an integral part of the
coverage of both carotid arteries * The information about this product is
preliminary. The product is under development center. A significant number of cases
yielding high resolution images for and is not commercially available in the U.S., with positive findings on MR are
plaque characterisation. and its future availability cannot be ensured.
catheterized and the results made
known to the MR team. Patients who
underwent angioplasty are actively
followed up using cardiac MR. The
close co-operation of radiologists and
cardiologists provide the necessary
feedback for quality interpretation of
the MR imaging.

Detection of myocardial
ischemia with perfusion
imaging and dobutamine
stress MR*
Figure 2 Imaging of Coronary Figure 3 Imaging of Corotid
Arteries with multi-detector CT at Arteries with bilateral carotid coil at Dr. Luk, a consultant cardiologist
Wakefield Hospital Wakefield Hospital. Acquisition taken with SRRSHC, began his lecture by
(Siemens SOMATOM Sensation-16). immediately above the bifurcation describing the operation of this
showing lumen unique centre, its team of professio-
(Siemens MAGNETOM Sonata). nals, and why they chose MRI for
100
EVENTS

their patients. “At SRRSHC we are a b signal-to-noise and anatomical


particularly interested in the detec- coverage.
tion and diagnosis of disease early
Cardiac perfusion imaging operates
within the ischemic cascade – dia-
at the advanced level of MRI techno-
gnosis of subendocardial perfusion
logies. SRRSHC is fully equipped
deficit and transmural perfusion
with state-of-the-art MRI equipment
deficit. Our clinical questions are:
including specialised radiofrequency
■ What is wrong with patients (RF) coils for high performance
c
having chest pain? parallel imaging. Patients are exami-
ned using a 12-channel coil system
■ Does a patient require
(Siemens dual 6-pack RF coil pair).
revascularization procedure?
Parallel imaging and TrueFISP tech-
■ Treatment follow-up? nologies are taken full advantage of
■ Cardiac functional assessment for in imaging of ischemic heart disease.
non-cardiac surgery?” A typical imaging protocol at SRRSHC
d e for ischemic patients is described:
The centre has existing catheterization
labs for angiogram and angioplasty Figure 1 54 year old male patient
1. 4-chamber cine,
with symptoms of chest discomfort
procedures. “What was needed in our
unrelated to exertion. Patient is 2. Localizers: basal, mid-ventricular
centre was a non-invasive diagnostic a non-smoker with no history of and apical slices,
tool for examining ischemic heart diabetes or hypertension. a) Stress
diseases. perfusion image showing extent of 3. Adenosine injection for 4-6 min
perfusion deficit associated with RCA
Our belief: cardiac MR provides ➔ cardiologist attending the
prior to stenting procedure, b) late
ample diagnostic information non- enhancement image demonstrating session,
invasively.” subendocardial infarct, c) semi-quanti- 4. Contrast injection + perfusion
tative perfusion curves displaying imaging (stress),
Dr. Luk described the equipment sector anlysis of contrast transport
requirements for CMR. Sir Run Run through the myocardium. The arrows 5. Wait for 10 min
Shaw Heart Centre chose Siemens demonstrate the areas of risk
Maestro Class MAGNETOM Sonata, a highlighted by the perfusion software ➔ perform cine imaging for cardiac
highly advanced MR imaging scanner, Dynamic Signal Analysis, function during this wait period,
for non-invasive examination of d) X-ray angiogram before stenting, 6. Contrast injection + perfusion
ischemic heart diseases. and e) angiogram after stenting.
imaging (at rest).
Dr. Luk emphasised the current 1) beginning with an overview of Dr. Luk commented on the advantages
knowledge gap that generally applies existing imaging techniques used in of having available both imaging
for cardiologists new to working cardiology for routine diagnosis of and semi-quantitative reporting for
directly with the MRI technologies, ischemic disease and the sensitivity diagnosis. “In the perfusion analysis
which are at an advanced level in of these in comparison with MRI, the reported upslope of the curve is
cardiovascular MR imaging (CMR), typically most sensitive to perfusion
and therefore the need for strong 2) physiological changes to myo- deficit.” Patient contrast dosage at
vendor support to overcome this cardial perfusion under the influence SRRSHC has been optimised for semi-
initial barrier. “Siemens provides this of vasodilator stress agents, quantitative analysis.
support for our team and in our case
3) how perfusion MR imaging using Dr. Luk had many clinical case
included an onsite clinical scientist
contrast works, examples to share with participants.
from Siemens cardiac research and
development group at Northwestern Figure 1 shows diagnostic images
4) the physics of imaging sequences
University in Chicago.” from the typical caseload at SRRSHC
used for perfusion imaging, and
– this patient a 54 year old male
Dr. Luk’s lecture material provided 5) the key issues in image quality and presenting with chest discomfort
participants with a comprehensive their interrelationships – temporal unrelated to exertion, is a non-
overview of perfusion imaging: resolution, spatial resolution, image smoker and with no history of diabetes
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MAGNETOM FLASH

a b a b

c c d
Figure 2 Imaging of a 52 year Figure 3 76 year old female with
old male patient following acute previous PTCS and stenting on LAD,
myocardial infarct. a) rest perfusion* now suffering symptoms of frequent
image, b) stress perfusion image*, chest pain. a) and b) stress perfusion
and c) X-ray angiogram. images more basal and apical
respectively, c) X-ray angiogram
showing multiple stenoses in LCX,
d) angiogram following stenting of
or hypertension. The clinical question LCX.
is whether this patient has CAD? Non-
invasive MR imaging answered this
Figure 3 shows imaging of a 76 year
question. MR perfusion imaging at
old patient who received percuta-
rest showed only mild hypo-perfusion,
nous transluminal coronary stenting
but under stress (Fig. 1a) demon-
(PTCS) on the LAD 6 years previously,
strates a significant region of hypo-
now presenting with frequent
enhancement associated with perfu-
symptoms of chest pain. The clinical Figure 4 Sir Run Run Shaw
sion deficit from the RCA. MR viability
questions are: Heart Centre, St Teresa’s Hospital,
imaging, figure 1b, indicates a small
Hong Kong
subendocardial infarct. Semi-quanti- ■ follow-up from PTCS, and
tative perfusion reported from soft- ■ reasons for chest pain.
ware analysis (Fig. 1c – Siemens
Dynamic Signal Analysis) identifies MR Perfusion imaging demonstrated
sectors at risk with delayed perfusion, hypoenhancement associated with
in this case related to the RCA. perfusion deficit from the LCX (see
Figure 1d demonstrates the angio- Figs. 3a and 3b). X-ray angiographic
graphic confirmation of significant examination, shown in figure 3c,
stenosis in the RCA, and figure 1e confirmed multiple significant steno-
the angiographic results following sis in the LCX artery.
intervention. In addition to perfusion imaging,
A second case presented by Dr. Luk Dr. Luk presented the dobutamine
involves a 52 year old patient who stress MR (DSMR) technique used at
received MR perfusion imaging SRRSHC for imaging wall motion
following acute myocardial infarct. abnormality that is the result of
Perfusion imaging demonstrates significant stenosed coronary arte-
hypoperfusion of the infarcted area ries. “Dobutamine stress MR may well
both at rest and at stress (Figs. 2a prove to be significantly more
and 2b respectively). Figure 2c shows sensitive and specific at detecting
the follow-up angiogram. MR provided ischemia than the more routinely
a beautiful demonstration of the practiced dobutamine stress echo-
microvascular changes after acute cardiography.”
myocardial infract. * The information about this product is
preliminary. The product is under development
and is not commercially available in the U.S.,
and its future availability cannot be ensured.

102
EVENTS

MAGNETOM Forum 2003 – A Norwegian


MAGNETOM World Users Meeting
Peter Kreisler, Ph.D.
Collaborations & Applications,
Erlangen

The seventh Norwegian MAGNETOM


users meeting took place between
October 16 and 18 in the historic
Terminus hotel in Bergen, on the
western coast of Norway. We were
pleased to be able to welcome more
than 100 persons from 23 centres,
including radiologists, technicians
and physicists, to our meeting.
The meeting, as in previous years,
was well organized by Siemens
Norway in a close collaboration with
Prof. Hans Jörgen Smith and Eldrid
Winther-Larssen from Rikshospitalet
Oslo.
The clinical, technical and educational
talks gave a valuable overview on
the routine clinical and scientific the breaks and in the evenings.
activities in Norway. The entire human Such communication will initiate new
body was addressed: from perfusion collaborations and intensify existing
and fMRI studies in the brain, to ones, helping to build up a strong
heart, pancreas and colon and to national network embedded in
orthopaedics. A large proportion of the worldwide MAGNETOM World
the presentations were given by community.
radiologists and physicists from the Many thanks again to the organizers
local Haukeland University in Bergen. and supporters of this meeting
for a very polished performance.

MAGNETOM
The radiographers’ session Friday
afternoon was an ideal forum for
discussing practical issues of daily
work.
In a special physics session, Dr. Klaus
Scheffler from the University Hospital
of Basel, Switzerland presented

Norway
details on signal generation in Hyper-
Echo sequences.
An important component in meetings
like this is the informal and very
fruitful discussions between collea-
gues from different centres during
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MAGNETOM FLASH

MAGNETOM World Activities in India

MAGNE
Mr. Ajay Mittal
MR Marketing
Siemens Medical Solutions,
India

MAGNETOM World Meeting


Mumbai
23 to 25 May 2003
Siemens India hosted the MAGNETOM
World meeting for eighty 1.0 and
1.5 T users in May 2003. The Renais-
sance Hotel, overlooking the serene
Powai lake, provided a fantastic
setting for the meeting. The three
day event was inaugurated by
Mr. J. Schubert, Managing Director
Siemens Limited, India and the
welcome address was delivered by
Mr. Heinrich von Wulfen, Executive
Vice President, Siemens India Medical
Solutions. Everything was efficiently
Following the inauguration ceremony imaging, Cardiac and Abdomen
organised by Mr. Ajay Mittal, Chief
and welcome address, Mr. Rudolf imaging. Dr. Milind Dhamankar
Manager, MR Marketing Siemens
Hahn from Siemens AG, Germany highlighted newer developments in
India Medical Solutions. The highly
gave a talk on MAGNETOM World MR with a focus on helping radio-
interactive atmosphere was charged
concepts. The following day presented logists understand their needs and
with MRI specialists sharing their
highly interactive sessions on MR make informed decisions. This
practical experiences.
Neurology, Spectroscopy, MR Cardiac, approach to upgrades and invest-
MR Orthopedic imaging, MR Angio- ments was very well received. The
graphy and MR Body imaging. Inter- fruitful discussions have helped
national luminaries Dr. Meng Law – radiologists to implement optimum
Assistant Professor of Radiology, NYU utilization of existing applications
School of Medicine and Dr. Schneider and focus on future planning,
of the University of Homburg shared investments and decisions.
their valuable knowledge. Dr. Stefan
The ultimate goal of the meeting
Roell from Siemens Spectroscopy
was to create a sense on belonging
development group highlighted the
to the MAGNETOM World. We proudly
use of spectroscopy in clinical routine.
reached this goal: the meeting
Dr. Schneider enlightened us on
proved to be highly beneficial for all
subjects covering technique and
the participants. Much praise was
sequences in Cardiac MR , Viability*
justly bestowed on Siemens India
Study and Cardiac Perfusion.
and there was unanimous eagerness
A number of speakers from India to attend many more such interactive
* The information about this product is shared their knowledge and expe- meetings in the future.
preliminary. The product is under development
and is not commercially available in the U.S., rience in various applications including
and its future availability cannot be ensured. Angiography, Spine and Joints
104
EVENTS

India
ETOM World
Mumbai MR Spectroscopy
Workshop, Mumbai
27 to 28 May, 2003
MR Spectroscopy immediately
followed the MR imaging workshop.
With workflow optimization through
syngo MR, it is gaining wider accep-
tance in clinical routine. A dedicated
workshop on MR Spectroscopy
focused on educating users about
the newer developments. Users
interacted with specialists in this field
including Dr. Meng Law from NYU
School of Medicine, and Dr. Stefan
Roell and Ms. Mariane Vorbuchner,
both from Siemens Medical Solutions,
Erlangen. The hands-on approach
was appreciated by one and all.

105
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MAGNETOM FLASH

Dr. Radhesh S.,


Consultant Radiologist,
Elbit Diagnostics, Bangalore

“I congratulate and offer my appre-


ciation to Siemens India for the way
it has brought together national and Dr. Bharat Aggarwal,
international speakers to share their DCA Imaging Centre
thoughts on current MRI practices. New Delhi

I would describe these programmes


as “a common platform for sharing “To sum-up, everyone went back
knowledge”. The workshops on home with some positive experiences
Proton Spectroscopy and Cardiovas- and new thoughts on how to better
cular imaging were well organized: utilize their scanners, which applica-
they had excellent material and were tions to expand and where to invest
very interactive. In a nutshell, it all next (and where not).”
bore a stamp of class. I look forward
to more of such workshops and wish
Siemens India the very best for their
future programmes.”

106
EVENTS

Mumbai
MR Cardiovascular
Workshop,
Hyderabad
22 to 23rd August, 2003.
MR Cardiac imaging is an emerging
application in India. Siemens invited
experienced users to a workshop
to share their experiences with the
participants.
Dr. Joerg Barkhausen from University
of Essen and Dr. Carmel Hayes from
Siemens AG shared their valuable
clinical and practical know how with
the Siemens Cardiac Imaging users.
The workshop included lecture
sessions and hands-on sessions and
was warmly appreciated by all parti-
3D MRCP cipants.
Courtesy – DCA Imaging Centre, New Delhi, India. Siemens is the leader in Magnetic
Resonance Imaging in India and has
Clinical test sites for Work-in Progress (WIP) sequences: over 50 % market share in the 1.5 T
The application team in close cooperation with our customers has tested some systems in the country. Siemens
WIP sequences like 3D myelography, 3D RESTORE sequence with 2D PACE for has heavily invested in educational
free breathing 3D MRCP. These WIP sequences were installed at DCA Imaging programmes. We are thankful to
Centre Delhi, Mallaya Hospital Bangalore, AIIMS New Delhi. Excellent feedback our esteemed customers for their
has been received and as a result optimized protocols based on the feedback excellent feedback and support.
will be available in the upcoming software release, syngo MR 2004A.

India
www.SiemensMedical.com/MAGNETOM-World
107
MAGNETOM FLASH

Siemens MAGNETOM User Club (SMUC)


Meeting in Ängelholm, Sweden...

MAGNET
Andreas Piringer MR. She showed some very interesting cases with their Swedish colleagues
Product Manager MR cases made on their MAGNETOM in a very open way.
Medical Imaging & Therapy Symphony (upgraded Vision).
Sara Brockstedt introduced the
Sweden/Finland/Iceland Dr. Thomas Larsson from Södersjuk- audience to the IDEA platform. She
huset, Stockholm, presented their showed the workflow when a new
first clinical experience of cardiac sequence is developed, the different
imaging on a MAGNETOM Symphony parts of IDEA and how these parts
Quantum. He showed functional basically work.
Cardiac MR (CMR) cases and also
images of late enhancement studies Siemens Product Manager Andreas
...a meeting that had with excellent image quality. Piringer rounded off the day with
everything, including a brief summary of the history of fast
One of the most exciting presenta- MR imaging and introduced the
UFO’s! tions was by Lars Erik Olsson, Amers- Parallel imaging technique, some
Congratulations and thanks to Andreas ham Health AB. Lars Erik talked about application hints and some thoughts
Piringer (MR Product Manager) and the development of hyperpolarized about the future of iPAT.
Anita Larsson (Marketing Assistant), contrast agents for MR and offered a
review of what hyper polarization is In the evening, we strolled in the
who organized this two-day user
and what we could gain from it, as woods of Ängelholm and were given
meeting in collaboration with Elenor
well as discussing the future of the a very interesting explanation of the
Thelander and Rolf Larsson, MR
technique. famous UFO that is alleged to have
assistants, and Eva Bjärtun, Head of
landed on the coast of Ängelholm in
Radiology Section of Ängelholm Sara Brockstedt gave an enjoyable
the 60 s. Apparently, NASA has all
Hospital, a small regional hospital in talk on diffusion tensor imaging, one
the available information of this very
a town beautifully located on the of the ongoing projects at the
special and top-secret x-file case.
west coast of Sweden. The meeting MAGNETOM Allegra 3 T head scanner
If there were any extra-terrestrials
took place at the Klitterbyn conference in Lund.
camping out in the woods of Ängel-
centre in the town, and was opened
The Siemens Product Specialist on holm that evening, they kept well out
by the local “lergöksorkestern”, the
workstations – Lisa Lindfors – gave a of sight and did not delay our sump-
only “clay cuckoo orchestra” in the
presentation on the new Leonardo tuous dinner party at the Klitterhus
world and a thoroughly original
workstation software. She also hotel, along the coast. The band
musical welcome to the 15 invited
showed some very effective VRT “Heartbreakers” gave a memorable
speakers, including the Siemens
studies in real-time, which were show and for most us, how could we
representatives.
highly appreciated by the audience. resist the urge to dance? Scandinavian
The meeting was a valuable Siemens service manager Volker cool had really turned up the heat.
opportunity for customers to come Sundberg and Johan Olsrud from
together to exchange experiences, Lund discussed a very important 26 September 2003
to learn about ongoing projects at topic – MR safety. Volker covered the
different MR-locations and to get system part (magnet hazards, etc.) Siemens Product Manager Zoltan
the latest product information from and Johan concentrated on the Vermes gave an excellent presen-
Siemens Medical Solutions. clinical part (clips, SAR, etc.). tation of the news about CMR and
also introduced new WIPs for the
After lunch we offered three parallel Siemens CMR package. The audience
sessions covering radiographers, was very enthusiastic and it seems
25 September 2003 doctors and physicists: that this talk has triggered some of
The Norwegian Application Specialist, Siemens Application Specialist the clinics to do more, including
Eldrid Whinter-Larssen (Oslo), gave a Agneta Rydman had her own corner implementing CMR on their own
presentation on the new techniques – “Agneta’s corner” – where tips and systems. At the next meeting we will
iPAT and PACE and their advantages tricks at the Numaris and the syngo see how many have actually managed
in abdominal imaging. platform were discussed. to start CMR in their hospitals.
Dr. Katarina Håkansson from Kalmar At the doctor session, 4 doctors from Finally, Volker Sundberg informed us
made a speech on acute abdominal Ängelholm hospital discussed patient all about news from the MR Service
108
EVENTS

Sweden
TOM User Clu
(CS sales, organization, remote
service) and Andreas Piringer talked
about communication in terms of
new Sweden Application Scientist
Magnus Karlsson, MAGNETOM
World, SMUC, CS-Sales, MR training
and syngo workshops.

Malmö
The first user meeting in Sweden
took place at the University Hospital
in Malmö in 1994. This means that
we will celebrate the tenth anniver-
sary of this first meeting next year.
Malmö has eagerly accepted the role
of host for this celebratory meeting.
We will also be able to show members
and participators the new diagnostic
centre (MAS-DC) in Malmö, equipped
with 4 new fully loaded MR-scanners,
as well as Siemens CT, angiography,
digital X-ray, nuclear medicine and
ultrasound. The meeting will be
something special, we can assure
you!

109
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MAGNETOM FLASH

MR Colonography as an
Interdisciplinary Cooperative Project
Dirk Hartmann1, Boris Baßler2, Background disadvantage is the inability to
Christoph Zindel3, Stefan Rings3, inspect the proximal sections of the
Hermann Breer2, Dieter Schilling1, Colorectal carcinoma (CRC) is a colon. Lieberman was able to show
Henning E. Adamek1, frequently encountered disease with that 50-60 % of all patients with
Jürgen F. Riemann1, Günter Layer2 a high mortality in the Western advanced proximal adenomas exhibit
world. According to statistics, after no distal polyps [4].
bronchial carcinoma, CRC is the
second most common cancer-related Due to the low sensitivity of the
cause of death in Germany. Studies occult blood test and high number of
performed by the Robert Koch unnoticed lesions during a sigmoidos-
Institute reveal that 51,700 people copy, colonoscopy is today regarded
Correspondence:
developed colorectal carcinoma in as the screening procedure of choice
Priv.-Doz. Dr. Günter Layer from a medical and financial point
1999 alone, and every year over
Zentralinstitut für Diagnostische 30,000 die as a result of this disease. of view. The American National Polyp
und Interventionelle Radiologie Consequently, the lifetime risk of Study has clearly shown that up to
Klinikum der Stadt Ludwigshafen developing CRC in Germany is 4-6 %, 90 % of intestinal cancers can be
Bremserstrasse 79 and depends greatly on age. In prevented by rigorous polypectomy
67063 Ludwigshafen particular after the age of 50, the of cancer precursors [5]. It is in this
incidence of the tumor rises expo- context that health insurance plans
nentially [1]. in Germany have added colonoscopy
to their early cancer detection
In light of the high incidence and program as of October 1, 2002.
mortality associated with colorectal
One significant advantage to colonos-
carcinoma, major efforts are being
copy as a screening method is that
made in the area of primary and
detected polypous changes can be
secondary prevention for economic
removed in a single procedure. The
considerations as well. Primary
1 disadvantages include the necessary
Medizinische Klinik C prevention encompasses the applica-
intestinal cleansing, discomfort
(Director: Prof. Dr. J.F. Riemann) tion of protective measures to pre-
during the examination, frequently
Gastroenterologie, Hepatologie, vent the formation of adenoma and
required sedatives and analgesics,
Diabetologie carcinoma. Secondary prevention
along with the risk of perforation.
2
Zentralinstitut für Diagnostische involves the detection of precursors
und Interventionelle Radiologie to colorectal carcinoma, along with Advances in computerized tomo-
(Director: Priv.-Doz. Dr. G. Layer) their treatment prior to malignant graphy and magnetic resonance
Klinikum der Stadt Ludwigshafen degeneration, and the detection of imaging have now made it possible
GmbH early carcinomas in primarily curable to noninvasively generate two- and
Akademisches Lehrkrankenhaus stages. three-dimensional images of the
der Johannes-Gutenberg- large intestine, enabling a virtual
Universität Mainz However, since only a small percen- flight through the colon possibly
3
tage of the population pays any comparable to conventional end-
Siemens AG, Medical Solutions, attention to the primary prevention oscopy. In the future, this might yield
Erlangen of colorectal carcinoma, preventive an early intestinal cancer visuali-
measures involving the early detec- zation procedure in addition to the
tion of polyps and carcinoma become aforementioned methods [6].
all the more important. The data
show that the incidence of intestinal However, at this point we only have
cancer can be reduced by 20 percent a very limited amount of data compa-
by performing an occult blood test ring virtual colonography with colo-
starting at the age of 55 [2]. noscopy, the current gold standard,
in the diagnosis of colorectal lesions.
Flexible sigmoidoscopy markedly Noninvasive colonographies are
reduces the mortality of colorectal therefore not yet suitable for wide-
carcinoma [3]. However, one serious scale use and early cancer detection.
110
GASTROINTESTINAL IMAGING

As a result, further prospective supplement with each meal for 36 plinary working group was establis-
studies are required to evaluate its hours before the study. In all sequen- hed to focus intensively on magnetic
significance in the diagnosis of tial MR procedures, this results in a resonance imaging in the diagnosis
colorectal lesions. homogenously black stool and good of gastroenterological diseases. Up to
delineation from the intestinal wall. now, one key effort has been the
This is the stated objective of
Initial results show a high sensitivity study of the biliopancreatic system.
the Ludwigshafen MR colonography
of 90 % for the detection of colorectal In this way, numerous scientific
project, which will be introduced
lesions [13]. According to the litera- studies were able to establish mag-
below.
ture and our own experience, com- netic resonance imaging and particu-
plete colonoscopy with intubation larly magnetic resonance cholangio-
of the caecum is possible in 90-95 % pancreaticography (MRCP) in routine
Current research of all examinations [16-18]. This is gastroenterological diagnostics
Initial studies with so-called CT where virtual colonoscopy is at an [20-22]. Further innovations were
colonography revealed a sensitivity advantage, since all sections of the achieved in the diagnosis of the small
level relative to conventional colonos- intestine can generally be examined intestine, particularly in chronic
copy of 91 % for polyps larger than with MR colonography, thereby inflammatory intestinal diseases [23,
10 mm [7, 8]. In addition to this enabling the detection of pathologi- 24].
limitation in comparison with cal changes in colon segments that
In October 2002, an additional, latest
endoscopy, the disadvantage to CT were not examined. In addition, MR
generation magnetic resonance
colonography is that it involves colonography allows an evaluation
imaging system (MAGNETOM Sonata,
significant radiation exposure. of the entire large intestine in the
Maestro Class, Siemens Medical
presence of stenosing tumors in the
MR colonography makes it possible Solutions) went into operation at the
distal colon that cannot be crossed
to image the colon without radiation Ludwigshafen teaching hospital,
by an endoscope. In a study of 29
exposure [9, 10]. A polyp detection with the latest in coil technology and
patients with endoscopically uncross-
sensitivity similar to that for CT most up-to-date post-processing
able colorectal carcinoma, virtual
colonography was achieved during capabilities (LEONARDO workstation,
colonoscopies revealed 2 additional
initial studies [11, 12, 13]. Another Siemens Medical Solutions). While
carcinomas along with 24 more
advantage over computerized tomo- our innovative cooperation between
polyps proximal to the stenosis [19].
graphy lies in the use of safe i.v. gastroenterologists and radiologists
contrast media, which lack the Based on these data, colonoscopy had in the past centered primarily
known nephrotoxicity, and exhibit a remains the method of choice, in on the diagnosis of the biliopancreatic
lower risk profile [14, 15]. particular for detecting the smallest system and small intestine, we can
adenomas. Additional comparative now expand the cooperation and
Initial studies comparing MR colono- experience that developed over
studies and improved detection for
graphy with conventional colonos- the years to the diagnosis of the large
even the smallest polyps are required
copy in the detection of colorectal intestine with virtual secondary
for the wide-scale use of MR colono-
lesions revealed a high degree of reconstruction procedures, and there-
graphy in the detection of colorectal
congruence between both methods by verify the importance of noninva-
lesions.
for polyps larger than 10 mm [11, 12]. sive MR colonography and develop
Luboldt et al. achieved a sensitivity it further. It is in this context that
of 96 % for lesions larger than 10 mm we began a prospective study in
with MR colonography [11]. Ludwigshafen
November 2002 entitled “Prospective
MR colonography project Comparison of MR Colonography
“Fecal tagging”* is a new method
for contrasting the colon in MR Interdisciplinary cooperation with Conventional Colonoscopy in
colonography. Oral intestinal clean- the Diagnosis of Colorectal Lesions”.
Medical Clinic C (focus on gastro-
sing is here unnecessary. The patient
enterology) and the Central Institute
takes a barium-containing nutritional Study design
for Diagnostic and Interventional
Radiology have been cooperating The study is monocentric in design,
* The information about this product is closely with each other at the with 200 patients for whom a
preliminary. The product is under development
and is not commercially available in the U.S., Ludwigshafen teaching hospital for colonoscopy had been indicated.
and its future availability cannot be ensured. several years. In 2001, an interdisci- Magnetic resonance imaging and
111
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MAGNETOM FLASH

conventional colonoscopy are perfor- good contrasting of the intestinal planar reconstructions) from this
med in all patients within one day, lumen. Normal dosis of antiperistalsis three-dimensional data set in a
after appropriate intestinal cleansing. medicine is then intravenously transverse and coronal plane, as well
Table 1 lists the inclusion and administered to relax the intestine. as a survey image of the colon and
exclusion criteria. Complete filling of the large intestine the spatial display as a virtual colonos-
and distension are then monitored copy (Fig. 2). In so doing, the colon
The primary objective of the study
via real-time acquisition of fast post-processing application supports
is to run a prospective comparison
gradient echo images by means of a the two conventional examination
between MR colonography and
TrueFISP sequence. techniques, scrolling through 3 D
conventional colonoscopy in the
data sets and an interactive fly
detection of colorectal lesions. The After sufficient intestinal distension
through with complete, automatic
goal here is to determine whether has been achieved with intraluminal
real-time navigation. A starting point
MR colonography, with the techno- water, transverse and coronal
can be determined to initiate the
logy available today, reaches TrueFISP sequences and a 3D VIBE
virtual flight at any location desired.
the gold standard of conventional sequence are initially generated
The ongoing flight in the intestinal
colonoscopy in the diagnosis of natively. Standard dosis of MR con-
segments can be visualized at any
colorectal lesions. trast material are then intravenously
time by updating the MPRs online
administered. The 3D VIBE sequence
Other study objectives are to compare and plotting the flight path in the
is then repeated at 75 and 90
both methods in terms of patient survey image. Later in the process,
seconds after contrast media appli-
acceptance and satisfaction, and to the virtual colonograph and survey
cation.
attempt to differentiate between the image are used for hardcopy docu-
various stages of adenoma with 3D VIBE stands for “Volumetric Inter- mentation. In addition, the software
respect to size and dignity as compa- polated Breath-hold Examination”, offers all functions necessary for an
red to the macroscopic findings and and is a 3D, ultra-fast gradient echo up-to-date evaluation of the findings
histology. sequence with an isotropic resolution. (including a summary report). The
The k-space scan is typically perfor- entire evaluation process only takes
Before the planned colonoscopy, med asymmetrically in this sequence, approx. 10 min.
the patient undergoes an MR colono- which reduces the number of phase
graphy after submitting a consent encoding steps in the slice-selection
form in writing. The two examina- direction. A frequency-selective fat
tions are performed and diagnostically Initial experiences
saturation pulse is transmitted before
evaluated independently of each each partition loop. To achieve a We can already infer a first, positive
other by experienced radiologists homogeneous fat saturation in the result from present experience with
and gastroenterologists. process, centric phase encoding is MR colonography at the Ludwigs-
used in the partition direction hafen teaching hospital. In the 18
(Fig. 1). 3D VIBE offers a complete examined patients, MR colonography
MR colonography three-dimensional anatomical could be performed without compli-
After a complete intestinal cleansing coverage within a short overall cations, and with a high patient
the day before and an overnight measurement time. acceptance rate. A diagnostic evalua-
fasting period, the MR colonography tion of images was possible in each
The 3D VIBE sequence is executed
is initially performed on the day of case. In a few examinations, however,
with the following parameters:
the examination using the latest the entire colon could not be
TR = 3.1 ms, TE = 1.17 ms,
generation of our 1.5 Tesla full body displayed with a high-performance
Flip angle = 10 degrees, 72 partitions
MRI (MAGNETOM Sonata, Siemens gradient system and a field of view of
in one breath in less than 24 seconds,
Medical Solutions). A thin intestinal 40 cm. As a result, a complete “virtual
FoV = 400 mm, slice thickness =
tube is inserted after rectal palpation. flight” through the entire colon could
1.5 mm.
After having assumed a supine not be achieved in all patients, but
position, the patient is conveyed into For purposes of efficient evaluation, a detailed evaluation was always
the diagnostic system, and the a dedicated colon post-processing possible. Due to the low number of
intestine is filled with 1.5-2 liters of application on a LEONARDO work- patients and prospective nature of
lukewarm water through the ind- station (Siemens, Medical Solutions) the study introduced above, we are
welling rectal probe. This enables a automatically calculates MPRs (multi- currently still working on a detailed
112
GASTROINTESTINAL IMAGING

Outer Loop: Fourier lines = N phases

Apply one fat sat pulse


for all partitions only inner loop: M partitions

 chem. sat. TR
TE evaluation of the results in compari-
MPartition son to colonoscopy.

RF Spoiler

Figs. 3 and 4 show two impressive
Grad. Spoiler

examples of what MR colonography


ADC NPhase is capable of doing. Fig. 3 shows a
broad-based polyp in a patient who
Fat Water presented for further diagnosis based
on a positive occult blood test. The
· very short TR and TE polyp could be diagnosed with both
· centric ordered encoding MR colonography and colonoscopy
· slice interpolated
and removed in the course of endos-
: broadband spatial selective excitation rf pulse copy. Fig. 4 shows an MR colono-
: spectral selective narrow band rf pulse (chem. sat.:  >> ) graphy image in comparison to a
conventional colonoscopy in a
Figure 1 3D VIBE sequence patient with known ulcerative colitis.
(Siemens Medical Solutions). The pseudopolyps typical for the
disease can be detected with both
methods.

Summary and outlook


MR colonography is a new diagnostic
procedure that makes it possible to
Figure 2 Leonardo evaluation software
(Workstation, Siemens Medical Solutions). noninvasively visualize the entire
large intestine without exposure to
radiation. However, thus far only a
small number of comparative studies
have contrasted MR colonography
with the gold standard, colonoscopy.
The Ludwigshafen MR colonography
project, a cooperation of radiologists
and gastroenterologists, is aimed
at this evaluation. We are convinced
that close cooperation between
partners is the only way to success-
fully pursue those projects in which
the expertise of both specialties is
indispensable. Neither radiologists
nor gastroenterologists are currently
in a position to set up objective and
acceptable studies on this issue by
themselves.
The possibility of using noninvasive
MRI in the prevention of colorectal
carcinoma can only be discussed
after these kinds of prospective
studies. This use may facilitate the
acceptance of preventive screening
for colorectal carcinoma without
exposing patients to high levels of
113
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MAGNETOM FLASH

radiation, as opposed to computer- [ 9 ] Luboldt W, Steiner P, Bauerfeind P, [ 21 ] Adamek HE, Albert J, Breer H, Weitz M,
Pelkonen P, Debatin JF. Schilling D, Riemann JF.
ized tomography. Detection of mass lesions with MR-Colono- Pancreatic cancer detection with magnetic
graphy: Preliminary report. resonance cholangiopancreatography and
The objective would not necessarily Radiology 1998;207:59-65 endsocopic retrograde cholangiopancreato-
be to compete with colonoscopy graphy: a prospective controlled study.
[ 10 ] Luboldt W, Luz O, Vontheim R, Lancet 2000;356:190-3
as the diagnostic gold standard, but Heuschmid M, Seemann M, Schäfer J, Stueker D,
rather to offer patients another Claussen CD. [ 22 ] Albert J, Schilling D, Breer H, Jungius KP,
screening option. Given that only Three-dimensional double-contrast MR Riemann JF, Adamek HE.
colonography: a display method simulating Mucinous cystadenomas and intraductal
about one fourth of all eligible patients double-contrast barium enema. papillary mucinous tumors of the pancreas in
avail themselves to colonoscopy AJR2001;176:930-932 magnetic resonance cholangiopanretography.
Endoscopy 2000;32:472-476
screening, MR colonography could [ 11 ] Luboldt W, Bauerfeind P, Wildermuth S, et al.
play an important role in the preven- Colonic masses: detection with MR colono- [ 23 ] Albert J, Breer H, Scheidt T, Basler B,
graphy. Schilling D, Layer G, Adamek HE, Riemann JF.
tive screening concept for colorectal Radiology 2000;216:383-388 Cronic inflammatory bowel disease: magnetic
carcinoma alongside the test for resonance imaging within the spectrum of
[ 12 ] Pappalardo G, Polettini E, Frattaroli FM,
occult blood, clinical and digital modern diagnosis.
et al.
Dtsch Med Wochenschr 2002;127:1089-1095
rectal examinations, and endoscopic Magnetic resonance colonography versus
conventional colonoscopy for the detection of [ 24 ] Albert J, Scheidt T, Basler B, Pahle U,
procedures.
colonic endoluminal lesions. Schilling D, Layer G, Riemann JF, Adamek HE.
Gastroenterology 2000;119:300-304 Magnetic resonance imaging in diagnosis and
follow-up of inflammatory bowel disease –
[ 13 ] Lauenstein T, Goehde S, Ruehm S,
Is conventional enteroclysm still necessary.
References Holtmann G, Debatin JF.
Z Gastroenterol 2002;40:789-794
MR colonography with Barium-based Fecal
[ 1 ] Ries L, Kosary C, Hankey B, et al. Tagging: initial clinical experience.
SEER Cancer Statistics 1973-1995; National Radiology 2002;223:248-254
Cancer Institute 1998, Bethesda, MD, USA
[ 2 ] Mandel JS, Church TR, Bond JH, et al.
[ 14 ] Murphy KJ, Brunberg JA, Cohan RH. Tables and figures
Adverse reactions to gadolinium contrast
The effect of fecal occult-blood screening on the media: a review of 36 cases.
incidence of colorectal cancer. Am J Roentgenol 1996;167:847-849
N Engl J Med 2000; 343:1603-7 Inclusion Criteria
[ 15 ] Prince MR, Arnoldus C, Frisoli JK.
[ 3 ] Selby JV, Friedman GD, Quesenberry CP, et al. ➔ Patients over 18
Nephrotoxicity of high-dose gadolinium
A case-control study of screening sigmoidos- compared with iodinated contrast. ➔ Colonoscopy indicated
copy and mortality from colorectal cancer. J Magn Reson Imaging 1996;6:162-16613a ➔ Good health
N Engl J Med 1992; 326:653-7
[ 16 ] Rex DK, Lehman GA, Ulbright TM, Smith ➔ Written declaration of consent from patient
[ 4 ] Lieberman DA, Weiss DG, Bond JH, et al. JJ, Pound DC, Hawes RH, Helper DJ, Wiersema
Use of colonoscopy to screen asymptomatic MJ, Langefeld CD, Li W.
adults for colorectal cancer. Colonic neoplasia in asymptomatic persons Exclusion Criteria
N Engl J Med 2000; 343:162-8 with negative fecal occult blood tests: ➔ Patients under 18
influence of age, gender, and family history.
[ 5 ] Winawer SJ, Zauber AG, O’Brian MJ, et al. Am J Gastroenterol 1993,88:825-31 ➔ Known intolerance to MR contrast media
Randomized comparison of surveillance
intervals after colonoscopic removal of newly [ 17 ] Lieberman DA, Weiss DG, Bond JH,
➔ Known MR contraindications, e.g.,
diagnosed adenomatous polyps. Ahnen DJ, Garewal H, Chejfec G. pacemakers, intracorporeal metal parts,
N Engl J Med 1993; 328:901-906 Use of colonoscopy to screen asymptomatic claustrophobia
adults for colorectal cancer. Veterans Affairs ➔ Pregnant or breast-feeding patients
[ 6 ] Adamek HE, Breer H, Karschkes T, Cooperative Study Group 380.
Albert J, Riemann JF. Magnetic resonance N Engl J Med 2000;343:162-8
imaging in gastroenterology: Table 1 Inclusion and exclusion
Time to say good-bye to all that endoscopy? [ 18 ] Imperiale TF, Wagner DR, Lin CY, Larkin
GN, Rogge JD, Ransohoff DF. Risk of advanced
criteria.
Endoscopy 2000;32:406-410
proximal neoplasms in asymptomatic adults
[ 7 ] Fenlon HM, Nunes DP, Schroy PC 3rd, et al. according to the distal colorectal findings.
A comparison of virtual and conventional N Engl J Med 2000;343:169-74
colonoscopy for the detection of colorectal
polyps. [ 19 ] Fenlon HM, McAneny DB, Nunes DP,
N Engl J Med 1999;341:1496-1503 Clarke PD, Ferrucci JT. Occlusive colon carcinoma:
virtual colonoscopy in the preoperative
[ 8 ] Yee J, Akerkar GA, Hung RK, et al. evaluation of the proximal colon.
Colorectal neoplasia: performance characte- Radiology 1999;210:423-428
ristics of CT colonography for detection in
300 patients. [ 20 ] Adamek HE, Albert J, Weitz M, Breer H,
Radiology 20001;219:685-692 Schilling D, Riemann JF.
A prospective evaluation of magnetic resonance
cholangiopancreaticography in patients with
suspected bile duct obstruction.
Gut 1998;43:680-683
114
GASTROINTESTINAL IMAGING

Figure 3 Broad-based polyp


of the transverse colon.
a) Coronal 3D VIBE sequence
b) Transverse reconstruction
c) 3D reconstruction
d) Endoscopic image
3a 3b

3c 3d

Figure 4 Pseudopolyps in
a 45 year old male patient with
known ulcerative colitis.
a) 3D reconstruction
b) Endoscopic image

4a 4b

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MAGNETOM FLASH

Cerebrospinal Fluid Flow Measurements


– Initial Results at 3.0 T
Ståhlberg F1,2, Brockstedt S1,2, Introduction resolution gradient-echo (GRE)
Mannfolk P1,2, Larsson E-M2 velocity mapping sequences at 3.0 T
Dept. of Radiology1 and Magnetic resonance (MR) velocity by phantom verification of flow-
Dept. of Radiation Physics2, mapping, utilizing velocity sensitized/ versus-signal linearity and phase
Lund University Hospital, non sensitized gradient echo sequence image quality and by determination
Lund, Sweden pairs [1, 2], is a well-established of in vivo CSF flow curves in healthy
technique for non-invasive flow volunteers.
quantification. Advantages of this
method are that it enables quantifi-
cation of velocity as well as flow and
Correspondence: that – although limited by the capacity Materials and methods
of the gradient system of the scanner
Ståhlberg F, Throughout the study, a Siemens
– it has a very large dynamic range
Dept. of Radiation Physics MAGNETOM Allegra 3.0 T was used.
[1-3]. For studies of the cerebrospinal
Lund University Hospital, Phase variations in a stationary
fluid flow circulation, which requires
S-22185 Lund, Sweden cylindrical phantom with 155 mm
velocity encoding (VENC) values
diameter, provided by the manufac-
around 10-20 cm/s, several specific
turer, was studied at 3.0 T as func-
velocity mapping strategies have
tion of axial slice position, shifted
been proposed [4-8].
stepwise in the range 0 (magnet
Methodological drawbacks for the center) to 50 mm from the magnet
study of slow flow in narrow channels center in the feet direction. The
include limitations caused by the imaging slice was oblique with
relationship between object (vessel/ angulation typical for flow measure-
channel) size and volume element ments in the cerebral aqueduct
(voxel) size [9], however several (transverse > coronal 20º). A GRE
techniques have been proposed for velocity mapping pulse sequence
Abstract correction of partial volume errors was used (VENC 20 cm/s, FOV 200,
[10-14]. General methodological matrix 512, in-plane resolution
Cerebrospinal fluid (CSF) flow and 0.39x0.39 mm, slice thickness 7 mm,
limitations also include influence on
production can be measured using TE 8 ms, TR 100 ms, FA 15º,
the background phase in the subtrac-
MR velocity mapping in the cerebral BW 257 Hz/pix).
ted phase map from gradient eddy
aqueduct. Limited spatial resolution
currents and Maxwell or concomitant
may, however, lead to partial volume Flow accuracy for different VENC
gradients [15].
errors which – at the cost of signal- values was measured quantitatively
to-noise – can be reduced by increased The establishment of magnetic field at 3.0 T using a tube phantom consi-
in-plane resolution. We assessed the strengths above 2.0 T for clinical sting of an outer cylinder filled with
accuracy of high-resolution velocity MRI is in progress, and several reports stationary tap water surrounding two
mapping at 3 T by phantom verifi- have described the use of 3.0 T for tubes with tube diameter 4.8 mm,
cation of flow-versus-signal linearity neuro MRA applications [16-17]. area 18.1 mm2 and wall size ≤ 0.1 mm.
and phase image quality and by Potentially, the intrinsic higher signal- In a first experiment, three different
determination of in vivo CSF flow to-noise ratio at this field strength VENCs (5, 10 and 20 cm/s) were
curves in healthy volunteers. Accuracy compared to 1.5 T could also be used studied in the flow range 0-0.4 ml/s
was within 10 % and reasonable to increase spatial resolution in in a transverse slice positioned in the
flow values were obtained in vivo. velocity mapping of flow in narrow center of the magnet (FOV 100 mm,
We conclude that high-resolution channels [18]. However, the accuracy matrix 256, in-plane resolution
CSF flow measurements can be of the velocity mapping technique 0.39x0.39 mm, slice thickness 10 mm,
made at 3 T. for 3.0 T MRI units using powerful TE 11 ms, TR 100 ms, FA 30º,
gradient systems has not yet been BW 130 Hz/pix). In a second experi-
evaluated thoroughly. ment, VENC 20 cm/s was chosen to
study the flow range 0-2 ml/s in
In this preliminary study, we there- transverse slices at two different slice
fore assessed the accuracy of high- positions, 0 (magnet center) and 40
116
ULTRA HIGH-FIELD

mm from the magnet center in the Sweden). In both cases, background was good (r>0.998). In fig. 3, flow
feet direction (FOV 100, matrix 256, ROIs were selected to correct for non- measured using MR is plotted versus
in-plane resolution 0.39x0.39 mm, zero phase background. nominal flow for a 40 mm axial slice
slice thickness 7 mm, TE 8 ms, shift in the feet direction using VENC
TR 100 ms, FA 15º, BW 257 Hz/pix). 20 cm/s.
In one healthy volunteer, a crude Results In vivo (Fig. 4), we obtained SNR
comparison of SNR at 3.0 T and 1.5 T ratios (3. T/1.5 T) in modulus images
(Siemens MAGNETOM Vision) was Phase variations in the stationary
of 1.55 (stationary tissue) and 1.64
made in modulus images in an phantom as function of axial position
(aqueduct). The result of flow mea-
imaging slice covering the cerebral are shown in figure 1. In this figure,
surements in two healthy volunteers
aqueduct. Images were acquired average phase in each ROI is given in
are shown in fig. 5, and the measured
with a GRE PC-MRA sequence at 3.0 T percent of the maximum phase value
peak caudal flow values in the
and a GRE velocity mapping sequen- corresponding to the VENC (+ 4096).
cerebral aqueduct were 9.5 and 15.8
ce at 1.5 T, using identical imaging As seen from the figure, observed
ml/min, respectively.
parameters (VENC 10 cm/s, FOV 230 phase values were between 0 and 5 %
mm, matrix 512, in-plane resolution of the maximum phase value.
0.45x0.45 mm, slice thickness 5 mm, In the flow phantom, phase image
TE 12 ms, TR 100 ms, FA 30º, BW 78 Discussion
quality was high (Fig. 2). The average
Hz/pix). For each system, the standard measurement inaccuracy [100*abs In this study, CSF velocity mapping
head-coil was used and no correc- (measured flow – nominal flow)/ was performed at 3.0 T. Using
tions for variations in coil performance nominal flow] for all VENC values in the high intrinsic SNR at this field
between the systems were made in the flow range 0.05-0.4 ml/s was strength, high in-plane resolution
this comparison. approximately 10 % and the linearity (0.39x0.39 – 0.43x0.43 mm2) was
Finally, CSF flow through the cerebral between flow values measured with obtained and CSF flow values were of
aqueduct was measured at 3.0 T using MR and nominal flow (measured reasonable order compared to earlier
a GRE velocity mapping sequence in with stop-clock and measuring glass) studies at lower field strengths
two healthy volunteers (VENC 20 cm/s,
FOV 200-220 mm, 6/8 rectangular
FOV in the phase (L-R) direction,
matrix 512, in-plane resolution
0.39x0.39-0.43x0.43 mm, slice
thickness 7 mm, TE 12 ms, TR 46-50 ms,
FA 30º, BW 78 Hz/pix, prospective
ECG triggering).
Phase variations in the stationary
phantom were studied in five regions-
of-interest (ROIs) with 4.9 cm2 area,
placed centrally (1 ROI) and along
the vertical and horizontal axis
approximately 2 cm from the phan-
tom edge (4 ROIs).
Figure 1 Phase variations in the
In vitro, flow evaluation was made stationary phantom as function of
using ROI tools available in the 3.0 T axial position (z) for a slice angula-
scanner software and ROI sizes were ted 20º from the transverse to the
coronal plane. Shifting of the slice
adjusted to be similar to the nominal
position from the origin was made in
tube size [13]. In vivo, the cerebral the feet direction. Average phase in
aqueduct region was delineated and each ROI A-E is given in percent of
flow was calculated using a specially the maximum phase value (+ 4096)
designed flow evaluation program and the position of each ROI is
(Context Vision RadGop, Linköping, indicated (upper left).
117
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MAGNETOM FLASH

Figure 2 Flow phantom images in


two tubes with oppositely directed Figure 3 Flow (MR) versus flow
flow in the range 0-0.4 ml/s obtained (stop-clock and measuring glass) for
using VENC5, increasing velocities in a transversal slice positioned at
images from left to right (FOV 100 z = 40 mm in the feet direction (FOV
mm, matrix 256, in-plane resolution 100, matrix 256, in-plane resolution
0.39x0.39 mm, slice thickness 0.39x0.39 mm, slice thickness 7 mm,
10 mm, TE 11 ms, TR 100 ms, FA 30º, TE 8 ms, TR 100 ms, FA 15º,
BW 130 Hz/pix). BW 257 hz/pix). For the slice position
z = 0 mm, a similar linearity was
observed (y = 0.91x + 0.067,
R2 = 0.998).

y = 9.94x + 0.046
2.00 2
R = 0.999

Normal flow (ml/s)


1.00

0.00
-2.00 -1.00 0.00 1.00 2.00
-1.00

-2.00
Measured flow (ml/s)

Figure 4 GRE modulus images


of the same volunteer with similar
positioning of the image slice at
1.5 T (velocity mapping sequence,
left) and 3 T (PC MRA sequence,
right). Note increased susceptibility
artefacts from the sphenoid sinus
and the petrous bones but also
visible SNR increase, at 3 T as compa-
red to 1.5 T. In the cerebral aqueduct
(arrow indicating central bright area)
CSF appears white due to inflow
enhancement.

Figure 5 CSF flow curves for two


healthy volunteers obtained at 3.0 T.
118
ULTRA HIGH-FIELD

[5, 8, 19]. The phase background References [ 14 ] Lagerstrand KM, Lehmann H, Starck G,
Vikhoff-Baaz B, Ekholm S, Forssell-Aronsson E:
varied with in-plane position, indica- Method to correct for the effects of limited
[ 1 ] van Dijk P: Direct cardiac NMR imaging of
ting influence from a combination heart wall and blood flow velocity. spatial resolution in phase-contrast flow MRI
of eddy currents and concomitant J. Comput. Assist. Tomogr. 1984; 8: 429. measurements.
Magn Reson Med. 2002; 48: 883-889.
gradients, although no major varia- [ 2 ] Nayler GL, Firmin DN, Longmore DB:
tions were seen as function of axial Blood flow imaging by cine magnetic resonance. [ 15 ] Bernstein MA, Zhou XJ, Polzin JA,
J. Comput. Assist. Tomogr. 1986; 10: 715-722. King KF, Ganin A, Pelc NJ, Glover GH:
position in the slice shift range Concomitant gradient terms in phase contrast
chosen in this study. We used a very [ 3 ] Feinberg DA, Mark AS: Human brain MR: Analysis and correction.
motion and cerebrospinal fluid circulation MRM 1996; 39:300-308.
simple phase correction routine demonstrated with MR velocity imaging.
(subtraction of adjacent stationary Radiology 1987; 163; 793-799. [ 16 ] Bernstein MA, Huston J 3rd, Lin C,
Gibbs GF, Felmlee JP:
background values) both in vitro and [ 4 ] Martin AJ, Drake JM, Lemaire C, High-resolution intracranial and cervical MRA
in vivo, although it can not be ruled Henkelman RM. at 3.0T: technical considerations and initial
out that more sophisticated correc- Cerebrospinal fluid shunts: Flow measurements experience.
with MR imaging. Magn Reson Med. 2001; 46: 955-962.
tion methods [20, 21] addressing Radiology 1989; 173: 243-247.
each potential phase error component [ 17 ] Al-Kwifi O, Emery DJ, Wilman AH:
[ 5 ] Thomsen C, Ståhlberg F, Stubgaard M, Vessel contrast at three Tesla in time-of-flight
separately will be necessary in Nordell B, the Scandinavian flow group. magnetic resonance angiography of the
precise studies of e.g. CSF production Fourier analysis of cerebrospinal fluid flow intracranial and carotid arteries.
rates and/or flow studies in image velocities: MR imaging study. Magn Reson Imaging. 2002; 20:181-187.
Radiology 1990; 177: 659-665.
positions significantly displaced from [ 18 ] Ståhlberg F, Larsson E-M, Brockstedt S:
the magnet origin. [ 6 ] Enzmann DR, Pelc NJ. CSF flow measurements at 3T – accuracy and
Normal flow patterns of intracranial and spinal initial in vivo results. Proc 11th meeting of
Potential clinical applications are, cerebrospinal fluid defined with phase-contrast ISMRM, Toronto, Canada 2003: In press.
cine MR imaging.
for example, determination of CSF Radiology 1991; 178: 467-474. [ 19 ] Nilsson C, Ståhlberg F, Thomsen C,
Henriksen O, Herning M, Owman C: Circadian
flow and production in patients with
[ 7 ] Nitz WR, Bradley WG, Watanabe AS, Lee RR, variation in human cerebrospinal fluid produc-
hydrocephalus and flow studies in Burgoyne B, O´Sullivan RM, Herbst M. tion measured by magnetic resonance imaging.
non-magnetic CSF shunts. Flow dynamics of cerebrospinal fluid: assess- Am J Physiol. 1992; 262:R20-4.
ment with phase-contrast velocity MR imaging
performed with retrospective gating. [ 20 ] Pelc NJ, Sommer FG, Li KC, Brosnan TJ,
Radiology 1992; 183: 395-405. Herfkens RJ, Enzmann DR:
Quantitative magnetic resonance flow imaging.
[ 8 ] Ståhlberg F, Nitz W, Nilsson C, Holtås S: Magn Reson Q 1994; 10: 125-147.
Use of k-space segmentation in MR velocity
mapping for rapid quantification of CSF flow. [ 21 ] Wigström L, Ebbers T, Fyrenius A,
J Magn Reson Imaging. 1997;7:972-978. Karlsson M, Engvall J, Wranne B, Bolger F.
Particle trace visualisation of intracardiac flow
[ 9 ] Wolf RL, Ehman RL, Riederer SJ, Rossman using time-resolved 3D phase contrast MRI.
PJ: Analysis of systematic and random error in MRM 1999; 41: 793-799.
MR volumetric flow measurements.
Magn. Reson. Med. 1993, 30: 82-91.

[ 10 ] Pelc NJ, Sommer FG, Enzmann DR,


Pelc LR, Glover GH:
Accuracy and precision of phase-contrast MR
flow measurements.
Radiology 1991; 181(P):189.

[ 11 ] Hofman MB, Visser FC, van Rossum AC,


Vink GQM, Sprenger M, Westerhof N:
In vivo validation of magnetic resonance blood
volume flow measurements with limited spatial
resolution in small vessels.
Magn. Reson. Medicine 1995; 33: 778-784.

[ 12 ] Tang C, Blatter DD, Parker DL:


Correction of partial-volume effects in phase-
contrast flow measurements.
JMRI 1995; 5: 175-180.

[ 13 ] Arheden H, Saeed M, Tornqvist E, Lund G,


Wendland MF, Higgins CB, Stahlberg F:
Accuracy of segmented MR velocity mapping
to measure small vessel pulsatile flow
in a phantom simulating cardiac motion.
J Magn Reson Imaging. 2001;13:722-728.
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Intracranial 3D ToF MRA with Parallel


Acquisition Techniques at 1.5 T and 3.0 T
J. Gaa1, S. Weidauer 1, Introduction whole body systems equipped with
M. Requardt 2, B. Kiefer2, identical state-of-the-art gradient
H. Lanfermann1, F.E. Zanella1 Magnetic resonance angiography sets (40 mT/m maximum, 200 mT/
1
(MRA) has undergone significant m/s slew rate) and similarly designed
Department of Neuroradiology,
developments over the past decade. 8-channel phased array head coils.
Klinikum der Johann Wolfgang
Time-of-flight (ToF) MRA sequences For the iPAT-supported MRA techni-
Goethe-Universität Frankfurt,
have been widely used for imaging ques, the GRAPPA (GeneRalized Auto-
Germany
intracranial vessels. With this techni- calibrating Partially Parallel Acquisi-
2
Siemens Medical Systems, que the vessels give high signal tion) reconstruction algorithm has
Erlangen, Germany intensity related to the inflow effect been implemented. The acceleration
Correspondence: of blood during its passage through factor was set to 2. To obtain a fair
the acquisition volume, whereas comparison between 1.5 T and 3.0 T,
Jochen Gaa, M.D. the background tissue appears dark each sequence was optimized for a
Department of Neuroradiology, because a short repetition time total imaging time of approximately
University of Frankfurt, prevents relaxation of stationary 7.35 and 7.15 minutes, respectively.
Schleusenweg 2-16, tissue. Imaging matrices were 512/640
60528 Frankfurt
Currently available pulse sequences (phase/read) at 3.0 T and 486/512
are well optimized for ToF MRA at (phase/read) at 1.5 T resulting in
1.5 T. However, one of the principal voxel sizes of 0.08 mm3 and 0.13 mm3,
limitations inherent to ToF MRA is repectively.
that they remain signal-limited when
pushed to the limits of higher resolu-
tion and shorter acquisition times.
The main advantage of high B-field Results
imaging is a significant improvement
in the signal-to-noise-ratio (SNR), Analysis revealed a significant increase
which increases in an approximately in both the vessel SNR and CNR at
linear fashion with field strength in 3.0 T. Overall vessel visualization was
the range of 1.5 T to 3.0 T. ToF MRA significantly better at 3.0 T. In parti-
is a technique that can benefit from cular, visualization of smaller vessel
the increased S/N available at 3.0 T segments such as M3 and P3 seg-
by decreasing voxel size resulting in ments as well as delination of PICA
improved spatial resolution compared and AICA was superior compared
to 1.5 T. In addition, advances in coil with 3D ToF MRA at 1.5 T (Fig. 1).
technology, such as circularly pola-
rized coils, have resulted in further Delineation of a left temporal AVM in
signal gains and multi-channel one patient was slightly better at
technology has allowed for novel 3.0 T (Fig. 2). One aneurysm of the
acquisition strategies such as integra- right MCA with a size of 2.8 mm was
ted Parallel Acquisition Techniques reliably detected only at 3.0 T. Wrap
(iPAT). around artifacts in the iPAT suppor-
We report on our preliminary results ted 3D ToF MRAs were minor at both
comparing intracranial 3D ToF MRA field strengths and had no noticeable
with iPAT at 1.5 T and 3.0 T. influence on image analysis. The
increased susceptibility effects at
3.0 T, especially at air-bone interfaces
along the floor of the anterior cranial
Material and methods
fossa and adjacent to the petrous
Intracranial 3D ToF MRA with iPAT portions of the temporal bones had
was performed at 1.5 T (MAGNETOM no side effects on the image quality
Sonata) and 3.0 T (MAGNETOM Trio) of ToF MRA at 3.0 T.
120
a a ULTRA HIGH-FIELD

b b

data in the image domain (SENSE).


However, one general limitation of
the iPAT approach is the propagation
of wrap-around artifacts into the
center of the image. We therefore
decided to use an AUTO-SMASH like
algorithm such as GRAPPA since
these artifacts are less prominent
Figure 1 Axial 3D ToF MIP images Figure 2 Axial collapse 3D ToF MIP
compared with the SENSE technique.
at 1.5 T (a) and 3.0 T (b). Note the images at 1.5 T (a) and 3.0 T (b). The
better visualization of distal MCA large left temporal AVM is slightly In our study aliasing artifacts were
and PCA branches as well as the right better delineated at 3.0 T. However, only mild and therefore did not limit
AICA at 3.0 T. Minor aliasing artifacts delineation of the distal MCA and the accurate assessment of fine
are noticed due to the use of the iPAT PCA branches is far superior at 3.0 T. vessel detail.
reconstruction algorithm.
In conclusion, we have demonstrated
the superiority of iPAT supported
Discussion partial volume artifact. Smaller 3D ToF MRA at 3.0 T compared with
voxels are less subject to intravoxel 1.5 T. The combined used of a multi-
ToF MRA is commonly used for the dephasing because they contain
evaluation of intracranial vascular channel phased-array head coil in
a smaller heterogeneity of spins, conjunction with iPAT allows for high
pathology. Currently available pulse providing further improvements in
sequences are well optimized for resolution intracranial vessel imaging
MRA. In addition, the effects of with adequate SNR in reasonable
ToF MRA at 1.5 T. However, one of magnetic field strength-related T1-
the principal limitations inherent to imaging times. With continued
lengthening of brain parenchyma optimization and refinements, 3D
ToF MRA is that they remain signal- and background tissue are beneficial
limited when pushed to the limits of ToF MRA at 3.0 T will further reduce
for ToF MRA at 3.0 T, providing better the need for conventional digital
higher resolution and shorter acquisi- suppression of background signal.
tion times. subtraction angiography, which is
still an invasive method with possible
In 1998 the FDA granted clearance The main applications of iPAT are
serious complications.
for the use of clinical MR imaging the reduction of examination time by
at main magnetic field strengths of faster imaging or the increase of
spatial resolution in a given acquisi-
up to 4.0 T. Prior to this approval,
tion time. However, the trade-off for
References
imaging with main magnetic field [ 1 ] Bernstein MA, Huston J, Lin C, Gibbs GF,
strengths greater than 1.5 T was reducing the number of acquired
Felmlee JP.
primarily reserved for investigational k-space lines using iPAT is a decreased High-resolution intracranial and cervical MRA
use and research applications. Previous SNR. Due to this loss of SNR, parallel at 3.0 T: technical considerations and initial
experience.
studies have already demonstrated acquisition techniques are particularly
Magn Reson Med 2001; 46: 955-962
improvements in image quality of useful when the corresponding
[ 2 ] Campeau NG, Huston J, Bernstein MA,
ToF MRA at 3.0 T (1, 2). However, image has a high intrinsic SNR, such Lin C, Gibbs GF.
they did not use state-of-the-art as in 3D ToF MRA at 3.0 T. On the Magnetic resonance angiography at 3.0 tesla:
other hand, implemetation of iPAT initial clinical experience.
gradient systems and the potential Topics Magn Reson Imaging 2001; 12: 183-204
benefits of using multi-phased array at 1.5 T might have a negative effect
coil technology in conjunction with on image quality due to the limited
parallel acquisition methods has not SNR.
been investigated.
Several techniques have been sugge-
There are various factors which sted for the iPAT image reconstruc-
enhance the overall image quality in tion from the reduced data sets. They
ToF-MRA at 3.0 T compared with MRA can be divided into two different
at lower field strengths. The increased groups such as techniques working
SNR available at 3.0 T was used in our on the data in frequency domain
study to increase spatial resolution, (SMASH, GRAPPA) and techniques
thereby reducing the amount of working on the Fourier transformed
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High Workflow of Maestro Class System


at a Brazilian Clinic
By: Alessandra Wasilenko for
Siemens Medical Solutions Brazil

49 MRI exams per day –


from head to toe
The Multi-Imagem clinic is located
in a large 500 square meter mansion
in Ipanema, the romantic neighbor-
hood in the southern part of Rio
de Janeiro. The city of Rio appears
in some of Brazil’s most picturesque
postcards, in addition to being
serenaded in some of the most
renowned bossa nova song lyrics and
poems. Attractive and historical lines
also give style to the clinic’s architec-
ture. This is the former residence of Figure 1
the Jaguaripe Baron during Brazil’s
imperial period and which, less than
one year ago, leased space to one
of the most important magnetic
resonance clinics in the country. “Combining a comfortable clinic and
Inaugurated in October of 2002, the well trained people with quick and
spacious, well built, comfortable, well executed exams, using the best
clean design and cozy Multi-Imagem resonance machine there is in Rio
Ipanema looks like anything but a de Janeiro, are just some of the
clinic (Fig. 1). competitive advantages that contri-
bute to the clinic’s success”, said
This is the perfect location for the Dr. Romeu Domingues when guiding
first MAGNETOM Symphony Maestro us round the interior of the clinic
Class system from Dr. Romeu Côrtes (Fig. 3).
Domingues’ network of clinics. “We
decided that a machine such as this The Multi-Imagem clinic performs
had to be installed in the city’s most an average of 40 to 45 examinations
exclusive region; to be adopted by per day. The last milestone, recorded
opinion leading doctors and installed recently, was a total of 49 exams in
in their offices. (...) It was not easy to a single day. That amounts to almost
find a house that would allow struc- more than one thousand procedures
turing a magnetic resonance clinic in a one month period. An outstanding
with its peculiarities (...), it was like figure when taking into account that
finding a needle in a haystack. the majority of the exams performed
A house located in one of the best are complex, including spectroscopy, Figure 2
neighborhoods in town, on a pleasant perfusion and diffusion. “In Rio de
street lined with trees, located Janeiro, we are the only clinic that
between the Rodrigo de Freitas Lake does brain tractography, bidimensional
and Ipanema, one of Brazil’s most myocardial perfusion and three-
famous beaches” (Fig. 2). dimensional spectroscopy of the
122
MAGNETOM SITE VISIT

The integrated coils represent a


major advantage since they allow the
performance of more than one exam
at a time without having to move the
patient. “For example, in an abdomen Figure 4
and pelvis examination, we no longer
have to put the patient on the table,
Figure 3 perform the abdomen exam, then
take him off to position the coil on
the pelvis and then put the patient
prostate. We are also one of the few back on the table. We simply put the
groups in Brazil that conducts cardiac abdomen and pelvis coil and, without
and cerebral functional studies”, moving the patient, perform the two
(Figs. 4, 5, 6, 7) he says. Our exami- exams. The same occurs with brain
nations are even more comprehensive and spine exams. This way, the clinic
because, since May, the clinic received no longer needs to schedule two
the work-in-progress software for appointments, since we can do both
Diffusion Tensor* and now offers in a single session and save a lot of Figure 5
diffusion tensor and tractography time. At times, I can schedule up to
images. “In spite of our daily agenda three exams in a single appointment.
of 40 exams per day, our neuro-radio- With this, the patient also saves a lot
logical exams are complete, regard- of time, not having to return to the
less of whether the doctor prescribed clinic and undergo the entire proce-
them”, he says. In Latin America, the dure again”.
intention of the pioneers is to test
the software, conduct scientific Another feature that has made
studies about white substance diseases exams very quick, including conven-
in the brain and present results at tional exams, is that between one
congresses. The Diffusion Tensor* sequence and another, there is no
was developed in partnership with longer the need to pre-scan. Siemens
has eliminated pre-scanning, which Figure 6
Harvard University in Boston. “We
are going to provide feedback to is something that the competition
professors in Boston and to Siemens’ does not yet offer. “We go from one
specialists in Germany. We already sequence that lasts a little over
have projects associated to multiple 60 seconds to another without losing
sclerosis, brain tumors and Alzheimer’s any time. In previous versions, the
disease. We are testing the software system required some time to
on patients that suffer from these perform adjustment and calibration
three pathologies”, affirms the between one sequence and another.
radiologist. With MAGNETOM Symphony, this
is all done automatically”.

Advantages of MAGNETOM Figure 7


Symphony for workflow Differentials adopted at
gains Multi-Imagem
Dr. Domingues points out two advan- The clinic, which is open from 6:45
tages that make this equipment a.m. to 11:00 p.m., has 30 employees
quicker, more efficient and ensures divided into three work shifts. The
productivity gains: integrated medical staff is composed of six * The information about this product is
preliminary. The product is under development
panoramic array coils and no need physicians, three fellows and eight and is not commercially available in the U.S.,
for pre-scanning. technicians. A nurse receives the and its future availability cannot be ensured.

123
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MAGNETOM FLASH

Figure 10

Figure 8 Figure 9 Figure 11

patient; instructs him or her to the cheapest in the world, so we Anamnesis, when done ahead of time,
change clothes; get his or her vein have to do a lot of them, quickly and also provides for gains in various
access, whenever necessary; sends with quality”, says Dr. Domingues stages. One of them is discovering
the person into the room; and posi- (Fig. 9). whether the case will require the use
tions him or her on the examination of contrast for the nurse to get the
table. The resident is responsible for patient’s vein before the exam begins.
The clinic possesses two anesthesia
talking to the patient, writing down About 40 % of the exams performed
machines. One in the MRI room;
the anamneses and collecting prior at the clinic require vein puncturing,
the second in the anesthesia recovery
relevant examinations. One radio- such as: abdominal, pelvic, angio-
room’s nursing center. Anesthetic
logist is responsible for monitoring graphic, cerebral and cardiac studies.
induction on patients that require
the exam and conducting post
such procedure – such as patients There are three cabins for changing
processing procedures on the Leo-
with claustrophobia, in coma, in clothes. “While one patients is leaving,
nardo workstation; the other radio-
severe pain or children– is done the other has already changed clothes
logist is responsible for the exam
outside the magnet room and always and is all ready to go, anesthetized
report or review. “Many complex
with two anesthesiologists and one and vein ready, if required”.
procedures, such as angiography,
nurse. When one examination is
cardio, functional neurological and
ending, the next patient is already
prostate spectroscopy examinations
under anesthesia. Once the exam is Special advantages of
require post processing. For this
completed, the patient’s recovery MAGNETOM Symphony and
reason, we always need two doctors
also occurs outside the exam room,
per shift” (Fig. 8). Multi-Imagem for patients
in the nursing center. Dr Domingues
explains: “The patient does not need The equipment is fast and has a nice
Patients are instructed to arrive half to be anesthetized and recover design, which makes it more toler-
an hour in advance. “When the time inside the resonance room, since this able, especially for claustrophobic
comes for the patient to enter the procedure takes some time. In the people. Dr. Domingues is proud of
examination room, we have already past, we used to schedule one hour the new facility: “We have patients
talked to this person, analyzed his or for the exam, since 20 minutes were that cannot stand being submitted to
her previous exams and, whenever spent with induction and another 10 exams at our other clinics that have
necessary, punctured the vein. At with recovery. By carrying out these older Siemens equipment, such as
present, we cannot waste any time. steps in the nursing center, we gain Vision, but tolerate Symphony and
The fee charged per exam is very low an average of 30 minutes”. The without anesthesia. I tell patients:
and, in order to continue investing, procedure adopted at Multi-Imagem ‘the equipment is short, safe and very
we need to be highly productive. The was adopted by the other clinics fast’, and also tell them how long
examination in Brazil ranks among within the network (Fig. 10). the exam will take. The reduction in
124
MAGNETOM SITE VISIT

Figure 12 From left to right:


Dr. Romeu Cortes Domingues and
Dr. Eric Martins. Dr. Roberto Cortes
Domingues and the Technicians:
Isabel Cristina Madeira Barreto and
Luís Antonio de Oliveira Alves

examination time eases things. It is


one thing to stay in the machine half
an hour and a whole different story
when we’re talking about five or
seven minutes. At times, I can even
perform exams on children without
having to anesthetize them”.
The team always asks if the patient
wishes to listen to some kind of
music during the exam. Music helps
diminish the feeling of claustropho-
bia and anxiety. A winter garden is time the patient enters and exits the Brazilian college of Radiology, partici-
within sight for patients from inside examination room”. pates in scientific congresses, having
the room and from on top of the At the Multi-Imagem Ipanema clinic, lectured at more than 300 conferences.
exam table, making the space more spinal column, knee, shoulder and In 2004, he will be presenting
peaceful and relaxing. hip exams are carried out in less than a class at the International Radiology
10 minutes, between 7 and 8 minutes. Congress, in Montreal, Canada.
Time savers per exam Simple neurological procedures take Dr. Roberto Côrtes Domingues studied
10 to 15 minutes. Complete exams at the Federal University of Rio de
According to Dr. Domingues, with
with functional techniques are done Janeiro, having also done his residency
MAGNETOM Symphony, all exams –
in less than half an hour. In the past, at Hospital do Fundão. In 1997,
neurological; angiography; cardiac,
a complete brain exam would take he undertook an 18-month speciali-
from the simplest to the most lengthy
almost one hour and now takes half zation course in Boston. Dr. Roberto
ones, such as those involving perfu-
the time, since the clinic performs was responsible for bringing func-
sion; breast tumor recurrence; abdo-
two exams in a single appointment. tional neuro techniques to the state
minal and pelvic exams of all types;
A Single Voxel Spectroscopy takes of Rio de Janeiro. In 1998, he was
cholangiographies; urological MRI
only three minutes, whereas a Multi- already performing diffusion, perfu-
and 3D spectroscopy of the prostrate
Voxel Spectroscopy takes about five sion and spectroscopy exams using
exams – are quick and simple to
minutes and the diffusion tensor a Siemens MAGNETOM Vision.
perform. Exams that took up a lot of
about two to three minutes.
time, such as abdomen and MR Radiologists Dr. Romeu and
Cholangiography, can now be perfor- Profile Dr. Roberto Côrtes Domingues focus
med in about 15 minutes. “Before, it Dr. Romeu Côrtes Domingues studied on internal medicine, vascular and
took half an hour to perform a spec- medicine and did his residency in neurological studies. A third brother,
troscopy, even using Siemens equip- Radiology at the Federal University of Dr. Rômulo Côrtes Domingues, also
ment. Now, this same procedure can Rio de Janeiro (UFRJ), at Hospital do works at Multi-Imagem clinic. His
be done in just five minutes. It is also Fundão. In 1989 and 1990, he did his focus is on musculoskeletal studies.
a lot easier to do MR Angiography fellowship in magnetic resonance at The clinic offers all types of ortho-
examination. In the past, we had to Harvard University’s main hospital pedic exams, including MR arthro-
do the bolus test and calculate the (Massachusetts General Hospital), in graphy, being a benchmark in the
best moment when the contrast Boston. Upon his return to Brazil, sports area. All athletes from Rio de
would reach the artery being analyzed. Dr. Romeu worked four years at the Janeiro soccer teams, the national
With this machine, the patient already Luis Felipe Matoso Clinic (RJ). In soccer team and the Brazilian Olympic
comes in vein ready; we then do the 1994, he opened his first clinic, IRM Committee (COB) only undergo
procedure; and, simultaneously, Ressonância Magnética, and his exams at the Multi-Imagem and CDPI
in real time, we see the contrast second clinic in 1995, CDPI. The third clinics. The degree of confidence is
arriving at the area in question, then clinic, Multi-Imagem, opened in attested by the Brazilian Olympic
record this sequence with a simple 1998. Multi-Imagem Ipanema was Committee’s invitation to Dr. Rômulo
click. It has become a simpler and inaugurated in October 2002. Today, Domingues of accompanying
quicker exam. A procedure that took Dr. Romeu spends his time as a the Brazilian athletes in the 2003
up 30 to 40 minutes can now be doctor working at Multi-Imagem and Pan-American Games, held in the
done in 10 to 15 minutes; from the CDPI. He is also vice-president of the Dominican Republic.
125
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MAGNETOM FLASH

Bilateral Four Channel Phased Array


Carotid Coil from Machnet
The bilateral 4-channel phased array Clinical images
coil is designed for bilateral proton
imaging of the carotids, and allows
for sub-millimeter resolution of the
carotid lumen, the vessel walls and
atherosclerotic plaques. Due to its
Company Description inherent contrast resolution, MRI has
Machnet BV is one of the few the potential to provide a surplus
suppliers who develop and produce of information on the composition of
special MRI Coils. They design, the atherosclerotic plaque.
manufacture and market specialty The coil provides high-resolution
coils for MRI all around the globe. images with good definition of the
The main office is in Eelde, The lumen and the vessel walls, without
Netherlands. For more informa- disturbance from flow artifacts.
tion or questions, please contact Note: even though the coil wasn't
Machnet Sales Department developed for such purposes, it has
+31 (0) 50 577 9846 been used to scan baby hearts
Email address: sales@machnet.nl because of the high-resolution and
the penetration depth (Fig. 5). Figure 1 Image courtesy of Aad
van der Lugt, MD, PhD, Mohamed
Ouhlous, MD, Piotr Wielopolski, MD
Introduction Technique Erasmus Medical Center-Daniel den
Hoed, Rotterdam.
The Phased Array Carotid Coil is a The Phased Array Carotid Coil is
Acquisition parameters:
flex coil. The assembly is coated with compatible with the MAGNETOM
TR 1976.3ms, TE = 8.6 ms.
a soft polymer foam to minimize Symphony and the MAGNETOM FOV = 147 x 180 mm, 448x359,
patient discomfort. The flexibility of Sonata 1.5 T MAGNETOM scanners. 3 mm slice thickness.
the coil enables it to be positioned All the images in this article were
on both sides of the neck and held in produced with these two types of
place with a soft collar. scanners.
Magnetic resonance imaging of the
carotid artery wall and in particular
of carotid artery atherosclerosis, has
the potential to identify patients at
risk of cerebrovascular events.
Magnetic resonance imaging has the
ability to identify lipid and fibrotic
components of complex atheroscle-
rosis, which are important determi-
nants for risk of complications in the
coronary circulation and – some
evidence suggests – the carotid circu-
lation also. What is required is high
resolution black blood imaging, with
an in-plane resolution of at least
0.5x0.5 mm.

126
CARDIO VASCULAR

Figure 2 Image was performed with MAGNETOM Sonata Figure 4 Images of a 55 year old patient with carotid
1.5 T Scanner. Image courtesy of Aad van der Lugt, MD, plaques. Image courtesy of Dr. Zahi A. Fayad, Imaging
PhD, Mohamed Ouhlous, MD, Piotr Wielopolski, MD, Science Laboratories, Mount Sinai School of Medicine.
Erasmus Medical Center-Daniel den Hoed, Rotterdam.
Acquisition parameters:
Acquisition parameters left image: TR 2000 ms, TE = 5 ms, 3 mm slice thickness,
TR 2234.8 ms, TE = 16.0 ms. FOV = 103x120 mm, 0.3 mm inter-slice distance.
440x512, 3 mm slice thickness. FOV was 140x140 mm; spatial resolution of 0.54x0.54 mm.
Acquisition parameters right image: Turbo factor = 11.
TR 2260.5 ms, TE = 64.0 ms. FOV = 103x120 mm,
440x512, 3 mm slice thickness.

Figure 5 Baby Heart. Image courtesy of Dr. N. Abolmaali.


J.W. Goethe Universitätsklinikum, Frankfurt.

Figure 3 Image was performed with MAGNETOM Sonata


1.5 T Scanner. Image courtesy of Aad van der Lugt, MD,
PhD, Mohamed Ouhlous, MD, Piotr Wielopolski, MD,
Erasmus Medical Center-Daniel den Hoed, Rotterdam.
Acquistion parameters left image:
TR 2234.8 ms, TE = 16.0 ms. FOV = 103x120 mm,
440x512, 3 mm slice thickness.
Acquisition parameters right image:
TR 2260.5 ms, TE = 64.0 ms. FOV = 103x120 mm,
440x512, 3 mm slice thickness.

Figure 6 Carotid Artery Wall. Image of a 25 year old


healthy male volunteer.
Image courtesy of Dr. Stephen Worthley, Adelaide Wake-
field Hospital, Australia.
Acquisition parameters:
The images show an axial T1 weighted turbo spin echo
image with a field-of-view of 11x11 cm, and 256x256
matrix and slice thickness of 3 mm. The image quality is
evident and in the magnified view of the common carotid
one can distinguish the normal media (high signal) from
the surrounding dense adventitia (low signal).

127
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MAGNETOM FLASH

Self-Gated Cardiac Cine*


Virtually Eliminates ECG Triggering
Gary McNeal and Kevin Johnson
Cardiovascular MRI Team
Siemens Medical Solutions USA,
Inc.

Innovative new technology


limitations of maintaining accurate Figure 1 High resolution Self-Gated
virtually eliminates ECG ECG signal on certain patients Cine images in the horizontal
triggering once and for all. There is a wireless long axis, short axis, and vertical
advantage especially for patients long axis.
Siemens recently introduced Self-
such as those with disease of the
Gated Cardiac Cine, an innovative More recent methods derive cardiac
pericardial sac or with right heart
new technology that virtually and respiratory motion directly from
overload.”
eliminates the need to obtain an the image data itself, with no loss
electrocardiogram (ECG) signal Prior to the introduction of Self- of efficiency because no additional
during cardiac magnetic resonance Gated Cine, the only alternative navigator echoes are required
(CMR) imaging. One of the remaining available when ECG triggering was (Larson; Simonetti; Laub; White).
challenges in CMR imaging is accurate not optimal was to use Real-Time Currently, three different methods
and reliable synchronization of Cine. However, with Real-Time Cine, are being used to extract cardiac
an MRI scan with the heartbeat. the MRI scan suffers from low spatial motion information from the raw
Although recent developments like resolution. Fortunately, Self-Gated data lines: Echo Peak Amplitude,
the Siemens Optical ECG Lead System Cine does not suffer from low spatial Center of Mass, and 2D ROI Corre-
have eliminated most problems, resolution because it is synchronized lation. The first method shows the
some patients, especially at 3T, still to the motion of the heart during most promise.
provide challenges. This software six to twelve successive beats.
extracts cardiac motion information
from MRI data and eliminates the
need for wires and electrodes to be Self-Gating methods
attached to the patient, thus avoiding Echo Peak Amplitude
the difficulties of obtaining a reliable Self-Gating methods were first method
ECG signal inside the high magnetic described in 1988-89 (Spraggins;
field of an MR system. Additionally, Hinks; Kim; Drobnitsky) and patented The Echo Peak Amplitude method of
initial results suggest that this by Siemens in 1990 (Spraggins and Self-Gating described by Larson et al.
technology may have image quality Owens). The Spraggins and is a variation of the original Spraggins
advantages over standard ECG Owens method used an interleaved and Owens model, except that a
synchronization. Siemens plans to acquisition of central k-space lines radial or spiral k-space trajectory is
extend the same technology to for motion information (navigator used instead of a conventional linear
respiratory gating to eliminate the echoes) and phase-encoded lines for trajectory. Since each line of raw data
need for patient breath holding image information. As the position passes through the center of k-space,
during CMR scans and to improve the of the heart changed during its beat, no additional motion navigator
reliability of coronary angiography the amplitude of the motion naviga- echoes are required, thereby making
exams. tor echo changed accordingly, thereby this method essentially 100% efficient.
providing a periodic signal to be used The average signal is dominated by
Richard D. White, M.D., Head, Section for retrospective reconstruction of blood pool expansion and contrac-
of Cardiovascular Imaging, Division the cine images. This method suffered tion through the cardiac cycle, thereby
of Radiology, The Cleveland Clinic from 50 % inefficiency because providing a periodic signal to be used
Foundation, explains: “Self-Gating every other line of raw data was used for retrospective reconstruction of
makes it possible to overcome the strictly for motion detection. the cine images.
128
CARDIO VASCULAR

image motion image


navigator

Figure 2 The Wireless-Gating


method uses interleaved lines of
image data and motion navigators,
but suffers from 50 % inefficiency.

Figure 3 The Echo Peak Amplitude


method uses a radial trajectory to
sample the center of k-space during
each acquired data line. Each echo
reflects the average signal in the
image, which is dominated by blood
pool expansion and contraction
through the cardiac cycle. The echo
peak signal cycles at the same rate
as the ECG signal, and thus is used
instead of the ECG signal.
Linear K-space Trajectory Radial K-spaceTrajectory

Applications
Although generally applicable,
early results show that in cases of Self-Gating Signal
arrhythmia and congenital disease
gating from the mechanical motion
of the heart will provide advantages
over the use of ECG triggering.

ECG-Gating Signal

* The information about this product is


preliminary. The product is under development
and is not commercially available in the U.S.,
and its future availability cannot be ensured.

129
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Self-Gating clinical
results:
The images speak
for themselves!

Figure 4 Healthy volunteer.


a) Self-Gated Retro Cine
b) ECG-Gated Retro Cine

Figure 5 Self-Gated Cine images


courtesy of Dr. Richard D. White and
Dr. Arthur E. Stillman, Cleveland
Clinic Foundation, Cleveland, OH.
a) Bicuspid aortic valve
b) Stenotic mitral valve
c) Regurgitant mitral valve
d) Right heart overload
e) Constrictive pericarditis

130
CARDIO VASCULAR

How to Improve your 3D ToF with


a Few Drops of Gadolinium
J. Dehem, M.D. spins also get saturated and signal in (see Figs. 1a-b) can be used to apply
Jan Yperman Hospital, the blood vessels will drop. This kind a higher matrix. Applying a higher
Ypres (Belgium) of problem does not occur in 2D ToF, matrix results in smaller voxels,
G. Laureys, M.D. where you excite slice after slice. leading to less intra-voxel dephasing,
MR application specialist, which assists in picking up smaller
The problem of 2D ToF, however,
Siemens Belgium vessels.
is that you have to use larger slice
thickness. Since we have a faster relaxation,
we may use an even shorter TR and
Accordingly, the engineers have
higher flip angle to further reduce
designed a kind of hybrid between
background signal, without satura-
Our main workhorse for 2D and 3D ToF: the so-called MOTSA
tion of inflowing spins. In fact, after
MR angiography of the (Multiple Overlapping Thin Slabs
a little contrast we can use such a
cerebral arteries is 3D ToF. Acquisition) to avoid saturation of
short TR that a stimulation monitor
the inflowing spins and to keep
will impose a limit!
To use the full potential of our 3D ToF the high resolution in a short time
we need to remember a few basic provided by the 3D technique. It is also possible to put the 3D block
principles. A high contrast between in an oblique way on the skull base,
flowing blood and stationary back- Another trick used to avoid early almost parallel to the circle of Willis,
ground is achieved with a relative saturation of the inflowing spins is providing a larger coverage of the
high flip angle and a short TR, so that the so-called TONE technique (Tilted cerebral blood vessels in the same
stationary tissue gets saturated Optimized Non-saturating Excitation): scan time (same number of slabs).
and only inflowing spins produce essentially the use of a lower flip
angle at the entry side and gradually With this approach a signal is
high signal, hence the name Time of
increase to the exit side (as the vessel obtained even in the ophthalmic
Flight.
traverses the slab) so that saturation arteries.
The highest possible inflow is achieved doesn’t occur in the excited slab.
by positioning the 3D block ortho-
To avoid signal from the veins,
gonal on the blood vessels. Since the What about the venous
a tracking saturation pulse on the
ophthalmic artery runs orthogonal to
cranial (venous) side of the slabs is
enhancement?
the carotid artery (and thus parallel
added. Since venous flow is much slower,
to the 3D block), it will not give any
venous enhancement can be mini-
signal.
mized with the use of just a small
For even further suppression of the How does IV contrast behave dose (1 cc), high enough to provide
background signal, the sequence on a 3D ToF sequence? enough relaxation to the fast flowing
designers have provided us with two arterial spins, but not enough for the
additional tools: This produces a higher signal in the slower flowing venous spins.
blood vessels, since the relaxation of
■ The use of magnetization transfer Gd-enriched blood is speeded up1. So, the basic principles being remem-
(since flowing spins don’t experience bered, let’s look at some examples.
the MT effect and the MT effect of The drawback is that you no longer
can saturate the venous signal: since The images were acquired on a
blood is lower than the MT effect of MAGNETOM Symphony with Quantum
brain tissue) to suppress signal from the relaxation is faster, the saturation
doesn’t last. gradients; the standard Head Coil
water molecules in the stationary was used. Images pre and post
background. Since gadolinium is insensitive to contrast have equal window settings
■ The use of water excitation the MT-effect and the background (center and width).
pre-pulses to suppress signal from remains as sensitive to the MT-effect
fat, e.g. orbital fat. as prior to gadolinium administration
(blood brain barrier), gadolinium
Since the effect of inflowing spins is administration results in higher
used to produce a high signal in the flowing blood – enriched with a few 1
A rough calculation gives a reduction from
blood vessels, the 3D block shouldn’t drops of gd – to stationary back- the T1 of blood without Gd of 1200 ms towards
be too thick, otherwise the inflowing ground contrast. This higher contrast 500 ms of blood with 1cc of Gd

131
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MAGNETOM FLASH

1a-b Figure 1a-b


One partition out of the 3D ToF sequence.
Left: without Gd;
right: with 1 cc of Gd.
Figure 1a
■ ROI # 1(intensity in vessel) = 138
■ ROI # 2 (intensity in GW) = 83
Figure 1b
2a-b ■ ROI # 1 (intensity in vessel) = 172
■ ROI # 2 (intensity in GW) = 82

Figure 2a-b
Thick MIP of the 3D ToF.
Left: without Gd,
right: with 1 cc of Gd.

Figure 3a-b
Magnified section out of
a thick MIP from a second patient.
Left: without Gd;
right: with 1 cc Gd.

Figure 4
Positioning of the partitions of the
3D slabs: inclination of the slabs is
increased in regard of the normal
“almost pure” transverse positioning.

132
CARDIO VASCULAR

We would like to draw attention to the


strength of the “Thin MIP” algorithm to
improve the visualization of certain vessels.
Figure 5a-b 1cc enhanced 3D ToF
of a patient with left carotid occlusion.
Left: standard MIP;
right: thin MIP with better visualization of
1: lenticulostriatal arteries
2: bifurcation artery cerebri media
3: PICA
4: SCA

Figure 6a-b
3D ToF enhanced with 1 cc Gd
Left: “ThinMIP” nicely
depicting the arteria ophtalmica;
right: standard MIP.

133
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MAGNETOM FLASH

The information in this document contains general


descriptions of the technical options available, which
MAGNETOM Flash –
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Fax: 610-448-2254 Published by
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in Asia: P.O. Box 3260, D-91052 Erlangen

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