Issue no. 1.

2003

MAGNETOM F L A S H

MAGNETOM World Meeting Sheraton Perdana Hotel Langkawi, Malaysia 17-18 Jan 2003

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medical

MAGNETOM FLASH

Content
Topic EDITORIAL Seeing is Believing: Phoenix Protocol Exchange Platform and Virtual Siemens MR Booths at the RSNA 2002 & ECR 2003 Page

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PHOENIX MAGNETOM World Phoenix Quick Guide 6

MAGNETOM WORLD MEETING Sheraton Perdana Hotel Langkawi, Malaysia, 17 -18 Jan 2003

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OPEN SYSTEM Cervical Spine Examination with MAGNETOM Concerto ULTRA HIGH-FIELD MRI of the Knee Joint: Comparing Sequences at 3 T and 1.5 T High Field Brain Imaging: Clinical Implications 16 20 14

PEDIATRIC IMAGING MT Tissue Contrast Effect and its Role in Pediatric MR Imaging Pediatric MR Workshop MRI and US in Diagnosis of Facial Angiodysplasia in Children Fetal MR Imaging MUSCULOSKELETAL Magnetic Resonance Imaging of the Elbow Topic 48 Page 24 28 36 44

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.

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GASTROINTESTINAL IMAGING MR Enteroclysis: a New Diagnostic Approach for Small Bowel Imaging TECHNOLOGY CORNER All You Want to Know About “HASTE” MRI SAFETY Medical Devices and Accessories Developed for Use in the MR Environment and Interventional MRI Procedures Accessories and Supplies from Siemens WOMEN’S HEALTH Contrast-Enhanced 3–Dimensional Dynamic Breast MR: Monitoring of Neoadjuvant Chemotherapy Thin-MIP Evaluation 3D Mammographic Imaging NEURO IMAGING Case Report: Stroke Diagnosis with MR CARDIO VASCULAR Dream Machines and Getaway Speed… MRI Flow Quantification Techniques Application Tip Basic Cardiac Positioning and Terminology Upper Extremity CE MRA with CARE-BOLUS Using syngo 2002B FAQs Cardiac Imaging Peripheral MRA with iPAT EVENTS MAGNETOM World Summit TECHNOLOGY CORNER 20 Years of Development and a Constantly Improving Performance = MAGNETOM 124 122 86 90 102 106 109 116 84 74 80 68 72 62 54

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Editorial

Seeing is Believing: Phoenix Protocol Exchange Platform and Virtual Siemens MR Booths at the RSNA 2002 & ECR 2003

“Protocol exchange through images on the internet, the exact examination parameters from the images on www.SiemensMedical.com/MAGNETOM-World directly to the MAGNETOM and voila! your scanner is replicating what a scanner in Massachusetts General Hospital or New York University (NYU) is doing, or a scanner in the University of Wuerzburg or anywhere else...” Nobody believed us when we said these ambitions would become a reality at RSNA in 2002. We were looked at as though we were giving away the plot of the latest Star Trek film, so far-reaching were our aims. In 2002, we at MR were proud to reveal Phoenix, simply the easiest protocol exchange method ever. Phoenix allows you to click on an image, drag it into the measurement queue and instantly duplicate the exact protocol-TR, TE, bandwidth, number of slices, echo spacing, etc. Phoenix extracts these values from the DICOM header and you are ready to scan. If your system has a different gradient strength configuration from the source image, Phoenix “adapts” the protocol in less than 30 seconds. To convert images, simply press the shift key while dragging the image into the queue. The queue of MR users by the internet demonstration console at the Siemens MR Booth waited patiently but full of anticipation to see and believe what, to our competitors, remains in the realms of science fiction. We have created a virtual RSNA and ECR MR booth on our community web page www.SiemensMedical.com/MAGNETOM-World containing the panels from the RSNA and ECR, the images with Phoenix functionality (syngo MR 2002B ) from the booths and the presentations. Our advice is: You do not have to leave the comfort of your home to see the MR show in the congresses. Simply log on to our web page and see the results in a fascinating and simple virtual booth full of images containing the Phoenix icon. These are downloadable with parameters by just clicking on the images. We don't believe we could have made it easier.

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Editorial Team

Tony Enright, Ph.D. Asia Pacific Collaboration, Australia

Laurie Fisher, B.S.R.T., R, MR US Installed Base Manager, Malvern, PA

Our virtual booth was not the only focus of attention: our community web page also attracted much attention as a source of state-of-the-art clinical applications’ and new technical developments’ demonstration platform. The technology corner demonstrated the latest technical steps taken by MR: Maestro Class, iPAT, TrueFISP lung imaging, viability imaging and more. Case reports are available from reference sites all around the world: VIBE MR Cholangiography from NYU, diffusion tensor imaging from Brisbane… Application tips will help you in your routine practice: Cardiac perfusion imaging from Royal Brompton, MR Angiography from Essen.... Clinical methods help you understand the new techniques being developed and used by other clinics : Imaging Acute Ischemia from MGH, MR demonstration of thoracic central veins from Auckland. Clinical protocols will help you improve your exam quality to the levels of internationally renowned clinics: Renal Mass protocol from NYU, MRCP with contrast from NYU… The future will bring our customers the complete protocol trees from different reference sites for different anatomical examinations, together with the opportunity to download them all with one click. The future will bring out Phoenix books on Neuro MR and Orthopedics MR where you can read text books and apply the techniques referred to with one simple click on the images. The future will bring case reports, application tips, clinical methods with the Phoenix option which allows you to download images which you believe offer solutions to your immediate questions. Our competitors may think of Phoenix books, Phoenix protocol trees and Phoenix application tips as pure science fiction. However, we at MAGNETOM world know, and our customers know, that we do not deal in fiction. We deal in fact, pure and simple. Seeing is believing.

Marion Hellinger, MTRA MR MarketingApplication Training, Erlangen

David Thomasson Ph.D. US R&D Collaborations Malvern, PA

Milind Dhamankar, M.D. MR MarketingApplications, Erlangen

Michael Wendt, Ph.D. US R&D Collaborations, Malvern, PA

Dagmar ThomsikSchröpfer, Ph.D. MR Marketing-Products, Erlangen

Helmuth Schultze-Haakh, Ph.D. US R&D Collaborations, Malvern, PA

Peter Kreisler, Ph.D. Collaborations & Applications, Erlangen

Judy Behrens, R.T. (MR) (CT) Adv. Clinical Applications Specialist

Enjoy this issue of Flash.

Charlie Collins, B.S.R.T. Market Manager (USA), Erlangen

Raya Dubner Design Editor, Malvern, PA

A. Nejat Bengi, M.D. Editor in Chief

Gary R. McNeal, MS(BME) Advanced Application Specialist Cardiovascular MR Imaging Siemens Medical Solutions USA

Achim Riedl Technical Support, Erlangen

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We thank Harald Werner, Lawrence Tallentire and Iman Staab for their editorial help.

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MAGNETOM World Phoenix Quick Guide
Marion Hellinger, MTRA MR Marketing-Application Training, Erlangen

Phoenix is a unique syngo-tool that allows you to click on an image, drag it into the measurement queue, and instantly duplicate the extracted protocol – TR, TE, bandwidth, number of slices, echo spacing, etc.. The Phoenix Quick Guide gives a step-by-step description of how to extract sequence protocol data from DICOM images worldwide via network, CD, or Internet using Phoenix. The Quick Guide is also included in the Phoenix CD attached to this MAGNETOM Flash issue. All images acquired with software syngo MR 2002B and all subsequent versions can be utilized to exchange parameter from clinical images amongst different MAGNETOM users. On the MAGNETOM World page in the internet the Phoenix logo indicates those images that are suitable for downloading on a PC. After transferring them to a CD these images can be used directly on your MAGNETOM scanner. We invite you to visit our MAGNETOM World. Go to www.SiemensMedical.com/ MAGNETOM-World and download interesting clinical images from hospitals all over the world.

For additional copies of this CD, visit our web-site at www.siemensmedical.com/MAGNETOM-World. Please click on „Contact“ on the right upper side of the page, give your name/address and the number of copies that you would like to receive. The CDs will be sent to you as soon as possible.

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PHOENIX

Step 1
Click on the wing of the red Phoenix logo

Step 2
Press the “Save” button in the pop up window in order to save the images on the hard disc of your PC. As soon as the desired images are transferred to a CD they can be taken to your MAGNETOM scanner. The next pages explain how to continue with Phoenix on your MAGNETOM scanner.

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Step 3
Insert the CD with the desired images acquired with syngo MR 2002B software into the CD-ROM drive. These may be DICOM images that have been downloaded e.g. from the MAGNETOM World Internet page.

Step 4
Call up the start menu by pressing <Ctrl> and <ESC> on your keyboard simultaneously. Select the entry “Program/Load images from CD” (Fig. 1).

Figure 1

Step 5
A window named “Load images from CD” shows up indicating the loading progress of the images from the CD to the browser. (Fig. 2)

Figure 2 8

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Step 6
The images will be available in the patient browser after a few seconds. From here you can select a single image, press the shift key simultaneously when performing drag & drop into the exam explorer. The protocol conversion takes place immediately and a pop up window informs you about the progress. The new generated protocol will be inserted under the desired program (Fig. 3)

Figure 3

Step 7
In some cases it can occur that the new inserted protocol is underlined. This indicates that protocol adaptations were made during the conversion (e.g. the original image had been acquired on a MAGNETOM Harmony and is now downloaded to a MAGNETOM Sonata). You can display the changes on the upgrade info sub card under the protocol properties (Fig. 4).

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MAGNETOM World Meeting ASEAN, Malaysia, 17-18 Jan 2003
MAGNETOM World Meeting in ASEAN The aim was to demonstrate the MAGNETOM Concerto’s range of clinical applications and image quality. There were two guest speakers, Dr. Craig Platenberg, MedTel International, USA and Dr. Kenneth Tan, Cardinal Santos Medical Centre, Philippines. Dr. Platenberg gave two presentations, one focusing on the clinical outcomes of low field MR and the other on the business model of his corporation. Dr. Tan also presented low field clinical outcomes and also a comparison between 1.5T and Concerto image quality and clinical results. Both speakers were extremely well received by the audience, which consisted of radiologists, administrators, Siemens sales staff and Siemens dealers, representing eight countries. Of particular interest was the diversity of applications and the extremely high image quality. Shaun Seery also gave a presentation on marketing concepts and how marketing could be used to strengthen a business model. This was greeted with enthusiasm by the attendees. The event concluded with a “jungle party”, including a barbeque and native Malaysian dancing (support by some of the attendees), conducted in a true tropical rainforest within walking distance of the hotel. All attendees gave the overall event a big “thumbs up” and look forward to future events to stimulate information exchange.

The ASEAN region covers countries like Indonesia, Malaysia, Philipines, Singapore, Thailand and Vietnam. We recognize a growing interest in 1.5T as well as in low field systems in this area. Our Asian business centre is located in Singapore. Marivic Santos (ASEAN MR Modality Manager) and Shaun Seery (General Manager MR Asia Pacific) organized the event over two days on the Malaysian Island resort of Langkawi.

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MAGNETOM WORLD SUMMIT MALAYSIA

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MAGNETOM WORLD SUMMIT MALAYSIA

“The customers were convinced at the end of the meeting that MAGNETOM Concerto was a real open system with great images. For me this was an important outcome of the meeting” Shaun Seery General Manager of Asia Pacific Region

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Cervical Spine Examination with MAGNETOM Concerto
Dudge, John C., MD Meredith, Lawrence A., MD Mullins, Patrick, RT Longmont United Imaging Center 1380 Tulip Street, Suite B Longmont, Colorado 80501

Examination was done with sagittal T1 pre and post Gadolinium (Fig. 1), sagittal T2 with TSE and STIR (Fig. 2, 3). MEDIC and CISS axial images (Fig. 4, 5) were also obtained. The bone signal intensity is unremarkable. No acute loss of vertebral height or disk space narrowing is seen. There is noted to be a central subligamentous disk protrusion at C5 and C6, extending posteriorly by perhaps 3-4 mm and with probably some mild pressure on the canal. Also of note is a syrinx beginning at approximately the C6C7 interspace and extending caudally to approximately T1-T2, with maximum diameter approaching 6 mm. There is no increased signal intensity noted on the post-gadolinium T1 sequence.

Figure 1 Sagittal T1 cervical spine

Figure 2 Sagittal T2 cervical spine using TSE

1. Significant syrinx measuring up to 6 mm wide from approximately C6-C7 to approximately T1-T2. 2. Central subligamentous disk protrusion, C5-C6, with perhaps minimal pressure on the cord.

Figure 3 Sagittal cervical spine with STIR

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Figure 4 Axial cervical spine images using MEDIC

Figure 5 Axial cervical spine images using CISS

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MRI of the Knee Joint: Comparing Sequences at 3 T and 1.5 T
B.M. Wietek MD and J. Machann Section on Experimental Radiology, Department of Diagnostic Radiology, Eberhard-Karls University Tübingen, Germany the objective assessment in clinical trials of new pharmacological and surgical treatments for articular cartilage lesions. High-field MRI systems enable small field-of-view images with improved spatial resolution due to an increased SNR. Factors such as B0 homogeneity and the increased chemical-shift artefacts can, however, reduce the gains offered by a higher magnetic field. Given this situation, the aim of our study was the direct comparison of sequences with identical parameters at different field strengths with respect to SNR, image contrast, and artefacts. In a second step, the adaptation of sequence parameters for optimal imaging at 3 Tesla has been initiated. cal sequence parameters. SNR at both field strengths were measured and tissue contrast was compared qualitatively between 1.5 and 3 T. As chemical shift doubles from 1.5 to 3.0 T, particular attention was given to the evaluation of chemical shift artefacts at 3.0 T.

Introduction
MRI of the knee performed at conventional field strengths is sensitive for the detection of cruciate and collateral ligament tears as well as for the detection of meniscal tears. The spatial resolution and excellent softtissue contrast provided by 1.5 Tesla clinical MRI scanners are perfectly satisfactory. The signal-to-noise ratio (SNR) and spatial resolution at this standard field strength, however, remain inadequate for the study of fine structural details in certain critical joint components such as articular cartilage. Consequently, the introduction of high-field whole body magnetic resonance imaging systems, such as 3.0 T and above, is a consecutive step to achieve a higher spatial resolution in vivo. Applications for this technology in musculoskeletal systems include the imaging of small joints and of morphologically complex and vulnerable structures such as articular cartilage. The accurate imaging of articular cartilage is of major clinical importance as cartilage degeneration is a significant cause of morbidity. Diagnostic arthroscopy is still frequently used for articular cartilage assessment despite the fact that only the surface condition of the cartilage can be directly evaluated by this method. In particular, cartilage repair and degeneration cannot be monitored over time by such invasive methods. Such monitoring becomes particularly important, however, for 16

Results
SNRs were found to be nearly two-fold higher in the 3 T images for all sequences using identical parameters. In this pre-clinical study, T1weighted images demonstrated no striking difference in tissue contrast between 1.5 versus 3.0 T (see Fig. 1). In the proton density and T2 weighted images, only a slightly improved tissue contrast could be demonstrated for higher field strength (see Fig. 2). However, in the additional cartilage sensitive sequences with fat suppression, such as DESS (i.e., sequences which were not disturbed by the more pronounced chemicalshift artefacts at 3.0 T), a significantly higher spatial resolution with similar SNR could be demonstrated using the same measuring time (see Fig. 3). In the multi-echo technique recorded with a higher bandwidth (MEDIC), the images revealed a higher SNR for the same spatial resolution (see Fig. 4). In the inversion recovery images (TIRM), fat suppression enabled obtaining artefact-free (i.e. chemicalshift) images. Furthermore, a significant 2.5 increase in SNR was achieved at 3.0 T. The GRE sequence images revealed a clear signal loss in regions with spongy bone marrow. This was particularly clearly visible in the epiphysis of the distal femur (see Fig. 5, small arrow), even when a relatively short TE of 10 ms were used.

Methods
MR imaging of the knee was performed on healthy volunteers, aged 31-45 years, with a 1.5 T MAGNETOM Sonata Scanner (Siemens, Germany) using a circularly polarized extremity coil. The routine protocol included a T1 weighted spin-echo sequence (TR = 450 ms, TE = 15 ms, FOV = 180 mm) and a turbo spin-echo sequence (TR = 5000 ms, TE = 15 ms and 100 ms) for simultaneous recording of proton density- and T2-weighted images. Additionally, two special techniques dedicated to depict cartilage were applied: a dual echo steady state (DESS) sequence (TR = 21 ms, TE = 6 ms) and a multi-echo sequence with a high bandwidth: MEDIC (TR = 120 ms, TE = 21 ms). Finally a TIRM (TR = 7000 ms, TE = 58 ms, TI = 180 ms) sequence and a standard gradient echo sequence (GRE) with different TE’s were applied (TR = 120 ms, TE = 10 and 20 ms, FOV = 180 mm). Examinations were repeated on a 3.0 T whole body imager (MAGNETOM Trio, Siemens, Germany) with identi-

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Figure 1 T1-weighted SE-images revealed no striking differences between 1.5 T (a) and 3 T (b) regarding to tissue contrast. Measurement parameters: TE = 15 ms, TR = 4500, FOV=180 mm, Matrix 256x256, BW 130 Hz, in plane resolution 0.7mm2, slice thickness 4 mm, Acq. time 4:20 min.

Figure 1a

Figure 1b

Figure 2 PD/T2-weighted fast spin echo images show a slightly improved tissue contrast at 3 T Measurement parameters: TE = 15 and 100 ms, TR = 5000, FOV = 180 mm, Matrix 256x256, BW 130 Hz, in plane resolution 0.7 mm2, slice thickness 4 mm, turbo factor 5, Acq. time 4:27 min [1.5 T T2-weighted (2a), PD-weighted (2c), 3.0T T2-weighted (2b), PD-weighted (2d)] 35 year old healthy male volunteer, without knee joint pain or trauma in his medical history.

Figure 2a

Figure 2b

Figure 2c

Figure 2d

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In summary, the usual T1 and T2 weighted spin echo and turbo spin echo sequences led to very similar contrast characteristics and showed increased chemical shift artefacts at 3.0 T compared to 1.5 T. To overcome this effect, larger bandwidth needed to be used, thereby decreasing the SNR. Consequently, such sequences used in MR articular imaging did not profit from the increased SNR at 3.0 T. Gradient echo sequences showed similar increased chemical shift artefacts as well as a faster signal decay with TE, especially in regions with trabecular bone structures, which are likely to be related to reduced T2*. However, new acquisition strategies such as the MEDIC-sequence performed with relatively high bandwidth resulted in high SNR, high image quality at 3.0 T. This applied also to fat suppressed imaging of cartilage – DESS-sequence- where improved SNR without any chemical-shift artefact was achieved. For these sequences the increase 3.0 T SNR could be exploited and lead to decreased acquisition time or increased resolution.

Figure 3a 1.5 T FOV 205, in plane resolution 0,8 mm isotropic Figure 3 3D Dual echo steady-state (DESS) sequence, TR = 21, TE = 6ms, FOV = 205 mm, Matrix 256x256, BW 130 Hz, Flip Angle = 25° , in plane resolution 0.8 mm2, partition thickness 0.8 mm, Acq. time 7:31 min In these cartilage sensitive sequences – especially fat suppressed images – no pronounced chemical shift artefacts disturb the improved SNR by the same spatial resolution (a) 1.5 T and 3.0 T (b). A significantly higher spatial resolution (in plane resolution 0.6 mm2) with similar SNR could be demonstrated using the same measuring time (c).

Figure 3b 3T FOV 205, in plane resolution 0,8 mm isotropic

Figure 3c 3T FOV 154, in plane resolution 0,6 mm isotropic

Conclusion
This preliminary study investigated the potential of 3.0 T field strength to improve diagnostic imaging of articular cartilage. Due to increased chemical shift, standard imaging did not show 3.0 T benefits. However, fat-suppressed and large bandwidth acquisitions (DESS, MEDIC) clearly profited from the increased 3.0 T SNR. These results show promise for faster or high resolution imaging at 3.0 T when using appropriate sequences.

Figure 4 Multiecho-data-imagecombination sequence (MEDIC), TR = 120, TE = 21ms, FOV = 180 mm, Matrix 256x256, BW 390 Hz, flip angle = 50°, in plane resolution 0.7mm2, partition thickness 0.7 mm, slice thickness 4 mm, Acq. time 0:32 min

The ‘MEDIC’ images revealed a higher SNR and an improved tissue contrast by the same spatial resolution. 1.5 T (a), 3.0T (b)

Figure 4a

Figure 4b

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Figure 5a

Figure 5b Figure 5 2D gradient echo (GRE) sequences, TR = 120 ms, TE = 10/20 ms, FOV = 180 mm, Matrix 256x256, BW 130 Hz, flip angle = 48°, in plane resolution 0.7mm2, partition thickness 0.7 mm, slice thickness 4 mm, Acq. time 0:32 min

Figure 5c In the gradient echo sequences the signal show a faster decay with TE especially in regions with trabecular bone structures (e.g. epiphysis) and more pronounced chemical-shift effects at 3.0 T: TE 10ms (a), TE 20 ms (b), MEDIC sequence (c).

Figure 6a

Figure 6b Figure 6 IR TSE-Sequence (TIRM) TR = 7000 ms, TE = 58 ms, TI = 180/190 ms, FOV = 180 mm, Matrix 256x256, BW 130 Hz, flip angle = 150°, in-plane resolution 0.7mm2, partition thickness 0.7 mm, slice thickness 4 mm, Acq. time 4:28 min. Suitable T1 Relaxation times for the complete fat suppression are between 180-190ms indicating a slightly higher T1 time for fat at 3T: a) TI = 180ms, b) TI = 190ms, c) TI= 200ms, d) TI= 220ms

Figure 6c

Figure 6d

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High Field Brain Imaging: Clinical Implications
A. Gregory Sorensen, M.D. Massachusetts General Hospital, USA ■ The investigation of microscopic anatomy with diffusion imaging and perfusion imaging is just beginning to achieve widespread clinical acceptance. However, such images are markedly limited by signal to noise constraints. This is one reason for the lower spatial resolution of diffusion and perfusion MRI compared to conventional imaging. ■ Spectroscopy and spectroscopic imaging have had limited success in the clinical arena, despite marked success in the laboratory setting. One key reason is the time needed to acquire clinically useful information. additional SNR is available, how best to use it is for the radiologist to decide. It is also important to note that increasing field strength is not the only way to improve the ratio of signal to noise. A four-fold increase in imaging time will lead to a doubling of the signal to noise ratio (SNR). This means that when one refers to SNR, it always assumes a fixed amount of imaging time, since one can improve SNR simply by imaging longer. SNR can also be improved by utilizing improved receiver coils (such as surface coils, singly or in arrays); in some instances by shortening echo times (made possible by improved gradient hardware); or by utilizing novel pulse sequences (these often optimize contrast to noise, or CNR, but sometimes boost SNR as well). However, most new 1.5T systems in use today are already using optimized hardware and software. While longer imaging times might provide better SNR, increasing the imaging time by a factor of four is simply not possible in many situations for a variety of patient related reasons. For example, the exam may already be as long as feasible, or the patient is not stable, or there may be economic reasons, e.g. throughput of patients. Therefore, using a higher field strength is an option that merits exploration.

Introduction
Magnetic resonance imaging has changed medical practice, particularly in the brain. Diagnosis of anatomic diseases has become possible with a level of precision that was previously unthinkable: tumors, aneurysms, congenital abnormalities, and traumatic injuries are now routinely diagnosed with a higher degree of accuracy than ever before. Nevertheless, the full potential of MRI remains to be realized. In a number of clinical applications in the brain, MRI might be able to offer significantly more benefit than it currently offers. Take these four examples: ■ Most psychiatric diseases have little if any gross anatomic change detectable by MRI. Instead, such diseases appear to be caused by incorrect functioning of normalappearing tissue. Functional MRI – an approach that may be able to change this shortcoming – has been limited by the lack of signal relative to the biologic noise present (as well as other problems). ■ Magnetic resonance angiography, though steadily improving, has not yet replaced catheter-based x-ray angiography as a gold standard. From a health care policy point of view, the sensitivity and specificity are too low; from a technical point of view, coverage and spatial resolution are both insufficient. 20

In each of these scenarios, a fundamental limitation that current MRI techniques suffer from can be thought of as simply too low a ratio of signal to noise. As users look for ways to get more signal, an increasing number are using higher field strengths. This article will illustrate some of the benefits we have recognized in our practice by moving from 1.5 Tesla (the current standard premier clinical system) to 3.0 Tesla. We have found significant benefit by moving to 3T in a variety of routine and investigative settings.

Signal to noise: the “currency” of MRI
An important concept in considering the benefits of high field imaging is that signal to noise can be viewed as a type of “currency” that the radiologist can choose to “spend” in a number of ways. Improved SNR might be used to increase the imaging matrix, or to choose thinner slices, or to reduce the number of signal averages, or in some cases to decrease the amount of contrast agent administered. This flexibility of improved SNR is one of its greatest advantages. Once

Areas of Potential Benefit
We will briefly explore each of the above listed areas of MRI limitation to see what benefit higher field imaging might bring.

Conventional Anatomic Imaging
Conventional MRI already provides high quality imaging in many

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settings. There are, however, some instances in which finer detail would be desirable, particularly if the imaging time is not increased. Figure 1 shows an example of the intracranial vasculature near the Cirlce of Willis, demonstrating small perforating arteries not typically visible. While the increased matrix size here would be possible at 1.5T, the resulting voxel size would lead to a grainy image. Such fine level of detail is appealing to surgeons, radiologists and radiation therapists, as well as neuroscientists. Remember that most CT images are 512x512 over a 20 cm field of view; this is a voxel size that is one quarter that of a typical MR image, or smaller. While MRI provides superior contrast to noise (CNR) for most lesions, increased spatial resolution would be welcome in most arenas. Specific diseases in which increased spatial resolution of conventional images might prove to be cost effective include tumors, in which pre-surgical planning could be assisted; and epilepsy and congenital abnormalities, which are often subtle and difficult to detect.

graphy. Diseases that could benefit from this improvement in spatial resolution include both aneurysms and atherosclerotic disease. Improved diagnostic confidence in MRA could preclude even more catheter x-ray angiography studies and, for example, allow more confident screening of patients with congenital or other predisposition to form aneurysms. With the recent focus on dynamic contrast-enhanced angiography, the benefit of improved SNR at 3T will be even more apparent. This is because these contrast-enhanced techniques are inherently SNR-limited: these techniques depend on acquiring multiple images during the rapid passage of contrast through the arterial tree, and increasing the imaging time is not an option. Figure 1 Ultra-high-resolution T2 weighted images showing the Circle of Willis. Note the high level of detail evident, in particular the lenticulostriate and perforating vessels arising from the middle and posterior cerebral arteries (arrows). While a similar matrix could be used at 1.5T, it would produce images with increased noise (a grainy appearance), and less diagnostic confidence. Courtesy Larry Wald, PhD. Images acquired on a Siemens Allegra 3T with a 4 channel array coil. Acquisition parameters: 15 echo Turbo Spin Echo: TR/TE = 4000/90ms, FOV = 156 x 180 mm, 450 x 512, 2 mm slice thickness 0.35 x 0.35 x 2.0 mm3 voxels, 9 min 16 sec scan time, 15 slices.

Functional MRI
The area of functional MRI is perhaps where high-field will be of greatest impact. Blood-oxygenation level dependent (BOLD) imaging gains an additional boost from high field because susceptibility effects generally increase as the square of the field strength. Hence, at 3T the level of signal change can be up to 7%, compared with 1.5% or less at 1.5T. This benefit is particularly apparent when investigating subtle changes, or when utilizing paradigms that require extra SNR, such as single trial designs or event-related studies. One way to measure the apparent benefit of higher field is to determine the extent of activation for a given paradigm. With better SNR, additional areas should be resolved from the background noise. Figure 3 demonstrates results from a visual stimulation paradigm at 3T and at 1.5T, and indicates that extensive additional information is available at higher field.

Magnetic Resonance Angiography
We have found substantial improvement in the appearance of MRA images at higher field, and are currently investigating the specific cause of this improvement. Figure 2 shows 1.5T and 3T images demonstrating the high level of detail available at 3T. Note in this case that the matrix sizes are the same (both 1024 MRA); the improvement in SNR shows as a reduction in the graininess of the image, and in increased conspicuity of the fine vasculature. We anticipate that with additional work to optimize parameters for 3T, MRA will improve further, and may eventually rival catheter x-ray angio-

Figure 2a 1.5T

Figure 2b 3T

Figure 2 performed at 1.5T on a MAGNETOM Sonata; image (b) at 3.0T on a MAGNETOM Allegra. Note the increasing vessel conspicuity and the level of detail. Both were 1024 x 384 matrix sizes; the 3T image took approximately 7 minutes and the 1.5T approximately 16 minutes. 21

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Paradigms to investigate dementia, drug addiction, migraine, and other human diseases are underway at our institution, as well as others, and have demonstrated benefits at 3T. Two potential drawbacks of the higher field should be remembered when considering fMRI, however: often, the echo-planar sequences on higher field instruments are substantially louder than on 1.5T systems and require additional hearing protection. Also, as noted in the previous paragraph, the increased field strength increases susceptibility effects. This is why the BOLD signal change is improved. However, susceptibility artifacts are also increased. This can be of particular concern if the area of interrogation is prone to such artifacts, such as the inferior temporal lobes. Nevertheless, most investigators find that these drawbacks are manageable and worth the benefits.

Diffusion and Perfusion MRI
These relatively new techniques, which use echo planar imaging and typically push SNR requirements to the limit, also benefit from higher field strength. Perfusion-weighted imaging has an additional way to “spend” the increased SNR that 3T yields. The susceptibility changes that are the basis of perfusion MRI can be obtained with a lower dose of Gd-based contrast agents compared with lower fields. In effect, the higher field strength means half the dose can be used compared with 1.5T for the same effect. Figure 4 shows perfusion MRI images obtained at 3T, and indicates that creating maps of relative cerebral blood flow as well as relative cerebral blood volume is easily done with the higher SNR available. Perfusion measurements have often been limited by 22

Figure 3 fMRI at 1.5T and at 3.0T. These images are computed eccentricity phase maps, used for mapping retinotopy in the visual field. The images are on flattened visual cortex, taken from the calcarine fissure (area circled on small image of brain cortex at top left). The subject is shown expanding rings, and the delay from the onset of the stimulus is mapped as a phase change. Colors represent isophase regions, with the white areas representing one particular phase value. Note that at 3T, the signal strength is higher and allows mapping of a larger area of visual cortex, whereas at 1.5T, many areas are simply not visible, since the noise hides the reaction of the brain tissue. Many more white areas are present at 1.5T, indicating that the ability to distinguish noise from signal is decreased. Figures courtesy of Anders Dale and Bruce Fischl, MGH-NMR Center.

ULTRA HIGH-FIELD

SNR, since the first pass of a contrast agents occurs so quickly and therefore there are relatively few data points to compute hemodynamic parameters from. The additional SNR boost (assuming the same dose of Gd is given) can allow more precise measurement of hemodynamics, particularly in disease states such as stroke where hypoperfusion is present and only a small amount of contrast agent might be arriving into a voxel. Diffusion MRI is also limited by SNR: many sites typically acquire multiple signal averages at 1.5T, and still have insufficient SNR to fully study phenomena such as anisotropy and behavior of the full diffusion tensor in disease states such as stroke. The additional SNR boost should help these studies as well. Figure 4 Perfusion MRI at 3.0 T* Maps of relative cerebral blood volume (rCBV) and relative cerebral blood flow (rCBF) can be created from dynamic data acquired at 3.0T. These images demonstrate abnormally elevated rCBF and rCBV in a residual grade 3 tumor. Note the excellent gray / white ratio, consistent with known differences in gray matter and white matter blood flow and blood volume (Siemens MAGNETOM Allegra, Spin Echo EPI).

The Future
We anticipate that the quest for higher field strength will continue. A few centers (including ours) are installing even higher field strengths: 7.0 Tesla and beyond (WIP). While there are a number of technical issues at high field, including radiofrequency power deposition, field inhomogeneity, and increased system performance requirements, we believe that these are challenges that are well worth the effort needed. As with echo-planar imaging, the widespread clinical acceptance of these systems requires a streamlined user interface and increased robustness, as opposed to the less reliable performance of research systems. Which of the above applications (or perhaps other applications not mentioned) will provide the most compelling reason to move to higher field in the clinical setting remains to be determined, but the move to high field for clinical imaging is undisputable. 23

* This informationconcerns use of contrast media that has not been approved by the Food and Drug Administration.

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MT Tissue Contrast Effect and its Role in Pediatric MR Imaging
Christine Harris, RT (R)(MR) Tamara D. Lee, BSRT(R)(MR)(CT) The Children's Hospital of Philadelphia transmission of neural impulses through the CNS. Myelination is ongoing throughout the first decade of life, and myelin contains protein and lipids, which contribute to T1 contrast. During the first two years of life, this development should be taken into account when selecting techniques that will produce optimal pediatric images. signal intensity from the free water. This is the process of magnetization transfer. Contrast is enhanced between tissues that undergo magnetization transfer (water-containing tissues) and those that do not (fatcontaining tissues). Magnetization transfer pulses may be used in Spin Echo (T1) following administration of a contrast agent and in Gradient Echo sequences (3D TOF MRA), to produce additional signal suppression of tissue water. The clinical applications of magnetization transfer can be divided into two categories: contrast augmentation and tissue characterization. In a given tissue, the saturation pulses used in magnetization transfer reduce the signal intensity. The degree of signal intensity reduction depends on the amount of magnetization transfer present in this tissue. Using magnetization transfer suppression, contrast between tissues with different amounts of magnetization transfer can be increased. Magnetization transfer saturation pulses can be combined with all conventional MR sequences. When using magnetization transfer for contrast augmentation, the familiar tissue contrasts on these sequences change. For example, when combining a T1 weighted sequence with an MT saturation pulse in brain imaging, fat appears brighter, and the gray matter of the central sulcus, putamen, and caudate increases in brightness and conspicuity. On Time of Flight (TOF) images, blood vessels stand out against a dark background due to selective saturation of stationary tissue. This effect is based on two phenomena. One, blood flowing into the imaging plane does not experience the saturating effect on the MT pulse, and two; the MT effect of blood is lower than that of brain parenchyma.

Introduction
When imaging the pediatric brain, many techniques and methods must be considered. We, the staff at The Children's Hospital of Philadelphia, plan to share with you our experiences in this area through a series of articles and tips. It is known that the pediatric patient presents many challenges during an MR exam. These challenges include: 1. Safe sedation techniques 2. Monitoring during the MRI exam 3. Technical parameters In this article, we will discuss tissue contrast considerations for imaging the pediatric brain.

MR pulse sequence: Magnetization transfer suppression (MTS)
Magnetization transfer (MT) suppression is a technique similar to fat saturation in terms of hardware implementation. However, instead of an RF pulse centered at the fat frequency, magnetization transfer uses a narrow bandwidth RF pulse with a center frequency approximately 1-10 kHz away from the main water resonance. This off-resonance pulse affects some of the tissue water protons, more specifically the “bound water” protons. Water within a tissue is either mobile (freely moving) or bound to macromolecules. While both free and bound water protons have the same resonance frequency, they will have different T2 relaxation times. Free water protons will have a long T2 and a sharp peak. Bound water has a very short T2 and a broad resonance peak, not normally visualized in an image. The two peaks will be superimposed at the same center frequency. Magnetization transfer sequences apply a narrow bandwidth presaturation pulse that is centered 1-10 kHz away from the central water frequency. The magnetization transfer RF pulse is applied off-resonance to saturate the bound water protons. Exchange between the bound and free water protons transfers the saturation to the free water protons, reducing

Brain development
Why does the pediatric brain present imaging challenges that the mature brain does not? The brain matures in an organized and predetermined pattern that correlates with the development of functions in the newborn and infant. As the pediatric brain develops, its water content decreases and its myelin content increases. The infant brain has a much higher water content than that of the older child or adult. The high brain water content at birth decreases rapidly over the first six months of life. It continues to decrease at a slower rate until age 2, and then levels off. Myelination of white matter is an important component of brain maturation. It facilitates the 24

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Another clinical application is the use of MT pulses in combination with contrast enhanced TOF. The repeated application of RF pulses in TOF MRA not only gives rise to saturation of stationary tissue, but also leads to saturation of blood flowing in the imaging plane. As a result, a reduction in the vessel-to-background ratio occurs. By using gadolinium chelates, this phenomenon can be reduced. These agents shorten intravascular T1 relaxation times, which diminishes the sensitivity of blood to saturation effects. Gadolinium is largely insensitive to MT pulses; however, the combination of gadolinium and MT pulses increases vessel to background contrast. Magnetization transfer suppression can also be used to quantitatively characterize tissues. The amount of MT in tissues depends on the physical and chemical characteristics of tissue components, which may change in disease states. Such changes can be quantified using magnetization transfer. To quantify these changes, two MR sequences are needed: one in conjunction with the MT pulse, and the second one identical but carried out in the absence of the MT pulse.

Figure 1

Figure 2

Figures 1 and 2 were both acquired with the same parameters, except that in Figure 2 we added an MT pulse. Note the decrease in gray/white matter contrast in Figure 2.

The benefit is similar to giving larger doses of contrast, but without the added expense. This will improve lesion visibility.

Protocol
At our institution, MTS is utilized with pre- and post-contrast imaging, and for enhancing lesions such as infection and infarction. Pre-MTS imaging is utilized to assess pathological enhancement accurately as well as the sensitivity of certain disease processes which may be obscured during standard T1 imaging (Fig. 3 and 4).

Pitfall
We have noted that when using the MT pulse sequence with children under the age of two, MT resulted in decreased conspicuity of edema as well as gray/white matter contrast. (Fig. 1 and 2).

Effects of MT on MR imaging
MT is utilized routinely with MRA to suppress the background signal while maintaining the signal contrast from the vessel. MT increases the conspicuity of small and distal blood vessels. By suppressing the background signal, the signal ratio between vessel and brain tissue will be improved. MT use with post-contrast imaging increases the contrast to noise ratio of enhancement, which is nearly doubled when compared with non-MT MR Imaging. Figure 3 Routine Spin Echo Figure 4 Spin Echo with MT Pulse. Note increased visualization of TS disease process vs. non-MT image (Fig. 3)

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When employing the MTS pulse to our standard Spin Echo sequence, we increased our TR. Longer TR with MTS results in loss of gray/white matter contrast. With the help of Siemens, we have developed a short TR/TE T1 MT protocol that has improved our gray/white matter visualization, as well as maintaining a short scan time. This change in T1 contrast improves the visualization of gray and white matter in children whose brains are undergoing normal development (see Fig. 5 and 6).

Figure 5 (TR 800) loss of gray/ white matter contrast

Figure 6 (TR 536, TE 12, Flip angle 90 192 x 256) increase in gray / white matter contrast

The authors recommend the following reading materials:

References:
Age-dependent changes in magnetization transfer contrast of white matter in the pediatric brain, Rassek, Engelbrecht V., in AJNR 1998 NovDec; 19(10): 1923-9 Characteristics and pitfalls of contrast-enhanced, T1-weighted magnetization transfer images of the brain, by Shrier S. Higano, in Acad Radiol 2000 Mar; 7(3):156-64 Contrast-enhanced magnetization transfer MRI in metastatic lesions of the brain, by P, Peretti-Viton, in Neuroradiology 1998 Dec; 40(12):783-7

Magnetization transfer analysis of brain tumor, infection and infarction, by MH Pui, in Magnetic Resonance Imaging 2000 Sep; 12(3):395-9 Contrast-enhance magnetization transfer MR of the brain: importance of pre-contrast images, by JR. Meyer, in AJNR 1997 Sep; 18(8)1515-21 T1-weighted three-dimensional magnetization transfer MR of the brain: improved lesion contrast enhancement, by DA. Finelli, in AJNR 1998 Jan; 19(1):59-64 Magnetic Resonance of Myelin, Myelination and Myelin Disorders 2nd edition, by M.S. van der Knaap, and J Valk

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Pediatric MR Workshop
The workshop was attended by: Christine Harris CHOP, Philadelphia Tamara Lee CHOP, Philadelphia Dr. Robert Zimmerman CHOP, Philadelphia The lack of radiation exposure, the possibility of multi-planar imaging and the wide range of tissue contrast have made magnetic resonance (MR) imaging an important tool in the evaluation of pediatric diseases. Siemens organized a workshop on this topic, which took place in Erlangen. Its aims were two-fold. Firstly, to get a better understanding of the use of MAGNETOM systems in this area, and secondly, to get feedback from Siemens’ customers regarding future developments which might impact on solutions provided by Siemens MR systems. Dr. Cornelia Czipull University of Karlsruhe Dr. Susan Palasis CHOA, Atlanta Dr. Damien Grattan-Smith CHOA, Atlanta Dr. Richard Jones CHOA, Atlanta Dr. Robert Ogg St. Judes, Memphis Dr. Thomas Keller Kantonsspital, Baden Prof. David Gadian University College London Prof. Dr. Ludger Sieverding University of Tuebingen Prof. Dr. Rudolf Stollberger University of Graz Prof. Dr. Franz Ebner University of Graz Prof. Dr. Thomas Rupprecht University of Erlangen They believed that a good way to measure EF was to measure extraction from blood into the cortex (descending aorta as input function) and from the cortex into the collecting system. The second focus in renal imaging was to evaluate the ADC (Apparent Diffusion Coefficient) of the kidney as a marker for renal development. Dr. Palasis concentrated on spectroscopy of the brain. She classified the use of spectroscopy under the following subgroups : 1. Brain tumors: Diagnosis and characterization of tumors in difficult locations particularly. Delineation of the extent of tumor infiltration past obvious anatomic abnormality. Monitoring of tumor progression or response to therapy. 2. Seizures: Localization 3. Ischemia: Prognostication in neonatal hypoxic ischemic injury and pediatric stroke. 4. Metabolic disorders: Diagnosis and characterization.

Highlights of the meeting Children’s Hospital of Atlanta
Dr. Grattan-Smith & Dr. Jones talked about their experience in evaluating renal perfusion and interpolating functional parameters from the information obtained from renal cortex, medulla perfusion (Fig.1). 28

She emphasized “Short TE” MR spectroscopy as an important tool in the diagnosis and classification of brain tumors. She mentioned that mI:Cr ratio, seen with short TE spectroscopy, had predictive value regarding tumor grade and histology. Also for tectal plate tumors, MR could predict aggressive (Fig. 2) or nonaggressive behavior (Fig. 3). Overall she said that MRS was valuable for the evaluation of brain tumors and had high accuracy in predicting tumor grade, adding that both short and long TE sequences needed to be performed. She summarized the future goals for Siemens in terms of spectroscopy as :

PEDIATRIC IMAGING

Long TE SVS
60 50 40 R1(sec-1) 30 20 10 0 0 100 200 300 400 500 600 700 800 Time(seconds) Cortex Cortex(fit) Renal pelvis Renal pelvis(fit)

Figure 1 Interpolating functional parameters from renal cortex, medulla perfusion. Figure 2 3 year old girl with vomiting. Tectal plate tumor, spectroscopy shows aggressive metabolite profile.

Short TE SVS

Long TE SVS

Figure 3 9 year old girl with headaches, tectal plate tumor is seen. Spectroscopy shows non-aggressive metabolite profile

Short TE SVS

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Figure 4 1. To evaluate as much of the brain as possible (2D CSI- 3D CSI), (Fig. 4); 2. To evaluate as much peripherally as possible; 3. To evaluate tissue microheterogeneity; 4. To maintain spectral resolution 5. Keep imaging time as short as possible

Karl-Franzens-University, Graz and LKH / General Hospital
Prof. Dr. Stollberger & Prof. Dr. Franz Ebner stressed protocol optimization. They sub-grouped the patients as 0-3 months, 3-12 months, 12-24 months and above. Their philosophy was to optimize the spatial resolution, contrast resolution, S/N and coil use. One of his interesting research topics was MR urography, which they said could replace the conventional techniques. Dr. Ebner defined this technique as “one-stop shop” imaging, replacing conventional techniques like IVU, scintigraphy and sonography (Fig. 5-6).

University of Tuebingen
Prof. Dr. Sieverding provided a summary of MR use in pediatric cardiac imaging including morphology, function (contractility, volume, flow, perfusion, viability) and metabolism. The sequences used for congenital heart diseases (Fig. 7) are black blood sequences, Spin Echo seqeuences, 2D Gradient Echo and 3D Gradient Echo sequences. He also expressed his needs in terms of faster imaging and, in particular, better monitoring of the patients.

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2 year old child with optic pathway tumor.

Children’s Hospital of Philadelphia
Christine Harris and Tamara Lee introduced the Children’s Hospital of Philadelphia where more than 11,000 MR examinations are performed in any one year. They were convinced that the new dedicated pediatrics coils from MRI Devices (Fig. 8) – supported with 2002 software – would be very useful in routine practice. In general they expressed a need for dedicated pediatric coils for almost all applications. They mentioned some recent remarkable improvements in image quality with syngo (Fig. 9). Dr. Zimmerman said that in his clinic spectroscopy was a routine examination reaching a total of 400 clinical examinations and 200 research patients. He grouped the indications as frequent and less frequent for the brain spectroscopy. Frequent indications were brain tumor diagnosis (Fig. 10) and a follow-up with treatment, to clarify whether or not bright lesions larger than 1 cm were tumors or metabolic diseases. Less frequent indications were defined as hypoxic ischemic brain injury in neonates, seizures and the differentiation of abscesses and tumors. He stressed the need for smaller voxels to be able to evaluate smaller lesions. He also expressed his view regarding fetal imaging, which he said was an area of potential growth. His requirements were for higher resolution HASTE, thinner section HASTE and rapid T1 weighted imaging for better fetal evaluation. He ended his talk by stressing that MR is the future of Neuro-anatomy and Neuro-pathology.

Multivoxel long TE 270ms

Multivoxel short TE 30ms

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Figure 5 IVU vs dynamic MRU: duplex system left kidney with ectopic megaureter of upper moiety

Figure 6 Dynamic renal MRI imaging vs conventional imaging

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Figure 7 Pulmonary atresia. Multifocal blood supply

Small

Large

Figure 8 Pediatric Neurovascular CTL Array Coils*
* Certain OEM coils require 510 (k) review and are not commercially available in the U.S

Figure 9 Image examples from CHOP : Pediatric MR imaging with syngo and optimized sequences

Figure 10 Choline map shows increased choline in the lesion which supports the suspicion that the lesion is a tumor. MR spectroscopy is frequently used in differential diagnosis of brain lesions.

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University College London
Prof. Dr. Gadian talked about structure and function relationships in children with brain disease. He stressed three major topics, epilepsy, ischemic disease and specific cognitive impairments. He gave examples of hippocampal sclerosis diagnosis using T2 mapping (Fig. 11) and also spectroscopic findings (Fig. 12) related to them. His focus in ischemic diseases was sickle cell disease (Scd). His conclusion was that Scd patients had potential for preventive therapy, and perfusion fills a key gap linking cerebrovascular abnormalities to tissue damage. Combined diffusion / perfusion MRI would help with identification of tissues at risk and contribute to patient management, including the evaluation of treatment outcome. In the area of functional MRI, Dr. Gadian said that this application might be used in mapping of subclinical/interictal events, presurgical identification of sensorimotor cortex, presurgical language/memory lateralization and identification of sites of functional reorganization. Dr. J. Ogg, from St. Jude Children’s Research Hospital, talked about the major research projects in his clinic. He also gave a detailed explanation of the use of fMRI to investigate cognitive deficits in survivors of childhood cancer, which he said was genuinely feasible (Fig. 13). Professor Dr. Thomas Rupprecht from Erlangen University gave an excellent talk on the use of low field Open Systems in the area of pediatric imaging. Dr. Thomas Keller, from Kantonsspital Baden Hospital, talked about fetal imaging in general and fetal lung measurements. He also shared his experience with other MR systems. The workshop was a great success, providing Siemens MR Team the necessary feedback for future development plans. The friendly atmosphere also strengthened the bond between us and our partners, the Siemens customers (Fig. 14). 34

Figure 11 Hippocampal T2 mapping in hippocampal sclerosis.

Figure 12 Hippocampal sclerosis and spectroscopic findings.

Figure 13 fMRI results. Patients

Healthy adults

PEDIATRIC IMAGING

Figure 14 The friendly atmosphere in the workshop strengthened the bond between us and our partners, The Siemens customers.

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MRI and US in Diagnosis of Facial Angiodysplasia in Children
dosage and needs iodinated contrast media injection. It may not be safe enough for pediatric purposes, especially for repeated dynamic examinations. The largest group of patients with facial soft tissues angiodysplasias are children. Noninvasive ultrasonography (US) with color Doppler mapping has been used for the diagnosis of angiodysplasias since the mid 1980’s. Over the last 10 years US has been improved by the power Doppler mapping of blood flow, which is very sensitive to low rate blood flow [2-3, 5-8, 10,12-14,16]. The US has become the main method for morphologic and dynamic examinations of angiodysplasia in pediatric radiology thanks to its safety and wide availability. V.O.Panov1 M.D., A.G.Nadtotchii2 M.D., A.V.Ivanov3 M.D., L.B.Denisova4 M.D., The Scientific Center for Obstetrics, Gynecology and Perinatology of The Russian Academy of Medical Sciences,
1

Introduction.
Angiodysplasias are a well-known and varied group of pathological disorders of blood vessels. Clinicalmorphological classification of angiodysplasias has been wellelaborated [1,4]. Typically, the diagnosis of facial soft tissue angiodysplasias is not difficult due to a very prominent clinical picture. However, its treatment is not so clear: for the correct treatment strategy in each individual case, it is important to evaluate the morphological parameters (type of structure, localization and volume of the lesion, lesion extension to other tissues and organs, main blood supplies) and the functional characteristics (blood distribution, and flow rates). Traditionally, selective and super selective angiography have been used to determine morphological variants of angiodysplasias, to more precisely calculate its volume and to show main blood supply and other involved vessels. But this “gold standard” method uses high x-ray New possibilities in diagnosis are being created by magnetic resonance imaging (MRI) with magnetic resonance angiography (MRA). It is well known that MRI produces an excellent contrast of soft tissues, high sensitivity for the detection of different fluids (including blood), and multi-planar imaging capabilities. MRI allows noninvasive demonstration of normal anatomy and pathological processes. Currently, MRA without contrast enhancement is widely being used for brain angiography [9,11,15] and for the examination of cardiac hemodynamic parameters [9,15]. The main purpose of this study was to determine the effectiveness of MRI with non-enhanced MRA in the examination of facial soft tissue angiodysplasias, to understand the exact indications and improve the methodology. Additionally, it was used to define the diagnostic role and the relationship of this method with other radiological methods – especially with US and with color Doppler mapping.

Moscow Center Of Children Maxillo-Facial Surgery of The Central Scientific-Research Institution of Stomatology,
2

Moscow State MedicoStomatological University,
3

Moscow Regional ScientificResearch Clinical Institution
4

Moscow-Russia

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Materials and methods.
38 patients (16 males and 22 females aged between 2 months and 22 years: mean age 3.2 years), with large and extensive facial angiodysplasias, were examined by US with color Doppler mapping and by MRI with MRA. Angiodysplasias can be classified as large if it affects only one anatomical region of the face and as extensive if it affects two or more facial anatomical regions. 7 patients had the capillary type of angiodysplasias and different types of arteriovenous fistulas were found in 20 patients. In 12 cases it was the primary diagnosis. Disorders were diagnosed after different types of treatment in 6 cases and during treatment in 20 patients. Results were verified in 9 cases by angiography and in 6 cases by histological examination after surgical treatment. US with color Doppler mapping examinations were obtained on Ultra_ark-9 (ATL, USA), Idea-4 and Megas (Esaote, Italy), Sonoline Sienna (Siemens, Germany) with linear detectors 5.0-7.5 MHz and emitting surface length from 35 to 64 mm. All MRI with MRA examinations were obtained on 1.0 T MAGNETOM Harmony (Siemens, Germany) [15] in three steps: 1. Non-specific standard examination of the head (skull and brain) – time of acquisition was about 16 minutes, FOV (Field of View) – 200-260 mm, slice thickness 3-5 mm, matrix 256x256): ■ T2-weighted single shot Turbo Spin Echo (TSE) sagittal image: TR/TE=3000-4000/1100 ms, echotrain length = 240, number of slices = 1, slice thickness 40-50 mm. ■ T2-weighted TSE axial images: TR/TE=3500-4500/120 ms, TSE factor = 7, number of slices = 20-24.

■ T1-weighted Spin Echo (SE) coronal images: TR/TE=300-600/ 14 ms, number of slices = 20-24. ■ T1-weighted Gradient Echo FLASH sagittal image : TR/TE=100-250/ 4,6 ms, flip angle =70-90º, number of slices = 9-17. 2. Examination of the region of interest – examination time was no longer than 30 minutes, FOV = 200-220 mm, slice thickness 1-3 mm, matrix 256x256/512x512): ■ T2-weighted TSE coronal or axial images: TR/TE=3500-4500/120 ms, TSE factor = 7, number of slices = 816, matrix 512x512. ■ T1-weighted Gradient Echo FLASH (TR/TE=125-350/11 ms, flip angle =60-90º, number of slices = 4-10, matrix 256x256) or TSE (TR/TE= 150-450/12-14 ms, tse factor = 2-3, number of slices = 4-10, matrix 512x512) coronal images. ■ Regional or “whole-head” 3D Time of Flight MR-arteriography (3D TOF) – 3D FLASH with flow compensation and magnetization transfer, TR/TE/ =39/10/25, slab thickness = 32-220 mm; ■ Regional or “whole-head” 2D timeof-flight MR-venography (2D TOF) – 2D FLASH with flow compensation and magnetization transfer, TR/TE/ =32/9, 8/35, slab thickness = 60-200 mm. 3. Regional measurement of blood flow rate was made on relatively large vessels (diameter more then 0,3 mm), FOV = 100-200 mm, slice thickness = 6-8 mm, matrix 128_128/256_256): ■ Special 2D FLASH sequence for blood flow rate measurement with ECG gating, TR/TE/ =24-179/ 5,5-6,5/30, number of slices = 1. Use of the combination of saturation slabs, different planes and localizations with regard to facial vascular

anatomy (Fig. 1). Manipulation of the MR-angiography data postprocessing (maximum intensity projection – MIP) (Fig. 2) allows one to obtain images of “vessels of interest” and to simulate “selective” and “super-selective” angiography. Special methodology and/or anesthesiology are necessary for MRI with MRA in infant children (younger than 5-6 years).

Results and Discussion
US with color Doppler mapping was more precise, faster and easier compared to MRI and MRA in regard to measurements of blood flow of small vessels in angiodysplasias. Blood flow rate determinations with MRI were not reliable enough: measuring error for extracranial vessels with diameter 6-8 mm was more then 15 % compared to the US data. The error increased to 25-30% when the vessels’ diameter had decreased to 3 mm. Moreover, the wide range of blood flow rates in the area of angiodysplasias did not allow the design of common standard parameters of such MR-examinations: for correct measurements it is necessary to experiment with new parameters for each case. At the same time, MRI has huge advantages over US in the determination of morphologic characters of angiodysplasias of facial soft tissues. In addition, MRI allows the examination of other potential intracranial disorders and lesions of the mandible and/or paranasal sinuses (Fig. 3).

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a

Figure 1 Saturation slabs are used to perform selective MR angiography.

b

1 2

3

c

Figure 3 Typical T2-weighted facial coronal image of patient D., 19-years old, with haemangioma of left side of the face. MRI allows one to easily determine lesion localization, and volume. Also one can determine the lesion’s morphological structure and involvement with other tissues and organs: 1 – disorders of infratemporal, pterygo-maxillary and associated pharyngeal spacial structures (intracranial part), 2 – part of angiodysplasia involving the bone, 3 – haemangioma of facial soft tissues (extracranial part). 38

Figure 2 Different views of MIP to be able to show “vessels of interest”: (a) basic MR-arteriogram; MIP-manipulations allow you to choose (b) larger area of interest or (c) smaller area of interest.

PEDIATRIC IMAGING

Clinical examples
Patient L, 1 year 4 months old: status post hormone therapy, the embolization of left external carotid artery and sclerotherapy of soft tissue capillary angiodysplasia of the left side of the face. Isolated active vessels with high blood flow rate (about 15-20 m/s) and diameter about 1.5-2.0 mm against background of diffuse fibrotic changes were found by US with color Doppler mapping (Fig. 4). MRI allowed the identification of the intracranial part of the lesion (Fig. 5). MRA (Fig. 6) shows that the blood supply of angiodysplasia was realized by dilated and tortuous vessels belonging to arterial type of blood flow.

Figure 4 US in patient L., 1 year and 4 month old, had shown that in the area of interest there were isolated active vessels (punctate and linear structures with high echo-signal marked by arrows). Surrounding tissues had diffuse fibrotic changes. a b

Figure 5 T2-weighted MRI images of the same patient L., 1 year and 4 month old, (a) in axial and (b) coronal planes allow more clear differentiation of the tissue structures. In these images you can see lesions of alveolar zone (thin arrows (a) and (b) and left lateral orbital structures (thick arrow (b)).

a

b

Figure 6 In MR-angiography images of the same 1 year and 4 month old patient L. (a) in oblique coronal projection and (b) oblique sagittal projection, left external carotid artery is not visualized. (Thin arrows show the usual localization of the external carotid artery). Note the large extent of collateral arterial blood supply (thick arrows).

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a

b

Figure 7 US data of patient K., 12 years old, shows successful treatment of left sided facial angiodysplasia: embolized vessels without blood flow (arrows) are well seen against background of soft tissues fibrosis.

Figure 8 MR-venograms of the same 12 years old patient K. (a) in axial and (b) oblique coronal planes. Local constriction of transverse sinus (thin arrow) with enlarged blood flow through superior sagittal sinus (thick arrow at (b)) and collateral veins (dashed thick arrows) at the side of embolization.

Figure 9 US data of patient D., 19 years old, shows large arteriovenous fistulas (arrows) with high speed turbulent blood flow.

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a

b

Figure 10 (a) Sagittal MR-venogram of the same patient D., 19 years old, shows rounded arteriovenous fistulas (dashed thin arrows) and (b) bag shaped ectasic dilatations of the angular vein (thin arrows). MR-arteriogram in oblique coronal plane demonstrated a lot of dysplastic arteries inside the lesion (thick arrows) and confirmed that in fistulas there was mainly venous type of blood flow. Note (b) that left external carotid artery is not visible and left internal carotid artery is stenotic and only proximal part of the vessel is visible (dashed thick arrows).

Patient K, 12 years old: status post complex treatment of capillarycavernous angiodysplasia of soft tissue of the left side of the face. Patient complained of headache for the last 6 months. US with color Doppler mapping had shown fibrosis of the lesion area and vessels without signs of blood flow (Fig. 7). MRI of mandibular and facial region supported the US data and additionally diagnosed MRI-characteristics of increased intracranial pressure, which was probably the result of decreased blood flow through left transverse venous sinus due to its local stenosis. (Fig. 8). In our studies, 21 patients (55%) had some type of venous sinus stenosis and 19 of them suffered headaches. This is a noteworthy feature in discussions about possible causes of these headaches. Accordingly, MRI with MRA data and data of US with color Doppler mapping were mainly in close agreement as to the extra-cranial parts of angiodyslplasia disorder. But as we have observed, MRI with MRA has great advantages in the examination of bone and/or intra-cranial lesions, which were more often displayed in older children.

a

b

Clinical examples
Patient D, 19 years old, with arteriovenous fistulas of the maxilla and soft tissues of left side of the face, was treated by different methods over a period of 14 years. Recent worsening of her status was characterized by increasing sizes of arteriovenous fistulas of soft tissues of the left cheek, provoked by a pregnancy which was aborted because of medical indications. Large tortuous arteriovenous fistula about 1.5 cm in diameter with turbulent high rate venous blood flow was found by US 41

Figure 11 (a) Axial MR arteriogram of the same 19 year old patient D. clearly shows additional dysplasia of left ophthalmic artery (thin arrow) and posterior communicating arteries (dashed thin arrows). During dynamic probe (squeezing of right common carotid artery) blood flow through this ophthalmic artery increased (thin arrow at (b)). So, this dysplastic left ophthalmic artery is involved in the active blood supply of the lesion.

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a

b

1. 4 cases of different forms of unclosed Willis ring; 2. 4 cases of significant middle cerebral arteries asymmetry; 3. 1 case of lateral choroidal artery atypical root, and 4. 1 case of neck soft tissues artery atypical root.

Figure 12 (a) T2-weighted coronal vertebra image of patient L., 22 years old, showed that dysplastic vessels had originated from thoracic vertebral circulation. (b) MR-arteriogram demonstrated that these vessels were primarily arterial type of blood supply.

Thus, MRI with MRA also has the following advantages in the diagnosis of facial soft tissues angiodysplasias over the other noninvasive method – US with color Doppler mapping: 1. MRI allows the examination of characteristics of facial soft tissues angiodysplasias more exactly and objectively; 2. MRI makes it possible to determine intra-cranial disorders and lesions of mandible and other facial bones, paranasal sinuses, etc. 3. MRI with MRA allows the specification of arterial or venous type of angiodysplasia blood flow with the determination of supply and flow-out vessels; 4. MRI with MRA makes it possible to examine the state of intra-cranial vessels and to define any intracranial angiodysplastic changes.

with color Doppler mapping (Fig. 9). MRI (Fig. 3) had accurately determined the volume of the intra-cranial part of angiodysplasia and the lesion’s extension into facial soft tissues and in cranial bony structures. MR-angiograms of lesion zone (Fig. 10) confirmed the presence of large arteriovenous fistulas with predominantly venous type of blood flow. MRarteriogram had shown (Fig. 11) that intra-cranial arteries (for example, left ophthalmic artery) are actively involved in blood supply of angiodysplasia. Patient L, 22 years old: examined by MRI because of pathological thoracic scoliosis with disorders of sensitivity and locomotor functions of the inferior part of the body. Spinal MRI (Fig. 12) had determined that vertebral and neurological disorders were produced by vertebral angiodysplasia with mainly arterial blood flow. 42

Research of patient’s history was undertaken after MRI examination and revealed that at 2 years old she had been surgically treated because of the exophytic capillary hemangioma (most likely an angiodysplasia!) of the soft tissues of the left cheek. This case illustrates a system characteristic of this lesion: angiodysplasia realized in different (and distant) anatomical areas. In our opinion this observation is rather a special case. This is confirmed by our results: in 5 patients (13% of all examinations), MRI with MRA had found 4 cases of intracranial arterial anomalies and 1 case of meningial venous malformation. Moreover, in our observations of 8 patients (about 19% of all examinations), MRI with MRA had also identified the following arterial abnormalities:

The US with color Doppler mapping essentially exceeds MRI with MRA in the determination of functional (hemodynamic) parameters of angiodysplasias. This makes this method irreplaceable in treatment planning and in the evaluation of treatment efficacy. Accordingly, the combination of imaging diagnostic methods is necessary for the exact, specific and adequate diagnosis of facial soft tissues angiodysplasias in children. The US with color Doppler mapping

PEDIATRIC IMAGING

and the MRI with MRA have to be at the top of the list of such methods. Moreover, our experience of examinations of patients with large and extensive facial angiodysplasias allows one to establish that facial angiodysplasias in 31% of cases (13 patients out of 38) were only the external manifestations of the segmental angiodysplasias. So, “wholebrain” (even “whole-body” – if it is possible) MRI with MRA is an expedient action in all cases of large and extensive facial angidysplasias in children when the “object” of examination is small.

children: angiography and dopplerographafy comparison.// Visualisation in clinic. – Russia-Moscow: Medicine. 1994. -_4. – p.26-29. – in Russian. [ 7 ] Nadtotchii A.G.,Dyakova S.V., Kulakov O.B., Elkonin A.B. Traditional usltrasonography and dopplerography in diagnosis of vascular neoplasm of mandible-facial region in children.// The Stomatology. – 1994. -_3. –p.73-77. – in Russian. [ 8 ] Nadtotchii A.G., Panov V.O., Ivanov A.V. Facial angiodysplasia in children: local manifestation of system vascular lesion?// In Abstracts of VII International Conference of Mandible-Facial surgeons and stomatologists. – Sanct-PeterburgRussia. - 2002. – p.107. – in Russian. [ 9 ] Edelman R.R., Hesselink J.R., Zlatkin M.B. Clinical Magnetic Resonance Imaging. - Philadelphia-USA: W.B.Saunders Company. – 1996. – p.2190.

Information about the Institution
Official name – The Scientific Center for Obstetrics, Gynecology and Perinatology of The Russian Academy of Medical Sciences. (Director V.I.Kulakov is a Member of the Academy of Medical Sciences). Internet site of the Center: www.pregnancy.ru Beds – 300 In-patient throughput – 12,700 per year (including 2,500 in obstetrics) and up to 40,000 outpatients per year – data are for the last year. The profile of The Center is revealed by its name. It covers obstetrics, gynecology and perinatology – all types of obstetric care. The Center is the leading institution in the Russian Federation (and ex-USSR countries) for solving problems relating to women’s genital functions, gynecological endocrinology (including complex treatment during climacteric and menopause), non-oncology surgical gynecology, child gynecology (including uro-genital system development anomalies and their surgical correction) and newborn pathology treatment. MR-patient throughput: one session from 9:00 till 15:00 allows the examination of 12 patients. Currently the work is organized in two sessions but in reality the maximum number of patients per day is 18 patients, including up to 3 pregnant patients with their fetuses. The Center is predominantly financed by the government via the Medical Academy of Medical Sciences, plus self-financing activities. 43

Literature
[ 1 ] Dan V.N. Diagnosis and surgery treatment of congenital angiodysplasias. // Thesis for a Medical Doctor’s degree. – Moscow-Russia. – 1989. - in Russian. [ 2 ] Diyakova S.V., Shafranov S.V., Nadtotchii A.G. et all. Diagnosis and treatment of large and extensive hemangiom children mandible-facial region.// Methodological recommendations. – Moscow–Russia: MSMSU. - 1996. – 11 p. - in Russian. [ 3 ] Kulakov O.B., Diyakova S.V., Kizyun L.Z., Nadtotchii A.G., Ivanov A.V. Tactics of treatment of vascular neoplasm of labrum and labium of children.// In Abstracts of the I Republican Conference “Stomatology and children health”. – Moscow-Russia. - 1996. - p.79. – in Russian. [ 4 ] Milovanov A.P. Pathomorphology of extremity angiodysplasias. – MoscowRussia: Medicine. - 1974. – in Russian. [ 5 ] Nadtotchii A.G. Ultrasonography examination at the stage of diagnosis and treatment of vascular neoplasm of face and neck of children.// IV Meeting of Russian Association of Physicians of Ultrasound diagnosis in perinatology and gynecoclogy. – Nijnii Novgorod-Russia. 1997. – in Russian. [ 6 ] Nadtotchii A.G., Dyakova S.V., Kulakov O.B., Shafranov V.V., Polyaev Yu.A., Konstatntinov K.V., Nikanorov A.Yu. Hemodynamic in vascular neoplasm of soft tissues face and neck of

[ 10 ] Kramer L.A., Crino J.P., Slopis J., Hankins L., Yeakley J. Capillary hemangioma of the neck: prenatal MR findings.// Am.J.Neuroradiol. – 1997. - Sep; 18(8). –p. 1432-1434. [ 11 ] Panov V., Ivanov A., Inaneishvily M., Nadtotchi A. Facial haemangiomas as external manifestation of the segmental angiodysplasia: MRI and MRA diagnosis advantages.// European Radiology. February 2002, vol.12, suppl.1, p.269 /B0719/ [ 12 ] Orvieto _., Zago S., Pollinzi V., Trasforini G. An unusual case of intramuscular hemangioma. // Pathologica. – 1997. - Apr; 89(2). –p.189-92. [ 13 ] Roebuck D.J., Ahuja A.T. Hemangioendothelioma of the parotid gland in infants: sonography and correlative MR imaging.// _m.J.Neuroradiol. – 2000. - Jan; 21(1). – p.219-23. [ 14 ] Robertson R.L., Robson C.D., Barnes P.D., Burrows P.E. Head and neck vascular anomalies of childhood.// Neuroimaging.Clin.N.Am. – 1999. - Feb; 9(1). -p.115-32. [ 15 ] Siemens MAGETOM Symphony Application Guide Numaris 3.5 VA11F, 2001 [ 16 ] Yang W.T., Ahuja A., Metreweli C. Sonographic features of head and neck hemangiomas and vascular malformations: review of 23 patients. // J.Ultrasound.Med. – 1997. -Jan; 16(1). –p.39-44.

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Fetal MR Imaging*
Stephen Sinnott M.D, Bridget Sutton M.D, Raymond Buckley.R.T (R ) (MR)

The Royal Brisbane, Women’s and Children’s Hospital is a shared campus offering diverse facilities. The Royal Brisbane consists of a 790-bed general, tertiary referral teaching hospital with a number of specialities including medicine, surgery, orthopedics, psychiatry, and oncology and trauma services. The Royal Women’s Hospital is a 192-bed tertiary, teaching health facility for obstetric, gynecological and neonatal intensive care patients. The Royal Children’s hospital is a 168-bed tertiary pediatric teaching hospital, with specialities including burns, liver transplant, oncology, pediatric surgery, rehabilitation, respiratory medicine and trauma services. The RBWH MRI unit comprises 2 Siemens 1.5 Tesla magnets. A MAGNETOM Vision Plus, and a MAGNETOM Sonata which is shared with the Centre of Magnetic Resonance, Brisbane, Univervisty of QLD.

CASE study
Fetal MRI Patient history. The mother is a 35 year old female. Single 29 week live fetus present. Normal amniocentesis. MRI referral from RWH ultrasound department.

Image Findings Ultrasound Findings : Isolated mild ventriculomegaly of the lateral ventricles. 3rd and 4th ventricles are normal. Cavum septum pellucidum normal. Cerebellum is normal. No other brain or spine abnormality seen. MRI confirmed the ultrasound findings of the fetal brain, of bilateral lateral ventriculomegaly. Gyral pattern was normal. No other significant abnormality. findings was confirmed. Patient was discharged from hospital after counseling. Short information about ultrasound imaging of the fetus : ■ Ultrasound is the primary imaging modality for pregnant women. ■ Allows real time imaging of the fetus. 2nd trimester, brain

Results and Discussion
* The safety of imaging of the fetuses and infants has not been established.

The finding of bilateral lateral ventriculomegaly without additional

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MRI Findings : MRI performed in 2nd trimester, same patient. ■ MRI is used for clarification purposes in cases where there may be doubt regarding continuation of pregnancy. ■ MRI fetal brain imaging demonstrates corpus callosum, pons, parenchymal structures, brain malformation and maturation. Also, growth retardation, base of the skull, cervical spine anatomy and placental abnormalities may be identified.

T2 cor.

T2 tra.

MRI Technique in RWBH
■ MRI sequences used are HASTE T2 non-fat sat in 3 orthogonal planes, sagittal, transverse, and coronal, plus a transverse FLASH T1 sequence. ■ HASTE sequence parameters; 3-4mm slice thickness, interleaved, distance factor 0, FOV 300mm, matrix 256 interpolated, ETL 218, echo spacing 7.34ms, TR 1100,TE 88, BW 195, flip angle 150, non fat sat. ■ Breath-hold during sequences if there is excessive abdomen movement. ■ CP Body Array coil used. ■ Flip angle reduced from 180 to 150 degrees to reduce SAR.

T2 sag.

T1 tra.

■ Siemens MAGNETOM Sonata.1.5T, 2002A software.

MRI Patient Preparation Ultrasound pitfalls :
■ Poor fetal visualization due to maternal habitus. ■ Poor fetal visualization due to reduced volume of amniotic fluid. ■ Multi-planar imaging difficult due to fetal position. ■ Subtle parenchymal abnormalities not always demonstrated. ■ Technical factors to view the side of the brain nearest to the transducer may be difficult. ■ Posterior Fossa may be difficult to image late in gestation. Short information about MRI of the Fetus ■ MRI can yield additional information and/or may be used to confirm the findings in ultrasound. This could ultimately change the patient counseling or management. ■ Patient position is oblique if in advanced pregnancy, to reduce compression effects of inferior vena cava of the mother. ■ No patient preparation or drug administration ■ No MRI contrast given for fetal imaging. ■ No known adverse effects to the fetus. 45

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MAGNETOM Trio Musculoskeletal MR Unlimited*

3.0T
MAGNETOM Trio is 3T Unlimited
3T MR systems are attracting great attention as new hardware and software become available for whole-body applications. In the area of musculoskeletal MR, the increased 3T Signal to Noise ratio enables increasing the resolution in the same acquisition time or reduce acquisition time. MAGNETOM Trio has been optimized at every level so that these advantages can be fully exploited in all applications. Maximal homogeneity, advanced coil technology, 8 RF channels in standard, iPAT applications and gradient speed are some of the many components that contribute to the quality of 3T MR on MAGNETOM Trio and that make it a solid investment for the future. 0.8 mm2 isotropic

1.5T

The benefits of MAGNETOM Trio in musculoskeletal MR: ■ 3T Signal-to-Noise for increased resolution or decreased acquisition time ■ Circularly Polarized extremity and wrist coils to maximize your SNR. Unmatched homogeneity for excellent fat saturation ■ 3D DESS sequences ■ syngo ergonomic user-interface

0.6 mm2 isotropic Increased Resolution at 3T with 3D DESS MAGNETOM Trio, CP extremity coil. The increased SNR at 3T enables the resolution to be increased without any apparent loss of SNR. (courtesy of B. Wietek, U. Tübingen, Germany). 3T enables isotropic resolution of 0.6 mm2 instead of 0.8 mm2 at 1.5T. Sequence 3D DESS.

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Wrist Coil*: Transmit / receive coil with integrated preamplifiers. No coil tuning. Used for high-resolution wrist imaging.

Increased Resolution in 3T extremity imaging Wrist: 3D water excitation, 1 mm slice thickness, 512 matrix, MAGNETOM Trio, CP wrist coil. Wrist imaging is particularly challenging as many bones and small tendons and ligaments need to be visualized. At 3T, high SNR enables the acquisition of small FoV, thin slices (1 or 2 mm) and high matrices (512) so that you can confidently make your diagnosis.

Faster acquisitions in knee imaging at 3T 2D TSE with fat sat, 2 mm slice thickness, 512 matrix in 2:06 min MAGNETOM Trio, CP extremity coil With the increased 3T SNR, protocols have been optimized so that you can perform acquisitions with the highest resolution (2 mm slice thickness) but also in the fastest way.

Fat saturation on MAGNETOM Trio 2D FLASH with off-center spectral fat saturation MAGNETOM Trio, Surface coil.

MAGNETOM Trio offers a homogeneity of 0.30 ppm on a 40 cm DSV. This enables the achievement of very good fat saturation spectrally or with the use of “water excitation”.

* Cartain OEM coils with the MAGNETOM Trio System require 510 (k) review and are not commercially available in the US.

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Product Info
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Magnetic Resonance Imaging of the Elbow
Bill J. Leon R.T. (R )(MR) From the Department of Diagnostic Radiology Magnetic Resonance Imaging Center Health South Doctors’ Hospital 5000 University Drive, Coral Gables, Fl 33146 These requirements result in demand of high signal to noise. Images are typically noisy or grainy if technical parameters are not chosen properly, such as: a) Selection of moderate to low bandwidth sequences. These sequences selectively filter out certain bandwidths of radio frequencies such as noise, thus increasing the overall signal to noise ratio. A trade off to this selection is chemical shift artifacts, which manifest themselves as misregistration of signal at fat/water interfaces in the readout direction [1]. Table 1 should aid in the selection of proper bandwidths [2]. b) Technologically advanced surface coils, such as Circular Polarized
BW (kHz) 16 10 8 BW (Hz/Px) 130 78 65 SNR 1.0 1.3 1.4

Anatomy and pathology of the elbow is rather unique. The numerous ligaments, tendons, musculo-tendinous structures and bone marrow to be evaluated within this small area each run in a different direction. Therefore, we must image the elbow in a different plane and pulse sequence for each of these structures. Clinical history from the referring physician or recognizing what pathology one is looking for is imperative so that the scans are obtained with the proper planes. Radiologists determine pathology of soft tissue anatomy such as ligaments, tendons or muscles with a variety of pulse sequences. Each
CS in Pixels 1.0T 1.13 1.88 2.26 CS in Pixels 1.5T 1.70 2.83 3.39

The elbow is a difficult joint to image because of its complexity and various anatomical variants. This article reviews the basic cross-sectional anatomy of the elbow joint, technical parameters, technical factors and indications of the elbow that most clinicians refer patients for an MRI scan. Imaging of the elbow must be done keeping in mind the normal anatomy, specific pathology requested, and the resolution and visualization of these anatomical structures with a variety of planes and pulse sequences. This combination should result in obtaining an accurate diagnosis for the patient. Magnetic Resonance Imaging of the elbow joint presents unique challenges: a) Anatomical structures are much smaller than other larger joints such as the knee or shoulder. Therefore, it demands high-resolution images, defined as: thin cuts (2-4mm), high matrices (256x256 or higher) and small Fields of View (10-14cms). This combination results in very small pixels. b) The most comfortable position for the patient is supine with the arms to the side. Imaging off-centered drives the MR system components, such as the gradients and the homogeneity of the magnetic field to its limits. c) Small joints require the use of dedicated surface coils. The closer the coil is to the joint and smaller the coil, the better the signal versus noise. 48

Table 1 Phase Array Coils or Circular Polarized Flexible Coils. With these devices the signal to noise is increased considerably. pulse sequence gives specific information on the anatomical structure: T1 weighted images, whether they are Spin Echo, Turbo Spin Echo (Fast Spin Echo), or Gradient Echo pulse sequences, have the characteristic of relatively good signal to noise. The images are usually pretty and one may obtain higher resolution images with this type of pulse sequence. T1 weighted images are known to have high sensitivity and low to poor specificity of pathology. This means that if the normal appearance of a tendon is of low signal intensity (black) and the tendon reveals intermediate signal (grey) on the T1 weighted image, the following pathology is possible: 1) Inflammation of the tendon (Tendinitis) 2) Partial tears (some fibers may

c) Advanced Pulse sequences such as Turbo Spin Echo (Fast Spin Echo), Turbo STIR (Short Tau Inversion Recovery), non-selective 3D gradient echo and low bandwidth pulse sequences. All these techniques improve the signal to noise while providing the same or similar contrast to noise and signal intensities of the different tissues evaluated.

The elbow, therefore, presents a technical challenge for technologists since all available resources should be employed to obtain the best quality scans in the shortest time possible.

MUSCULOSKELETAL

be torn, but not the entirety of the tendon) 3) Complete tear of the tendon. One must conclude that although the pathology with T1 weighted images is found, one cannot conclusively determine the specific process of the ailment. T2 weighted images, on the contrary, experience low signal-to-noise and are much noisier than T1 weighted images. Pathological processes behave differently in these types of images. T2 images are characteristic of having low sensitivity and good to high specificity. This means that if a normal tendon in T1 images is of low signal that normally as low signal (black) in T2 is seen as well. If a tendon is of intermediate signal in T1, then one can refer to T2 weighted images and observe the behavior of that tendon: 1) If it remains of low signal intensity in T2, although it was of intermediate signal (gray) in T1, the differential diagnosis includes tendinopathy (inflammation or strain) or tendon degeneration (possibly due to previous injury or chronic inflammation). 2) If the same tendon that experienced intermediate signal (gray) in T1 images, experiences high signal intensity (bright) with T2 weighted images, this most likely represents a tear of the tendon, partial or complete can be observed depending of the signal intensity of the tendon, whether it involves all or part of the tendon. Sensitivity and specificity of pulse sequences are critical for radiologists. They must make selection of planes and sequence types for each area of the body, and furthermore for each structure of that specific area. We cannot afford to keep a patient in the scanner for too long a period of time.

Wise and educated selection of planes and pulse sequences is the true art of knowing how to image a body part. Positioning The elbow joint may be localized 1/2 inch distal to midpoint of humeral epicondyles. Coil Small Circular Polarized Flexible Coil. Patient supine with the arm by the side, hand supinated

Structures in the elbow will be discussed according to the requirements of different protocols: a) Anatomy, b) Pathology, c) Protocols, technique and specific techniques for different pathologies

Anatomy
1) a) Ulnar Collateral Ligament (UCL). Also known as Medial Collateral Ligament. Most commonly injured in throwing athletes [3,4,5,6] such as baseball pitchers, catchers, swimmers, divers, tennis, Jai-Lai players. The UCL complex consists of anterior, posterior and oblique (i.e., the transverse ligament) bundles. It extends from the medial epicondyle of the humerus to the medial aspect of the coronoid process and the medial aspect or margin of the olecranon process. [7] b) The Radial Collateral Ligament is less commonly injured and its single band attaches from the lateral epicondyle of the humerus to the upper margin of the annular ligament. [7] An axial localizer or scout is necessary through the humeral epicondyles. Then oblique coronal images are obtained in alignment with the epicondyles [3]. Spin Echo T1, T2, Gradient Echo T2* or Turbo SpinEcho (Fast Spin-Echo) may be obtained to determine tears. 2) Osteochondral Defects (OCD) or fractures of the capitellum are the typical source of loose bodies. Identification of the fracture is difficult, however a combination of pulse sequences may prove invaluable. T1, T2 Spin Echo and 3D Gradient Echo, in particular a DESS sequence (Dual Echo in Steady State) with reconstructions in radial mode with its axis on the actual OCD on the capitellum, 49

Figure 1 Positioning with CP-Flex Small Coil, patient Supine, hand supinated

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with an in-plane resolution of less or equal to 1.5 mm thickness, is our method of choice to work up this diagnosis. An MRI scan is not sufficient to identify loose bodies. Plain films, spiral tomography or high resolution CT in combination with MR may be the choice of imaging modalities for small fragments.(3) 3) Biceps Tendon: The musculoskeletal junction of the biceps tendon is approximately 3-4 cms proximal to the elbow joint. The mid substance of the tendon is most commonly torn and retraction of this tendon is known to be found as proximal as the mid shaft of the humerus. Its distal insertion at the posterior aspect of the radial tuberosity is also a site for tears. Weight lifters are prone to these injuries. Evaluation of this structure is done in the sagittal and transverse (axial) projections with T1 and T2 Spin-Echo or Turbo Spin-Echo (Fast Spin-Echo) sequences. The set-up of slices is fairly easy. The axial slices are set-up utilizing the sagittal images. One medial and one lateral need to be chosen, demonstrating the musculoskeletal junction (medial) and the distal attachment (radial tuberosity) (lateral). Sagittals are set up utilizing axial images, they are done obliquely perpendicular to the alignment of the humeral epicondyles in order to include most of the mid substance of the tendon. 4) Triceps Tendon. Injuries to its attachment, at the olecranon process, is most often seen. However, direct trauma is the main cause of pathology. Imaging of the triceps tendon in full flexion is important in order to assess partial and complete tears compared to bursitis in the olecranon bursa. T1 and T2 Spin-Echo or Turbo Spin-Echo (Fast Spin-Echo) 50

in the sagittal and axial projections are necessary.

Pathology
1. Osteochondral defects (transchondral fractures), loose bodies, olecranon osteophytes. 2. Medial collateral ligament, radial collateral ligament complex, complete and partial tears. 3. Biceps, triceps. Tendinitis, partial and complete tears. 4. Median nerve compression.

Protocols
OCD, MCL, R/O PATHOLOGY 1. 3d gre coronal (T2*) 2. tse t2 coronal fatsat 3. tse pd sagittal 4. tse pd transverse BICEPS, TRICEPS TENDON 1. tse t2 coronal fatsat 2. tse pd sagittal 3. tse pd transverse 4. tse t2 transverse fatsat

Technique
Plane 2d gre cor 3d gre cor tse pd c/a/s tse T2 c/a/s fatsat se T1 cor 3D DESS sag Turbo stir cor se T1 c/s/a fs Sequence fl2d_22rb44.wkc fi3d_21rb33.wkc tse7_45b130.ykc tse7_45b130.ykc se_20b65.ykc de3d_9b130.xkc tirm7_29b130.ykc se_20b65.wkc TE 22 21 45 45 20 9 29 20 TR 748 48 4000 4000 500 27 3915 912 SL 17 26 45 45 15 64 15 16 Th/Gap 2/0.2 1.3/0 3/0 3/0 3/0.2 1.5/0 3/0.2 2/0.2 Mx 256x256 192x256 256x512 256x256 256x512 192x256 196x256 192x256 Acq 1 1 1 1 1 1 1 1 FOV 130 100 130 130 140 130 130 120 Time 6’25” 8’01” 5’09” 4’53” 4’19” 7’26” 3’44” 5’53”

MUSCULOSKELETAL

Specific techniques for different pathologies

Figure 2 UCL (Ulnar Collateral Ligament), Common Flexor and Extensor tendons

med epicondyle lat epicondyle

common flexors ucl

common extensors

common flexors ucl

common extensors

Setup of coronal slices

tse T2 cor fs

3D gre t2* cor

ucl tear ucl tear

se T2 cor

turbo stir cor

ucl avulsion

ucl avulsion

turbo stir cor

3D gre T2* cor

lateral epicondylitis medial epicondylitis

tse T2 fs cor

tse T2 fs cor 51

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Figure 3 OCD’s (Osteo-Chondral Defects), loose bodies

ocd

Set-up radial images dess

3D DESS original cor

loose body

ocd

3D DESS mpr axi

3D DESS mpr sag

3D DESS mpr sag

Biceps, triceps tendons tears

mid biceps distal biceps attachment

tse pd sag scout

tse pd sag scout

tse pd axi proximal

tse pd axi distal

mid biceps tear

distal biceps tear triceps tear triceps tear

tse T2 sag

tse T2 axi fs

tse T2 sag

tse T2 axi fs

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Bone Marrow (Contusions, fractures)

Bibliography
[ 1 ] Magnetom applications Guide. Artifacts and Remedies. 1992 by Siemens AG. page 22. [ 2 ] Magnetom applications Guide. Artifacts and Remedies. 1992 by Siemens AG. page 34.

FX’ FX

[ 3 ] Murphy BJ. MR Imaging of the Elbow. Radiology 1992, 184:525-529 [ 4 ] Schwab GH, Bennott JB, Woods GW, Tullos HS. Bio-Mechanics of Elbow instability: The role of the medial collateral ligament. Clin Orthop 1980;146:42052 [ 5 ] Jobe FW, Newber G. Throwing Injuries of the Elbow, Clin Sports Med 1986;5:621-635 [ 6 ] Indelicato PA, Jobe FW, Kerlan RK, et al. Correctable elbow lesions in professional baseball players: a review of 25 cases. AMJ Sports Med 1979;7:72-80 [ 7 ] Stoller DW. Mag Res Imaging in Orthopaedics Sports medicine 1993 page 634.

tse T2 fs cor

se T1 cor

In conclusion, technical requirements for small joints are challenging. To be able to examine small parts such as the elbow, technologists must look for the appropriate coils and make sure they order the necessary tools from the manufacturer. In addition to state of the art equipment, the knowledge of anatomy and the perception of imaging the patient according to the pathology are of utmost importance in order to assess a protocol that fits the patient’s ailment. It is guaranteed that the clinician will not refer you another patient if he/she cannot get a specific answer from the MR scan, and certainly these are not times in which we can afford to scan all pulse sequences and all planes. High resolution images with the proper alignment of the slices is the ultimate responsibility of the radiologist and the technologist.

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MR Enteroclysis: a New Diagnostic Approach for Small Bowel Imaging
Nickolas Papanikolaou, M.Sc. Biomedical Engineer, Department of Radiology, University Hospital of Iraklion University of Crete Medical School, Iraklion, Crete, Greece Nicholas C. Gourtsoyiannis, M.D. Professor & Chairman, Department of Radiology, University Hospital of Iraklion University of Crete Medical School, Iraklion, Crete, Greece be increased to result in clinically acceptable image quality. All these requirements can be fulfilled when using high-end MR scanners. High field strength magnets (1.5 Tesla) can provide intrinsically higher signal to noise ratio comparing to lower field strength systems. Short repetition and echo times which are of great importance in ultra fast imaging can be only achieved by using advanced gradient systems. Dedicated abdominal phased-array RF coils should be utilized to further increase the limited signal to noise ratio of the ultrafast pulse sequences. MRI examination protocols of the small bowel usually comprise T1- and T2-weighted sequences in axial and coronal planes. Both T1- and T2weighted sequences should be fast enough to allow comfortable breathhold acquisition times and reduce the motion related artifacts. For T1weighted images, most authors are using gradient echo sequences in 2D and 3D acquisition modes with or without fat saturation prepulses, while for T2-weighted images, TSE and HASTE sequences are commonly employed [1-7]. More recently, the TrueFISP sequence has been successfully applied in small bowel (SB) imaging [1], providing high resolution images of the bowel wall (Fig. 1) and additional information from the mesenteries. Fat suppressed TSE or STIR sequences have been also applied to assess the activity in Crohn’s disease [4]. A three-dimensional (3D) version of SGE sequences was recently introduced (3D FLASH) [5]. As opposed to 2D FLASH, 3D FLASH provides increased through-plane and in-plane spatial resolution by the acquisition of thin partitions (2 mm) and high matrices (512) (Fig. 2), respectively. Additionally they offer higher signal to noise ratio comparing to the 2D sequences. The acquisition time for

Introduction
With the advent of high performance gradient systems, image quality of already existing ultrafast pulse sequences i.e. HASTE, true FISP and FLASH improved substantially and clinical applications including small bowel imaging became feasible. Within this context, MR Enteroclysis was developed, as a comprehensive examination of the small bowel, providing luminal, transmural and exoenteric diagnostic information of small bowel diseases. Clinical applications of MR Enteroclysis include diagnostic evaluation and follow up of patients with inflammatory or neoplastic diseases and small bowel obstruction.

Figure 1 Coronal TrueFISP section demonstrating small bowel at its entire length. The use of an isoosmotic water solution as an intraluminal contrast agent resulted in homogeneous opacification of the bowel lumen. Note the increased conspicuity of the normal bowel wall due to the high resolution capabilities and total absence of motion.

Pulse Sequences
Ultrafast pulse sequences should be employed to reduce motion related artifacts arising from physiological motion (respiration and peristalsis) in the abdominal area. The spatial resolution of these sequences should be high enough to permit demonstration of small lesions i.e. ulcers, commonly present in small bowel diseases. Inherent poor signal to noise ratio of these sequences has to 54

Figure 2 Coronal 3D FLASH image with fat saturation acquired 75 seconds after intravenous injection of gadolinium. Increased gadolinium uptake is evident on descending colon corresponding to inflammatory processes due to Crohn’s disease. Normal bowel wall exhibits moderate signal intensity when active inflammation is present.

GASTROINTESTINAL IMAGING

Figure 3 Coronal HASTE image acquired after antiperistaltic drug administration, demontrates equally well as the TrueFISP sequence the anatomy of the small bowel by the high contrast resulted from the low signal intensity intestinal wall and high signal intensity intraluminal contrast agent. a

covering the whole small bowel is 22-25 seconds and it can be further reduced by employing slice interpolation techniques (VIBE sequence) which recently became attractive in abdominal imaging. When combined with positive intraluminal contrast agents they may be used as source images for virtual endoscopic views generation. The major disadvantage of the 3D FLASH sequence is the increased sensitivity to motion artifacts that may cause blurring of the intestinal wall; administration of antiperistaltic drugs can overcome this drawback. The single shot variant of TSE sequence with half fourier technique, the so called HASTE sequence, generates heavily T2 weighted images maintaining signals from solid tissues although with lower resolution. The acquisition time is less than 1 second per slice resulting in minimal respiratory related artifacts. Normal intestinal wall exhibits low signal intensity (Fig. 3), while inflammatory or neoplastic lesions are presented with high signal intensity. The long echo train used in HASTE sequence makes it insensitive to susceptibility artifacts which may appear in gradient echo sequences due to intraluminal air presence. Additionally, it is not sensitive to chemical shift artifacts thus it can be used for accurate quantification of intestinal wall thickness (Fig. 4). Adequate reduction of the endoluminal signal intensity, provided by the use of a negative contrast agent, results in depiction of bowel wall abnormalities with high conspicuity. In case of positive endoluminal contrast agents, HASTE sequence is sensitive to intraluminal flow voids related to intraluminal motion (Fig. 5). This problem may be reduced when acquiring HASTE images after spasmolytic drug administration. Another limitation of HASTE sequence is the poor demon-

stration of the mesenteries due to k-space filtering effects. Tissues with short T2 relaxation constant, such as lymph nodes and fibrous tissue, are missing the high order spatial frequencies due to the special way that the k-space is filled in HASTE sequence resulting in a blurring effect in these tissues (Fig. 6). TrueFISP sequence was introduced for MR examination of the small bowel after duodenal intubation [1]. The contrast in TrueFISP images is somewhat more complex and invoke both T1 and T2 contributions in the form of the T2/T1 ratio. The higher this ratio is the brighter the tissue will be, thus bowel wall exhibit intermediate to low signal intensity (T2/T1 ~ 0.2 at 1.5T) while fluids presented with high signal intensity (T2/T1~ 0.9 at 1.5T). Motion related artifacts are minimal on TrueFISP images due to short acquisition time [8,9] (Fig. 7). TrueFISP sequence is capable of demonstrating the mesenteries due to high contrast resolution between the bright peritoneal fat and the dark vessels and lymph nodes (Fig. 6) [1]. One important difference between TrueFISP and HASTE sequences is the insensitivity of the former to intraluminal flow voids, due to the balanced and symmetric gradient design in the TrueFISP sequence (Fig. 5). Consequently, the use of antiperistaltic drugs can be avoided giving a major advantage to TrueFISP over the other sequences previously used requiring pharmaceutical reduction of bowel motion [2,3,7]. The major difference between TrueFISP and the other steady state sequences is that rephasing gradients are applied in all three directions, thus making the sequence velocity compensated in all three directions [8,9]. Therefore steady state coherence can be maintained even in the presence of non-accelerated (1st order) motion. Additionally, the TrueFISP sequence can be used 55

b

Figure 4 HASTE (a) and TrueFISP (b) images acquired from a patient with Crohn’s disease located on the sigmoid colon. Wall thickening measurements can be performed accurately in HASTE images due to insensitivity to chemical shift artifacts. TrueFISP image demonstrate the involved sigmoid colon with higher conspicuity while the chemical shift artifact is seen as a black thin line at the boundaries of the intestinal wall and the mesenteric fat. Thickened wall on TrueFISP images exhibits moderate signal intensity thus it is easy to differentiate it from the underlying chemical shift artifact.

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for studying vascular abnormalities related to small bowel diseases due to its velocity compensation capability. Fast flow in the major mesenteric vessels renders high signal intensity. On the contrary the distal small mesenteric branches appear with low signal intensity, probably due to saturation effects. When utilizing water solutions as intraluminal contrast agents, the high T2/T1 ratio results in high endoluminal signal intensity that remains relatively constant throughout the entire small bowel lumen, when administered via a nasojejunal catheter [1]. Single shot TSE (SSTSE) sequence, was initially introduced [10] to visualize the pancreatobiliary tree, providing heavily T2 weighted images. Within the context of MR enteroclysis it is extremely helpful for monitoring the infusion process and assessing the degree of distention of bowel lumen [1]; in addition it provides functional information [2]. With the advent of gradient systems, the acquisition of high resolution SSTSE projectional images become feasible (Fig. 8).

a

b

Figure 5 Coronal HASTE (a) and TrueFISP (b) images acquired without any antiperistaltic drug administration on a patient with normal small bowel. Intraluminal motion, demonstrated as flow voids, can be seen on HASTE images resulting in poor luminal homogeneity. On the contrary, TrueFISP images are rather insensitive to this kind of motion due to the flow compensated gradient scheme in all three directions intrinsic to that sequence. a b

MR Comprehensive Examination Protocol of the Small Intestine
A state of the art MRI examination of the small intestine should comprise: adequate bowel distention, homogeneous lumen opacification, increased conspicuity of the bowel wall, demonstration of the mesenteries, information about bowel motility, ability to obtain dynamic post contrast images, high contrast resolution and sufficient spatial resolution to evaluate subtle mucosal lesions, images free from artifacts – especially motion artifacts – and rapid acquisition times. All these virtues can be integrated in a comprehensive MRE 56

Figure 6 Coronal HASTE (a) and TrueFISP (b) images in a patient with Crohn’s disease located at the distal ileum. Wall thickening and mesenteric changes i.e. increased vascularity (“comb” sign) and mesenteric lymph nodes presence, are signifacantly more conspicious on TrueFISP images while HASTE sequence suffers from short T2 k-space filtering effects.

GASTROINTESTINAL IMAGING

a

b

Figure 7 Coronal TrueFISP (a) and post gadolinium 3D FLASH (b) images demonstrating normal jejunal loops in a patient with poor breath-holding performance. Note the superior image quality of the TrueFISP which as a sequentially technique is freezing motion while the 3D FLASH sequence suffers from blurring related to respiratory motion.

examination protocol including small bowel intubation, administration of a biphasic contrast agent, i.e. an isoosmotic water solution (PEG), heavily T2 weighted single shot Turbo Spin Echo (SSTSE) images for MR fluoroscopy and for monitoring the infusion process, T2 weighted imaging employing HASTE and TrueFISP sequences and dynamic T1 weighted imaging using a post-gadolinium 3D FLASH sequence with fat suppression. This protocol can provide anatomic demonstration of the normal intestinal wall (TrueFISP, HASTE, 3D FLASH), identification of wall thickening or tumorous lesions (TrueFISP, HASTE, 3D FLASH), lesion characterization or evaluation of disease activity (3D FLASH, TrueFISP), assessment of exoenteric/mesenteric disease extension (TrueFISP, 3D FLASH) and information concerning intestinal motility (SSTSE).

Clinical Applications Crohn’s Disease
MR Enteroclysis can disclose a variety of lesions commonly found in patients with Crohn’s disease. These lesions can be classified according to their location as superficial, mural and extramural. Subtle mucosal abnormalities such as nodularity or superficial ulcerations may be depicted by MR Enteroclysis, although to a lesser extent comparing to conventional enteroclysis, due to the lower spatial resolution of MR Enteroclysis. Dedicated ultrafast, high resolution sequences and stronger gradients will be needed to increase the detection rate of these subtle, early, but not specific, manifestations of the disease. Using TrueFISP images, MR Enteroclysis can demonstrate the characteristic discrete ulceration of Crohn’s disease; deep linear ulcers appear as

thin lines of high signal intensity, longitudinally or transversely (fissure ulcers) oriented within the thickened bowel wall (Fig. 9). Cobble-stoning pattern can also be appreciated on MR Enteroclysis images, as patchy areas of high signal intensity, sharply demarcated, along affected small bowel segments (Fig. 10). TrueFISP images are superior to HASTE in demonstrating linear ulcers or cobblestoning and intramural tracts, while 3D FLASH images are less sensitive. Wall thickening is clearly shown by all MR Enteroclysis sequences (Fig. 11) provided that the small intestinal lumen is adequately distended; otherwise MR Enteroclysis may result in false positive or negative results. The thickened wall in the absence of extensive edema has low to moderate signal intensity on TrueFISP and HASTE images. The thickness of bowel wall and the length of the involved small bowel segment can be accurately measured on MR Enetroclysis images. Luminal narrowing and associated prestenotic small bowel dilatation are easily recognized within all sequences. MR Enteroclysis was in full agreement with conventional enteroclysis in detecting, localizing, estimating the length of all involved small bowel segments and in assessing thickening of bowel wall, luminal narrowing or high grade stenosis in one series [11] (Fig. 12). MR Enteroclysis has a clear advantage over conventional enteroclysis in the demonstration of exoenteric manifestations or complications of Crohn’s disease [11]. The extent of fibrofatty proliferation and its fatty or fibrotic composition can be assessed on TrueFISP images, while it can be only suspected on conventional enteroclysis. Fibrofatty proliferation may present space-occupying lesion characteristics, separating and/or displacing small bowel loops (Fig. 13). 57

Figure 8 Projectional SSTSE coronal view resembling that of conventional enteroclysis. Increased acqusition matrix (512) and short scan time (3.7 seconds) in combination with increased signal to noise ratio arising from the iso-osmotic water solution used as intraluminal contrast agent result in excellent image quality. Intestinal folds can be depicted consistently with high conspicuity.

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The involved mesentery may contain small lymph nodes, mostly less than 8 mm in diameter, easily detected by their low signal intensity against the bright mesenteric fat, on TrueFISP images. Such lymph nodes are not clearly demonstrated on HASTE images, due to k-space filtering effects or on 3D FLASH images, due to saturation of mesenteric fat signal. Gadolinium uptake on 3D FLASH images allows identification of small inflammatory nodes (Fig. 14) which might serve as a marker for recording disease activity. Sinus tracts and fistulas are demonstrated by the high signal intensity of their fluid content on TrueFISP and HASTE images, but they may be overlooked on the 3D FLASH images, due to limited contrast resolution with surrounding tissues. Abscesses can be recognized by their fluid content and post-contrast wall enhancement. There are strong indications that disease activity can be assessed with MR Enteroclysis technique [4,12] and this may represent one of the most important indications of the examination in the near future. The so called “comb sign” corresponding to increased mesenteric vascularity, can be ideally seen on TrueFISP images (Fig. 6), close to the mesenteric border of a small bowel segment in the form of short, parallel, low signal intensity linear structures perpendicular to small bowel loop long axis [11]. The “comb sign” can be demonstrated on 3D FLASH images as high signal intensity linear structures due to vascular enhancement. Small bowel wall contrast uptake is considered the most important indicator of disease activity [4,12] and it can be appreciated on T1 weighted 3D FLASH images. Wall thickening, significant enhancement of the mucosa and relatively hypointense submucosal edema have been reported as common findings on post 58

Figure 9 Coronal TrueFISP spot view of the ileum in a patient with active Crohn’s disease (CDAI = 266). Fissure ulcer and modarate wall thickening can be depicted on the antimesenteric wall of the involved loop.

Figure 10 Coronal TrueFISP image in a patient with long standing Crohn’s disease. The patient were examined due to disease recurrence presenting with abdominal pain, diarrhia and fever. Cobblestoning appearance of the mucosa is shown while small superficial ulcers in another affected loop can be depicted as well.

Figure 11 Limited wall thickening demonstrated in all three MR Enteroclysis sequences. TrueFISP (left) and HASTE (center) images are depicting minor wall thickening as low signal intensity against the bright lumen while on post-gadolinium 3D FLASH image (right) the degree of contrast uptake can be appreciated.

Figure 12 Patient with Crohn’s disease presenting with ileous. A fibrotic stenotic lesion can be depicted both in the post-contrast 3d FLASH (left) and TrueFISP (right) images which was confirmed with surgery. Prestenotic dilatation is demonstrated equally well on both images.

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Figure 13 Cross-sectional and projectional evaluation of a patient with Crohn’s disease. On the left side, a TrueFISP thin section is demonstrating wall thickening of the terminal ileum while on the right side fibrofatty proliferation and separation of the adjecent bowel loops can be better appreciated on the SSTSE image.

gadolinium FLASH images in active Crohn’s disease [4] (Fig. 14). The severity of disease process can be ranked using measurements of wall thickening, the length of the involved segment and gadolinium uptake in comparison to renal cortex enhancement. It may be argued that measurements of bowel wall might be influenced by the degree of luminal distention in normal bowel loops or in inflamed but distensible involved segments, where extensive fibrosis is lacking. Consequently, determination of a reproducible threshold for bowel wall thickening measurements corresponding to active disease may require optimal luminal distention that could be achieved either by intubation or by any appropriate oral contrast agents that might be developed in the future. Active disease in small bowel segments may also be manifested by high signal intensity of intestinal wall on T2 weighted images [4] due to the long T2 relaxation time of edema. Fat suppressed T2 weighted images may be more sensitive in demonstrating submucosal edema due to scaling effects that are responsible for gray-scale rearrangement during the image reconstruction process.

enhancement patterns post gadolinium administration [13]. High contrast between the tumor and surrounding high signal intensity fat enables MRI to demonstrate the local extention of the lesions [13]. Small bowel leiomyoma, leiomyosarcoma, adenocarcinoma, carcinoid tumor and lymphoma present postcontrast enhancement that is better appreciated on fat-suppressed T1weighted 3D FLASH images. Intense enhancement can be seen with carcinoid tumor, leiomyoma and leiomyosarcoma. Lipomatous tumors and tumor hemorrhage can be detected on nonenhanced, non-fat suppressed 3D FLASH images which should be acquired in addition to the MR Enteroclysis comprehensive imaging protocol. Small bowel loops distortion or neoplastic invasion is depicted by all MR Enteroclysis sequences, while associated lymphadenopathy, is well demonstrated on TrueFISP and 3D FLASH images.

Small Bowel Obstruction
MR Enteroclysis can provide anatomic and functional information identical to that provided by conventional enteroclysis in cases of small bowel obstruction [9]. In addition, extraluminal causes may be better illustrated using MR Enteroclysis. MR fluoroscopy, utilizing a dynamic projectional SSTSE sequences, is extremely helpful in diagnosing low grade stenosis and in determining the level of obstruction. TrueFISP and post gadolinium enhanced 3D FLASH images can disclose the level and the cause of obstruction. In a recent study of 27 patients with post surgical adhesions, cine MR imaging using the TrueFISP technique resulted in a sensitivity of 87.5% and a specificity of 92.5% [14]. 59

Neoplastic Bowel Disease
MR Enteroclysis incorporates the advantages of cross-sectional MRI with those of conventional enteroclysis, which is highly sensitive in the detection of small bowel tumors. High signal intensity of the intraluminal fluid and mesenteric fat on TrueFISP images, allows for the demonstration of tumors exhibiting intermediate signal intensity. Small bowel neoplasms are mildly hypointense to isointense in comparison with the intestinal wall on precontrast non-fat suppressed T1 weighted FLASH images and present various

Figure 14 Patient with active Crohn’s disease. Post gadolinium 3D FLASH image demonstrates contrast uptake by small and medium size mesenteric lymph nodes while the characteristic ‘target’ sign can be found on a nearby involved ileal loop. Note that the mucosa exhibits similar signal intensity to the vessels due to increased gadolinium uptake.

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Others
The role of MRI in small bowel ischemia has not been established, yet. Limited reported experience indicates that bowel wall changes, vascular engorgement and mesenteric edema can be appreciated on MRI [15]. Superior mesenteric artery blood flow changes in chronic mesenteric ischemia can also be studied with phase-contrast cine-MRI [16]. In addition, there are indications that gastrointestinal bleeding can be diagnosed by dynamic post contrast enhanced 3D MR Angiography, using a blood pool agent on animal studies [17].

Combination of CP Body Array Flex, CP Body Array Extender and CP Spine Array with IPA ■ Ideal for MR Colonography, MR Enteroclysis and combination of upper abdomen and pelvic examinations. ■ No patient repositioning ■ Uniform signal intensity allows for optimal soft tissue contrast ■ CP Body Array and CP Body Array Extender, each with 4 coil design with 4 integrated preamplifiers

negative oral contrast media in combination with enteroclysis. Eur Radiol 2000;10(9);1377-82. [ 7 ] Holzknecht N, Helmberger T, v. Ritter C, Gauger J, Faber S, Reiser M. Breathhold MRI of the small bowel in Crohn’s disease after enteroclysis with oral magnetic particles. Radiologe 1998;38: 29-36. [ 8 ] Haacke M, Tkach J. Fast MR Imaging: Techniques and Clinical Applications. AJR 1990;155:951-964. [ 9 ] Oppelt A, Graumann R, Barfuss H, Fischer H, Hertl W, Schajor W. A new fast MRI sequence. Electromed 1986;3:15-18. [ 10 ] Laubenberger J, Buchert M, Schneider B, Blum U, Hennig J, Langer M. Breath-hold projection magnetic resonancecholangio-pancreaticography (MRCP): a new method for the examination of the bile and pancreatic ducts. Magn Reson Med 1995;33(1):18-23. [ 11 ] Prassopoulos P, Papanikolaou N, Grammatikakis J, Roussomoustakaki M, Maris T, Gourtsoyiannis N. MR Enteroclysis imaging findings in Crohn’s disease. Radiographics 2001; 21:S161-72. [ 12 ] Schunk K, Kern A, Oberholzer K, Kalden P, Mayer I, Orth T, Wanitschke R. Hydro-MRI in Crohn’s Disease. Appraisal of disease activity. Invest Radiol 2000;35:431-437. [ 13 ] Semelka RC, John G, Kelekis N, Burdeny DA, Ascher SM. Small bowel neoplastic disease: demonstration by MRI. JMRI 1996;6:855-860. [ 14 ] Lienemann A, Sprenger D, Steitz HO, Korell M, Reiser M. Detection and Mapping of intraabdominal adhesions by using functional cine MR imaging: preliminary results. Radiology 2000;217:421-425. [ 15 ] Ha HK, Lee EH, Lim CH, Shin YM, Jeong YK, Yoon KH, Lee MG, Min Y, Auh YH. Application of MRI for small intestinal diseases. JMRI 1998;8:375-383. [ 16 ] Li KCP, Whitney WS, McDonnell CH, et al. Chronic mesenteric ischemia: evaluation with phase-contrast cine MR imaging. Radiology 1994;190:175-179. [ 17 ] Hilfiker PR, Weishaupt D, Kacl GM, Hetzer FH, Griff MD, Ruehm SG, Debatin JF. Comparison of three dimensional magnetic resonance imaging in conjunction with a blood pool contrast agent and nuclear scintigraphy for the detection of experimentally induced gastrointestinal bleeding. Gut. 1999 Oct;45(4):581-7.

References Conclusions
MR imaging has a potential to change how we evaluate the small intestine, because of its superb soft tissue contrast and functional information it can provide, its direct multiplanar capabilities and the lack of radiation exposure. Adequate bowel distention, homogeneous lumen opacification, fast sequences with breath-hold acquisition times, both T1- and T2-weighted imaging and contrast enhancement are cornerstones for an optimal MRI examination of the small bowel. A comprehensive MR Enteroclysis imaging protocol should comprise SSTSE, TrueFISP, HASTE and fat suppressed 3D FLASH sequences. SSTSE is utilized for monitoring the infusion process and performing MR fluoroscopy while TrueFISP and HASTE are mainly used for anatomic demonstration and detection of the pathology. 3D FLASH sequences after intravenous gadolinium injection may aid tissue characterization. Inflammatory or neoplastic diseases, including intestinal wall abnormalities, exoenteric disease manifestations and complications, disease activity and to a lesser extent, mucosal abnormalities can be appreciated on MRE. 60
[ 1 ] Gourtsoyiannis N, Papanikolaou N, Grammatikakis J, Maris T, Prassopoulos P. Magnetic Resonance Imaging of the small bowel using a True-FISP sequence after enteroclysis with water solution. Invest Radiol 2000;35(12):707-711. [ 2 ] Umschaden HW, Szolar D, Gasser J, Umschaden M, Haselbach H. SmallBowel Disease: Comparison of MR Enteroclysis Images with Conventional Enteroclysis and Surgical Findings. Radiology 2000;215:717-7125. [ 3 ] Schunk K, Metzmann U, Kersjes W, Schadmann-Fischer S, Kreitner KF, Duchmann R, Protzer U, Wanitschke R, Thelen M. Serial observation in Crohn´s disease: Can hydro-MRI replace followthrough examinations? Fortschr Röntgenstr 1997;166: 389396. [ 4 ] Maccioni F, Viscido A, Broglia L, Marrollo M, Masciangelo R, Caprilli R, Rossi P. Evaluation of Crohn’s disease activity with magnetic resonance imaging. Abdom Imaging 2000; 25:219-228. [ 5 ] Gourtsoyiannis N, Papanikolaou N, Grammatikakis J, Maris T, Prassopoulos P. MR Enteroclysis protocol optimization: Comparison between 3d FLASH with fat saturation after intravenous gadolinium injection and true FISP sequences. Eur Radiol 2001;11(6):908-13. [ 6 ] Reiber A, Aschoff A, Nussle K, Wruk D, Tomczak R, Reinshagen M, Adler G, Brambs HJ. MRI in the diagnosis of small bowel disease: use of positive and

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MAGNETOM Trio Body MR Unlimited*
MAGNETOM Trio is 3T Unlimited
3T MR systems are attracting great attention as new hardware and software become available for whole-body applications. New coil designs, combined with iPAT technology and excellent shimming procedures, open the door for fast, excellent image quality body MR at 3T. MAGNETOM Trio has been optimized at every level so that these advantages can be fully exploited in all applications. Maximal homogeneity, advanced coil technology, 8 RF channels in standard, iPAT applications and gradient speed are some of the many components that contribute to the quality of 3T MR on MAGNETOM Trio and this makes it a solid investment for the future. The benefits of MAGNETOM Trio in Body MR: ■ Best homogeneity of 0.30 ppm on 40 cm FoV, including in the z-direction for best coronal abdominal and spine images ■ Advanced RF system with 8 independent channels in standard supporting the 8-channel body array, 12-channel spine array, 8-channel cardiac array, …. ■ iPAT is standard for fast acquisitions

Figure 1 Very fast MR spectroscopy of the prostate Works in Progress, 1 cm3, 39 s acquisition time! MAGNETOM Trio, WIP endorectal coil (MedRad Inc.) The increased SNR at 3T enables very fast acquisitions. The increased chemical shift at 3T shows as a nice separation of the metabolite peaks in the spectrum. (courtesy of Pr Herschapp, Barentsz, Fütterer, Klomp, Scheenen, Nijemgen, the Netherlands).

Spine imaging at 3T 12 coil design with 12 integrated preamplifiers (6 CP pairs). Smoothly integrated into the patient table. No coil tuning. Used for high resolution imaging of the whole spine.

2D FLASH with off-center spectral fat saturation MAGNETOM Trio, 12-channel spine array C-spine: FLASH, TR/TE 500/ 11 ms, 3 mm slice thickness.

Without iPAT, TA: 27 s With iPAT x2, TA: 15 s

Large FoV fast acquisitions in abdominal imaging 2D FLASH fat sat, 40 cm FoV, with and without iPAT MAGNETOM Trio, 8-channel torso array Excellent homogeneity, including in the z-direction, guarantees an excellent fat saturation even in coronal abdominal imaging. In addition, the flexible standard iPAT feature on MAGNETOM Trio enables acquisition times to be accelerated.

T- and L- spine: TrueFISP, 512 matrix, 3mm slice thickness

Body Array Coil: 8 coil design with 8 integrated preamplifiers. No coil tuning necessary. Coverage in z-direction 30 cm. Optimized for high resolution imaging of thorax, abdomen and pelvis.

* Cartain OEM coils with the MAGNETOM Trio System require 510 (k) review and are not commercially available in the US.

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All You Want to Know About “HASTE”
David Purdy, Ph.D. US R&D Collaborations, Malvern, PA 180º pulses 90º pulse

The syngo MR HASTE sequence allows the user to make a smooth transition between the traditional HASTE sequence and the single shot RARE technique. This article illustrates how the user controls this transition. HASTE ( Half-Fourier Acquired Singleshot Turbo Spin-Echo) is a “singleshot” technique, that is, the slice is excited by a single 90° pulse, followed by a large number of 180° pulses that form multiple echoes [1]. Each echo has a different phase encoding gradient strength, so all of the information for a slice is collected in a single echo train (Fig. 1). Unfortunately, the MR signal decays a little between each echo (T2 decay), so the raw data from the later echoes does not have the desired intensity. This is very similar to the effect of the raw data filters that you can apply to your protocols. The result is image blur. To minimize the blur, it is best to collect all of the echoes as quickly as possible using the shortest possible echo spacing. Since low amplitude gradients can be ramped up and down more rapidly than high amplitude gradients, the syngo MR sequence is optimized to reduce the echo spacing when lower gradients are used for thicker slices or lower resolution (which includes larger readout FoVs at the same base matrix size). The echo spacing is also reduced as the performance of the gradients increases (Turbo to Ultra to Quantum). The Sequence tab card shows this echo spacing. 62

signal echoes

Figure 1 Pulse and echo timing for HASTE. For clarity, only the first 15 echoes are shown. A different phase encoding gradient amplitude is used for each echo. This is applied before each echo, and reversed after each echo.

Although each raw data line has a different echo time (TE), the brightest lines will dominate the image contrast, and the brightest line occurs when the phase encoding gradient is zero. It is reasonable to define the effective TE as the time between the 90° pulse and the echo corresponding to the “zero” phase encoding step. By changing the starting point of the phase encoding steps, we can change the effective TE of the HASTE sequence. The purpose of the original HASTE sequence was to obtain a very fast image with the shortest possible TE. Therefore, the sequence began by using the initial echoes for the lowest phase encoding gradient amplitudes, and acquired the higher amplitude gradient steps with later echoes. The “half-Fourier” technique is an efficient way to do this.

We normally consider that an image with 256x256 resolution requires 256 phase encoding steps. However, if all of the spins in the slice are perfectly in phase, we only need 129 steps (the “zero” amplitude, and 128 increasing steps). In practice, the spins are not perfectly in phase, and some phase correction is needed. This is provided by acquiring a few extra lines of data on the other side of the “zero” line. This allows us to reconstruct a low resolution image, and thus obtain the image phases. In practice, we need about seven extra lines of data, so the relative phase encoding amplitudes for the low resolution image are –7, –6, –5, –4, –3, –2, –1, 0, +1, +2, +3, +4, +5, +6, and +7. The Margosian algorithm [2] can then be used for reconstruction of the high resolution image. The user interface shows that the “Phase partial Fourier 4/8” reconstruction is used.

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For the shortest TE of the HASTE sequence, the relative gradient amplitudes for the echoes run from –7 through zero to +128. Thus, the eighth echo has no phase encoding, and the effective TE is eight times the echo spacing. Example: For the Turbo gradients in “normal” mode, a 340 mm FOV, a bandwidth of 391 Hz/pixel, a 40 mm slice thickness, a 256 base matrix, 100% phase resolution, and “normal” RF, the echo spacing is 6.24 ms, so the effective TE is 50 ms (Fig. 2). The complete echo train consists of (7 + 129), or 136 echoes, so the last echo occurs 849 ms after the 90° RF pulse. Because a little extra time is needed for the first half of the first RF pulse, the second half of the last echo, and a little housekeeping, the whole image acquisition takes 856 ms (the minimum TR). If you increase TR, the system just adds a little wait time after the image is acquired.

7 lines the “zero” Line

128 lines

TE

Figure 2 Simplified timing diagram for the original HASTE sequence. Each block represents multiple 180° RF pulses and the resulting echoes. The “zero” line is the echo that is not phase encoded, also called the central line of k-space. Phase oversampling is turned off. TE is eight times the echo spacing, and the acquisition window is 136 times the echo spacing.

Longer TE
Suppose you want a longer TE? In theory, you could greatly increase the echo spacing to make the eighth echo occur later, but this would dramatically lengthen the duration of the echo train, and there would be little signal in the late echoes. A better solution is to collect more than seven negative phase encoding lines. Figure 3 shows an example with phase encoding steps –64 to –1, followed by the ‘zero’ line, followed by steps +1 to +128. In this example, the “zero” phase encoding line occurs in echo 64, so the effective TE is 64 x 6.24 = 399 ms. For this you only need to change TE in the user interface. As you click the “up arrow” to increase TE, you can see TE jump in units of the echo spacing. With each click, another echo and phase encoding line is added to the left side of the left box in Figure 3.

63 lines

128 lines

TE

Figure 3 Shows an example with phase-encoding steps -63 to -1, followed by the “zero” line, followed by steps +1 to +128.

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In theory, we could use the Margosian algorithm to reconstruct just lines –7 to +128, which would limit the acquisition window (and T2 decay) to 849 ms. In practice, the “phase partial Fourier 6/8” algorithm is used to reconstruct all 192 data lines to improve the SNR; the acquisition window is increased to 192x6.24 = 1198 ms.

127 lines

128 lines

TE

Single-Shot Turbo Spin Echo (RARE)
Suppose you want an even longer TE? By setting TE to the maximum value in the user interface, we can acquire a full 127 negative phase encoding steps before the “zero” line (Fig. 4). The effective TE is then 128x6.24 = 799 ms, and the acquisition window is a little more than 256x6.24 = 1597 ms. Since this is a full matrix of data, the user interface shows that Phase partial Fourier reconstruction is “off”, and the SNR is improved with respect to HASTE . There is significant T2 decay of the signal during this long acquisition. This full-matrix sequence can be called “Single-shot Turbo Spin Echo” or RARE (Rapid Acquisition with RElaxation) [3]. Even longer TEs are possible by adding additional echoes between the 90° RF pulse and the “zero” line. This occurs as a byproduct of phase oversampling (see below). All of the examples above assume a square FOV and 256x256 square pixels. The echo spacing and TE values will vary significantly with the protocol parameters. Figure 4 Setting TE to the maximum gives a single-shot turbo spin echo sequence, here with 256 echoes and 256 phase encoding steps. TE is 128 times the echo spacing, and the acquisition window is 256 times the echo spacing.

95 lines

96 lines

TE

Figure 5 Single-shot turbo spin echo with maximum TE and 192 echoes and 192 phase encoding steps. TE is 96 times the echo spacing, and the acquisition window is 192 times the echo spacing.

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TECHNOLOGY CORNER

Echo Spacing
In general, we want to keep the time between echoes short. As noted above, the sequence can run faster with lower gradients. This means that the “echo spacing” will decrease with lower resolution and thicker slices. Larger readout fields of view will also reduce the echo spacing, because this reduces resolution. Making the FoV rectangular by changing the “FoV phase” percentage does not affect resolution, and will not change the echo spacing. For the example above, the “Whisper Gradients” add 0.3 ms to the echo spacing. The Fast RF option reduces the echo spacing by 0.2 ms, while the Optimized RF adds 0.3 ms. The higher the performance of the gradient amplifier, the shorter the echo spacing. All of these changes are made automatically, and directly affect the minimum and maximum echo times. When you change parameters that affect the echo spacing, the system attempts to maintain your original selection of TE, but this might not be possible. In its attempt to maintain TE, the system will usually change the number of echoes before the “zero” phase encoding line, automatically shifting between HASTE, and single-shot TSE as needed. This can cause more change in the appearance of the image than you might expect for a “simple” change in echo spacing.

the echo spacing, as shown in Figure 2. Phase oversampling requires extra phase encoding lines, and therefore extra HASTE echoes. If 100% phase oversampling is requested, the minimum TE will be 16 times the echo spacing. The maximum TE (Fig. 4) is the echo spacing (ES) times half of the number of Fourier lines that are acquired. The number of Fourier lines will depend on the base matrix size (B), the phase resolution (R), the phase FoV (F), and the phase oversampling (PO). The last three are expressed as percentages, so the formula looks a bit complicated:

The total number of phase encoding lines is rounded up to 152. Because phase oversampling inserts extra steps between the normal phase encoding steps, the minimum echo time is not seven times the echo spacing, but ten times it (56.8 ms). Because these matrix parameters affect TE, it is best to set the bandwidth first, then the matrix parameters, and then TE. The minimum TE is shortened by using the normal gradient mode, fast RF mode, a high bandwidth, larger FoVs, reduced phase resolution, thicker slices, and no phase oversampling. The other matrix parameters have no effect on the minimum TE. One way to lengthen the maximum TE is to increase the echo spacing by reducing the bandwidth on the Sequence tab card (for comparison, the MAGNETOM Vision tse240_1100b156 sequence had a bandwidth of 156 Hz/pixel). You can also slightly increase the echo spacing with the “Whisper” gradient setting or the “Optimized” RF option. A more efficient way to lengthen the maximum TE is to increase the number of acquired lines. Use “100% FoV phase” (square FoV) to avoid reducing the number of lines. A phase resolution of 100% helps, but the square pixels may be too small for good SNR. A good alternative is to pick the appropriate phase resolution for good SNR, but increase the maximum TE by adding phase oversampling. Phase oversampling should be used with care, since it increases the already long acquisition window, and will increase the blurring caused by T2 decay. These tricks to increase the number of acquired lines also increase SAR. Another possibility is to use more phase resolution than desired, and 65

Example: Start with the previous example (Turbo gradients in “normal” mode, a 340 mm FOV, a bandwidth of 391 Hz/pixel, a 40 mm slice thickness, “normal” RF, 256 base matrix, 100% phase resolution, no phase oversampling, echo spacing 6.24 ms, minimum TE 50 ms, maximum TE 799 ms). Change the phase resolution to 63% (“161x256” pixel resolution), the phase FoV to 75% (340x255 mm), and the phase oversampling to 25%. The reduced gradients shorten the echo spacing to 5.68 ms, so the maximum TE is:

Effect of Matrix Parameters on TE
Comparing Figure 4 with Figure 5 shows that reducing the number echoes (phase encoding steps, Fourier lines) reduces the maximum value of TE. If phase oversampling is turned off, the shortest TE is always eight times

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then regain the SNR by applying a fairly strong raw data filter.

Magnetization Preparation
Selecting the FATSAT option applies a single FATSAT pulse before the 90° pulse. This can only be effective if the TE is short (the HASTE sequence, Fig. 2). This sequence uses a large number of RF pulses, so each slice should experience the full magnetization transfer effect without any special preparation. Selecting the magnetization transfer option applies a single MT pulse before the 90° pulse, so its effect will be negligible compared to all of the 180° pulses. There is no preparation scan for this sequence. The effective TR is infinite unless you select multiple acquisitions, or request closely spaced slices. If you make a single acquisition of several widely-spaced slices, TR can be set as short as possible, provided that the SAR is within bounds. If you need multiple acquisitions of exactly one slice, or if you request one or more acquisitions of closely-spaced slices, TR should be set long (for example 4000 ms). For multiple acquisitions of two widely-spaced slices, TR can be reduced to half that.

comparable to HASTE, say 4 seconds, the acquisition time is 12 seconds. The HASTE sequence acquires the whole image for one slice with a single 90° RF pulse, so the tissue has the full (equilibrium) magnetization. Depending on TE, the HASTE sequence requires between 0.86 and 1.6 seconds. The syngo MR HASTE sequence also has a much more flexible choice of TE values. Some “tse” protocols use the TSE sequence and some use the HASTE sequence. Identifying which pulse sequence is associated with a particular protocol is achieved by moving the cursor to the sequence code located to the right of the Scan Time display above the protocol. After a few seconds, a tool tip will appear showing the sequence name.

HASTE lung imaging, PAT x3, GRAPPA, 256x256

Comparison of HASTE to EPI Sequences
Single-shot Turbo Spin Echo is similar to EPI, since they both use a single 90° RF pulse followed by multiple echoes with different phase encodings. However, the term EPI is usually reserved for sequences that form multiple gradient echoes, while TSE uses multiple 180° RF pulses to form spin (and also gradient) echoes. TSE is slower and has much higher SAR, but the image quality is better, and fat-water separation is not a problem.

MAGNETOM Harmony, HASTE, 0.9 s/ slice

Comparison of HASTE to Standard TSE Sequence
The standard TSE sequence allows turbo factors of up to about 129, so at least two 90° excitations are needed to acquire a full 256 matrix. With two excitations, TR becomes a significant factor in the image contrast. For this reason the standard TSE sequence runs one prescan with this TR to establish a steady-state level of magnetization, for a total of three excitations. For a TR somewhat 66

[ 1 ] B. Kiefer, J. Graessner and R. Hausmann, J. Magn. Reson. Imaging 4(P) (1994) 86. [ 2 ] P. Margosian, F. Schmitt and D. Purdy. Health Care Instrum. 1 (1986) 195 [ 3 ] Hennig J, Nauert A, Friedburg H., “RARE-imaging: a fast imaging method for clinical MR.” Magn. Reson. Med. 3 (1986) 823

HASTE Thick Slab, right kidney with double collecting system, 2.45 sec acquisition time

TECHNOLOGY CORNER

HASTE liver imaging, MAGNETOM Trio, 8-channel Body Array Coil TR/TE 2000/90 ms TA: 0.39 s FOV 300x400, 192x512 matrix, SL 6 mm

HASTE fetal imaging

HASTE with respiratory trigger Courtesy of Dr. Op de Beeck Antwerp University Hospital HASTE for MR Enteroclysis

HASTE 512 matrix for liver imaging, 11 sec for 20 slices, 4 mm slice thickness 67

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Medical Devices and Accessories Developed for Use in the MR Environment
Frank G. Shellock, Ph.D. Adjunct Clinical Professor of Radiology, University of Southern California Founder, Institute for Magnetic Resonance Safety, Education, and Research In consideration of the many devices and accessories that are commercially available for safe use during MRI procedures, it is surprising that incidents and accidents related to ferromagnetic projectiles, excessive heating of devices and other problems, continue to occur. These have resulted in at least one fatality, several injuries, substantial damage to MR systems and down-time (i.e. loss of revenue) for MRI centers. Therefore, the intent of this article is to review the various devices and accessories that are specifically designed for use in the MR environment or for interventional MRI procedures, with the hope that this information will help prompt MR healthcare professionals to recognize the many products that exist and which are essential to ensure patient safety. In addition, these devices and accessories may help to create a more efficient or more profitable MR center.

Non-magnetic Oxygen & Gas Cylinders
According to Chaljub et al., accidents related to ferromagnetic oxygen tanks and other gas cylinders that become projectiles may be increasing. Therefore, MR facilities should devise an appropriate policy for delivery of oxygen or other gases to patients undergoing MR procedures. The use of non-magnetic (usually aluminum) oxygen and other gas cylinders is one means of maintaining a risk-free MR environment with regard to this equipment (Fig. 1). It should be noted that non-magnetic tanks must be prominently labeled to avoid confusion with magnetic cylinders. Furthermore, all healthcare workers that work in and around the MR environment must be informed regarding the fact that only nonmagnetic oxygen and other gas cylinders are allowed into the MR system room. Non-magnetic oxygen regulators, flow meters, cylinder carts, cylinder stands, cylinder holders for wheelchairs and suction devices, are also commercially available to provide safe respiratory support of patients in the MR environment.

The increasing capabilities of magnetic resonance (MR) studies to impact medical diagnosis and prognosis have dramatically increased the number of MR procedures performed worldwide. Many more patients, especially those in high-risk or special population groups, are undergoing MR examinations for an ever-widening spectrum of medical indications. Additionally, as Jolesz et al. have stated, continuous progress has been made to expand the use of MRI beyond diagnosis and into intervention. This has resulted in the development and performance of innovative procedures that include percutaneous biopsy (including breast, bone, brain and abdominal), endoscopic surgery of the abdomen, spine and sinuses, open brain surgery, and MR-guided monitoring of thermal therapies, i.e. laser-induced, RF-induced, and cryomediated procedures. Various manufacturers and sellers, prompted by recommendations and requests from MR healthcare professionals, have recognized the need for developing specialized medical devices, equipment, accessories and instruments necessary for use in the MR environment and for interventional MRI procedures. Accordingly, there are now numerous patient support devices and accessories that have been developed and which have undergone thorough evaluation to assess and verify appropriate use in the MR environment or during interventional MRI procedures. 68

Figure 1 Non-magnetic oxygen tanks of various sizes (Magmedix, Gardner, MA).

Patient Comfort Devices
Certain patients who undergo MRI procedures experience emotional distress that can range from mild anxiety to a full-blown panic attack. Patient distress contributes to adverse outcomes for the MRI procedure, including unintentional exacerbation of patient anxiety, a compromise in the quality – and thus the diagnostic power – of the imaging study, and decreased efficiency of the imaging facility due to delayed, cancelled or prematurely terminated studies.

MRI SAFETY

Fortunately, there are a variety of techniques that can help minimize these problems for patients. For example, special systems can be used during MRI procedures to manage the anxious patient, such as MRcompatible headphones to provide music to the patient (which also reduces gradient magnetic fieldinduced noise) and MR-compatible video systems to provide a visual distraction to the patient (Table 1). There is even a virtual reality environment system that provides combined audio and visual distraction to the patient (Fig. 2). A similar device is designed for use in fMRI procedures.

recommendations concerning the monitoring of patients during MR procedures. This information indicates that all patients undergoing MR procedures should, at the very least, be monitored visually and/or verbally (e.g. via an intercom system), and that patients who are sedated, anesthetized or are unable to communicate, should be physiologically monitored and supported by the appropriate means. Of note is that guidelines issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) indicate that patients who receive sedatives or anesthetics require monitoring during the administration and recovery from these medications. Additionally, policies and procedures must be implemented which continue appropriate physiologic monitoring of the patient by trained personnel after the MRI procedure is performed. This is especially needed for a patient recovering from the effects of a sedative or general anesthesia. Conventional monitoring equipment and accessories were not designed to operate in the harsh magnetic resonance (MR) environment where static, gradient and radio frequency (RF) electromagnetic fields can adversely effect or alter the operation of these devices. However, various physiologic monitors and other patient support devices have been developed or specially modified to perform properly during MRI procedures (Table 1). Besides patient monitoring, various support devices and accessories may be needed for use in the high-risk patient to ensure safety. Many of these have likewise been modified or designed to be safely used in the MR environment or during interventional MRI procedures (Table1).

define the activities, use of equipment, and other pertinent issues pertaining to a medical or other emergency is important for patient safety in the MR setting. For example, a specific plan needs to be developed for handling a patient where there is the need to perform cardiopulmonary resuscitation in the event of a cardiac or respiratory arrest. This includes the means to immediately remove the patient from the MR system to a place outside the MR environment to properly conduct CPR, allowing the use of necessary equipment such as a cardiac defibrillator. For this reason, it may be necessary to have a stand-by nonmagnetic stretcher or gurney available for the rapid transfer of the patient, especially for MR systems that do not have tables that separate from the MR system or that quickly disengage. Notably, the healthcare professionals who are members of the Code Blue team, (i.e. responsible for establishing and maintaining the patient’s airway, administering drugs, recording events and conducting other emergency-related duties) must be identified, trained in MR safety and continuously practiced in the performance of these critical activities relative to the MR environment. For cases when it may not be possible to remove the patient from the MR system room during an emergency, particularly where the patient is experiencing a respiratory or cardiac arrest, it is advisable to have various non-magnetic devices and accessories readily available, including an oxygen cylinder, laryngoscope, suction system, stethoscope, blood pressure manometer and other similar emergency equipment appropriate for the MR environment (Table 1).

Figure 2 Specialized equipment used to provide virtual reality environment and for fMRI studies (Resonance Technology, Inc., Northridge, CA).

Monitoring Equipment
In general, monitoring during an MRI examination is indicated whenever a patient requires observations of vital physiologic parameters due to an underlying health problem or whenever a patient is unable to respond or alert the MRI technologist or other healthcare worker regarding pain, respiratory problem, cardiac distress, or other difficulty that might arise during the examination. In addition, a patient should be monitored if there is a greater potential for a change in physiologic status during the MR procedure. In 1992, the Safety Committee of the Society for Magnetic Resonance Imaging published guidelines and

Emergency-Related Equipment
Emergencies can, and do, happen in the MR environment. Therefore, the development and regular practice of an emergency plan to address and

MR Contrast Agent Injection Systems
The controlled power injection of MR contrast agents is gaining in popularity for a variety of clinical 69

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applications, including examinations of abdominal organs, vascular anatomy and dynamic MRI studies of the breast. Power injectors must be able to operate in the MR environment without affecting magnet homogeneity, degrading signal-to-noise, or causing artifacts. Two of devices that are available for power delivery of MR contrast agents: the Optistar MR Contrast Delivery System (Mallinckrodt, St. Louis, MO) and the Spectris MR Injection System (Medrad, Inc., Indianola, PA) (Table 1).

Figure 4 Examples of non-magnetic devices and accessories developed or modified for use in the MR environment.

MRI Compatible Ventilators
Devices used for ventilation of patients typically contain mechanical switches, microprocessors and ferromagnetic components that may be adversely affected by the electromagnetic fields used by MR systems. Ventilators that are activated by highpressure oxygen and controlled by use of fluidics (i.e. no requirements for electricity) may still have ferromagnetic parts that can malfunction as a result of interference from MR systems. MR-compatible ventilators have been modified or specially designed for use during MRI procedures performed in adult as well as neonatal patients. These devices tend to be constructed from non-ferromagnetic materials and have undergone preclinical evaluations to ensure that they operate properly in the MR environment, without producing artifacts on MR images. There are at least two sources of respirators for patients that require respiratory support in the MR environment (Table 1). These devices have been tested in association with MR systems operating at 1.5-Tesla or less (Fig. 3).

Figure 3 The Omni-Vent Series D Ventilator used for respiratory support of patients in the MR environment (Magmedix, Garner, MA). environment by obtaining a selection of non-magnetic or other suitable accessories or equipment. For example, useful items for an out-patient facility include non-magnetic equipment such as one or more wheelchairs, stretcher or gurney, step stool, IV pole, laundry cart, stethoscope, blood pressure manometer, storage or utility care, fire extinguisher and custodial cart (Figs. 4 and 5).

MR facilities that handle both out-patients and in-patients should additionally consider obtaining a non-magnetic patient slider board, physiologic monitoring equipment (e.g. fiber-optic pulse oximeter), nonmagnetic oxygen tank (including non-magnetic regulator, cart or stand), portable suction, Mayo stand, and other devices and accessories (Table 1). Of note is that MR centers should have a sufficient number of nonmagnetic oxygen tanks and fire extinguishers in the immediate and general area to prevent responding emergency staff members from introducing ferromagnetic objects into the MR environment. In fact, some hospital-based MR centers have non-magnetic oxygen tanks and fire extinguishers used throughout their buildings to prevent projectile accidents.

Biopsy Needles, Biopsy Guns, and Tissue Markers
Interventional MRI has been used to guide tissue biopsy and apply markers with encouraging results. Obviously, the performance of these specialized procedures requires tools that are compatible with MR systems. Many conventional biopsy needles, biopsy guns, and tissue markers have been evaluated with respect to compatibility with MR procedures, not only to determine ferromagnetic qualities but also to characterize imaging artifacts. The results have indicated that most of these are not useful for MRI-guided biopsy procedures due to the presence of excessive ferromagnetism and associated

Basic Patient Management Accessories and Equipment
All new and existing MR facilities should be prepared to handle patients and everyday situations (including maintenance) in the MR 70

Figure 5 Non-magnetic custodial cart (the wheels, casters, and bucket handle are all non-magnetic). A non-magnetic mop handle and mop head clamp should be used with this equipment.

MRI SAFETY

imaging artifacts that limit or obscure the area of interest. Fortunately, several biopsy needles and biopsy guns have been constructed out of non-ferromagnetic materials specifically for use in interventional MRI procedures. These are now commercially available from various vendors (Table 1). The placement of a marking clip or wire enables the accurate localization of the surgical excision site and is a useful surrogate target, even if the entire lesion is removed and there is a subsequent need for wire localization prior to surgery. Marking clips and wires have been specially designed for use in interventional MRI procedures (Table 1).

COMPANY AESCULAP, INC. 3773 Executive Center Pkwy Center Valley, PA 18034 (800) 282-9000 www.aesculap.com DRAEGER MEDICAL , INC. 3135 Quarry Road Telford, PA 18969 (800) 437-2437 www.draeger.com E-Z-EM, INC. 717 Main St. Westbury, NY 11590 (800) 544-4624 www.ezem.com IN-VIVO RESEARCH 12601 Research Pkwy. Orlando, FL 32826 (800) 331-3220 www.invivoresearch.com MAGMEDIX

PRODUCTS MRI Surgical instruments

Anesthesia equipment Ventilator

Biopsy needles Biopsy guns Biopsy site markers

Monitoring equipment

Non-magnetic accessories Respiratory equipment MR facility start up kits Monitoring equipment Patient comfort/positioning devices MRI tools and instruments Patient transport equipment Cryogen accessories MRI carts and maintenance devices Signs and site control devices OptiStar MR Contrast Delivery System

Surgical Instruments
Interventional MRI procedures have evolved into clinically viable techniques for a variety of minimally invasive surgical and therapeutic applications. Besides the typical MRI safety concerns, there are possible hazards in the interventional MRI environment related to the instrumentation and accessory equipment that must be addressed to ensure the safety of MR healthcare practitioners and patients. Surgical instruments are an obvious necessity for interventional MRI procedures. However, many of these instruments are made from metallic materials that can create substantial problems in association with interventional MRI procedures. The interventional MRI safety issues that exist for a surgical instrument include unwanted movement caused by magnetic field interactions (e.g. the missile effect, translational attraction, torque), heating generated by RF power deposition, and artifacts associated with the use of the instrument, if it is in the imaging area of interest during its intended use. To address these various problems, surgical instruments have been developed that do not present a hazard or additional risk to the MR healthcare practitioner or patient in the interventional MRI environment (Table 1, Fig. 6).

158R Main Street Gardner, MA 01440 (866) 646-3349, (978) 630-5580 www.Magmedix.com

MALLINCKRODT, INC. 675 McDonnell Blvd. St. Louis, MO 63134 (314) 654-3981, (314) 654-2000 www.mallinckrodt.com MEDRAD One Medrad Dr. Indianola, PA 15051 (800) 633-7231, (412) 767-2400 www.Medrad.com MRI DEVICES CORPORATION 1515 Paramount Drive Waukesha, WI 53186 (800) 524-1476 www.mridevices.com RESONANCE TECHNOLOGY, INC. 18121 Parthenia St. Northridge, CA 91325 (818) 882-1997 www.fmri.com, www.mrivideo.com

Monitoring equipment Music system Spectris MR Injection System

Biopsy needles Biopsy positioning devices Biopsy localization systems

MRI audio/video systems fMRI products Custom built devices

Figure 6 MR-compatible surgical instruments (Aesculap, Center Valley, PA).

Table 1 Examples of companies that provide devices and accessories for use in the MR environment or for interventional MRI procedures (for a comprehensive listing of companies, please refer to Shellock FG. Reference Manual for Magnetic Resonance Safety: 2002 Edition. Amirsys, Inc., Salt Lake City, Utah, 2002)
Important note from Siemens: We wish to offer our sincere apologies to Frank G. Shellock for mis-spelling his name in the safety video for which he acted as consultant.

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Accessories and Supplies from Siemens
Injectors*
MEDRAD MR Injector Spectris Solaris A high-quality injector for the preciselytimed injection of MR contrast media. It administers a tight CM bolus, thereby maximizing dynamic and functional MR examinations. By allowing a reproduction of examination results, it enables constant and repeatable injection parameters to be set. MEDTRON Injektor MRT

In addition to its own products, Siemens is also able to offer products from leading manufacturers, tested for compatibility with our MR systems. These fulfill the requirements for the highest quality of diagnostic imaging as well as comply with standards laid down by law. Here are just a few of the highlights of the product range offered by Siemens.

ULRICH MR Contrast media injector

Laser Cameras & Printers*
AGFA Drystar 2000 A digital dry imager which produces highquality monochrome films for diagnostic purposes. Since the films are non lightsensitive, handling is comparable with an office printer: space-saving and easy to operate. AGFA Drystar 3000 DICOM The Drystar 3000 is a completely dry working documentation system for costefficient and decentralized applications. The small footprint and low power consumption alleviate the positioning of the printer. A selection of two film formats is possible. It boasts a geometrical resolution capacity of 320 ppi. An online densitometer guarantees stable image quality. There is an integrated controller module. Documentation is via DICOM PMS through a software option.

More detailed information can be obtained from our virtual 3D hospital rooms at

http://www.med.siemens.com/ medandmore

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AGFA Scopix LR 5200 P This laser imager with integrated film processor has a resolution capacity twice that of previously-known laser imagers, and is therefore used in areas in which an especially high-detailed display is important.

Special Furniture*
AGA MR Stretcher, non-magnetic A sturdy CrNi steel construction for the safe and comfortable transporting of the patient, including a totally adjustable head part.

Monitoring Systems*
INVIVO Patient Monitoring System Consisting of a 3150 Omni Trak patient monitoring system and a 3155 remote screen with wireless data transmission, several configurations are available.

MAQUET IV Stand, non-magnetic A stable stand, equipped with electrically conductive and lockable castors, also suitable for use in the MR room, thanks to its non-magnetic effect.

MEYRA Wheelchair – non-magnetic This foldable wheelchair facilitates patient transport into the MR room. An adjustable I.V. pole is a significant contribution to ease-of-transportation.

INVIVO Pulsoximeter MRI 4500 Due to its MR compatibility, this system facilitates precise monitoring as well as interference-free MR scanning.

Respirators for use in the MR Room*
BLEASE Frontline Genius Anesthetic System This simple-to-operate and flexible Frontline Genius system can be used for the anesthesia of adults and children in the MR room on systems of up to 1.5 Tesla.

Technical Equipment*
HEIMANN Handheld Metal Detector For non-contact examination of persons for any type of metal object prior to entering the examination room.

TOTAL Fire Extinguisher Non-magnetic fire extinguisher filled with carbon dioxide in accordance with fire class B.

* Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safet or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries

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Monitoring of Neoadjuvant Chemotherapy with Dynamic Breast MR
Bruce A. Porter M.D. FACR First Hill Diagnostic, Seattle, Washington, USA However, it is clear that neoadjuvant chemotherapy can often control LABC locally to a sufficient degree that many patients become operable, and some are even converted to become candidates for breast conservation surgery [4,6]. A longstanding and significant problem in monitoring neoadjuvant chemotherapy has been the inability of conventional methods (breast exam, mammography, and ultrasound) to reliably and accurately determine breast cancer size (T classification) and then to reliably measure tumor changes in response to treatment [1,2,5,6,8]. Physical exam and mammography have known limitations for monitoring therapy; post-treatment fibrosis can readily mimic cancer on both exams, which may either under or overestimate the size and viability of residual cancer. A number of authors [1,2,8,9] have reported on the successful use of contrast-enhanced breast MR to monitor neoadjuvant chemotherapy. MR allows accurate (6) and noninvasive initial staging of the patient’s tumor (which is particularly vital in this group, since conventional surgical-pathological staging is not available). Evaluation of architectural/ morphological features of breast lesions is key to diagnosis [10,11]. Breast MR can also detect treatmentrelated effects not only on tumor size and morphology, but also on tumorassociated angiogenesis and neovascularity, by documenting alterations in blood flow [3]. These changes are reflected by enhancement curves generated during dynamic image acquisition [9,11,12-14] and can be seen earlier than alterations in tumor size or morphology [3]. Absence of enhancement, while a favorable finding, does not indicate cure or eradication of tumor. This paper presents a pictorial overview of our current methods for breast cancer evaluation using a 3-dimensional dynamic method. It will then focus on the ability of MR to monitor neoadjuvant therapy of breast malignancies.

Technique Introduction:
Recent advances in understanding the pathophysiology and genetics of breast cancer have led to more specific and effective therapies. Patients with locally advanced breast cancer (LABC) appear to benefit from and be appropriate candidates for these new therapies [1-4]. These patients frequently have extensive tumors, which may involve the skin, chest wall, or regional lymph nodes, or have the typical clinical findings of the T4 or inflammatory carcinomas. Although these often aggressive tumors tend to be highly sensitive to chemotherapy [1], LABC patients have a generally poor long-term prognosis, with predicted five-year survival rates of 30% or less. Conventional surgical options for locally advanced breast cancer have been limited; many of these patients have been, understandably, considered inoperable [5]. As a result, over the past 15 to 20 years a variety of preoperative chemotherapeutic treatments have been proposed and used for the treatment of LABC to improve management, and this approach has been termed “neoadjuvant chemotherapy”. The intent of neoadjuvant chemotherapy is to shrink or, ideally, to sterilize the tumor before surgery and thus improve operability and long-term survival [1,6,7]. Although some reports have indicated a survival advantage with neoadjuvant chemotherapy, the question of an improvement in survival remains unresolved. 74 All the images in this report were produced on a 1.0 Tesla MAGNETOM Harmony MR system with standard software and gradients (20 mT/m). Evaluation of all breast cancers at our facility begins with a large (450 mm) Field of View coronal short TI inversion recovery (STIR) image set [15] of the chest, angled parallel to the sternum as determined from a midline sagittal pilot image (See Protocol Table) (Fig. 1) [6]. This is a highly sensitive screening tool for distant metastases, particularly to the

Figure 1a Coronal STIR chest reveals multiple hyperintense minute bone metastases which confluently involve a right posterior rib (arrow).

Figure 1b Coronal STIR image more anteriorly portrays a proximal left humeral metastasis as a rounded very bright focus; additional lesions (not shown) were found in the spine, clavicles and scapula.

WOMAN’S HEALTH

bone [16,17]. STIR also allows detection of regional lymph node metastases involving the axillary, internal mammary, supra- and infraclavicular and cervical nodes (Fig. 2a, b), as well as soft tissues of the chest and liver [17]. Axial STIR images of the chest are often used when lesions are identified on the initial coronal images; both initial STIR image sets are acquired with the patient supine in the body coil. If bone or visceral metastases are identified, the patient has documented Stage IV metastatic disease, and neoadjuvant therapy may not be appropriate. STIR images also portray lymphedema associated with inflammatory (T4) carcinomas (Fig. 2) However, the most valuable contribution of the initial chest study for this sensitive exam is to detect unsuspected Stage IV metastatic disease or to improve the clinical confidence that the patient indeed has locally advanced, but not metastatic, cancer. The next portion of the exam is combined dynamic and highresolution 3D bilateral contrastenhanced study of the breasts, which is done in the prone position. Axial STIR breast coil images (Fig. 2c) are initially acquired for assessment of internal mammary nodal involvement, tumor-associated edema, or chest wall infiltration. This very fluidsensitive sequence also is useful for identification of breast cysts and fibroadenomas, both of which are generally of very high signal on STIR. Dynamic contrast-enhanced MR of the breasts is performed with a dedicated bilateral circularly polarized breast imaging coil (Siemens Medical Solutions), with an 80 slice pre-contrast T1- weighted 3D FLASH (See Protocol Table) (Fig. 3a). curves (Fig 3d) are generated from these serial dynamically acquired source images. Prior to the exam the patients are carefully coached regarding the extreme importance of remaining completely still during the

Figure 2a 44 year old woman with rapidly advancing inflammatory carcinoma of the left breast, palpable axillary and supraclavicular lymphadenopathy. Coronal STIR images reveal inflammatory changes of the breast with skin thickening and hyperintensity, edema of the pectoralis muscle, and extensive left axillary adenopathy with perinodal edema. Note the enlarged and hyperintense azygoesophageal node (arrow).

examination. The examination is done with fat saturation; however, to further improve the contrast of the subsequent maximum intensity projection images (MIPs) the fat saturation source images are subtracted (post-contrast minus pre-contrast), particularly at 1 or 2 minutes post-injection (Fig. 3e) and then at 4 minutes for review and production of representative high-contrast MIPs. The MIP images are filmed in the axial (Fig. 3f), coronal, and obliquesagittal (MLO-like) projections. The contrast is administered via an antecubital vein using a 20-22 gauge

Figure 2b Coronal STIR image more anteriorly detects bilateral supraclavicular adenopathy extending into the upper anterior mediastinum (arrows). The extent of the lymphedema is well seen on this very watersensitive sequence.

Figure 3a A 71 year old woman with an infiltrating ductal carcinoma and a question of multifocal/multicentric tumor and possible nipple infiltration on mammogram. Precontrast axial T1-weighted FLASH images show heterogeneously dense breast parenchyma. As is often seen with bilateral imaging, there is some mild inhomogeneity of fat suppression.

Figure 2c Axial STIR breast coil image also shows fluid extending along the pectoralis muscle as well as malignant left axillary nodes with irregular ill-defined margins and perinodal edema, an indicator of extranodal tumor extension (N2 adenopathy). The right parasternal high signal (arrow) was an ultrasound confirmed 5 mm malignant internal mammary lymph node.

Figure 3b Axial fat-saturated T1weighted FLASH image at 2 minutes after contrast reveals a heterogeneous, lobulated, irregular, spiculated enhancing mass in the subareolar space just lateral to the nipple, measuring 2.4 cm at its maximal point. 75

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Figure 3c The most intensely enhanced voxels are identified by review of images at high-contrast settings, and the ROI is placed there to generate the enhancement curves in Figure 3d.

section, highresolution “VIEWS” images (Volume Interpolated Exam, Water-Stimulation) are complementary to the dynamic exam and provide great morphologic detail (Fig. 3g, h). They are particularly helpful in neoadjuvant chemotherapy patients following treatment, since they are acquired with a delay of between 5 and 10 minutes after contrast injection. At this time treatment-suppressed but still viable tumor may become visible, which may not be seen at the normal maximal enhancement time of untreated cancers, 1 to 2 minutes following injection of contrast. Therefore, careful review of these delayed high-resolution images can be of particular importance in the postchemotherapeutic setting.

entire 80-slice image set on one projection image. A contrast enhancement curve (Fig. 4b) was generated from a region of interest placed at the periphery of the markedly enhancing mass. This illustrates the typical rapid uptake of contrast material with subsequent washout pattern, which is a curve very highly predictive of malignancy. Other curve types seen with malignant lesions have been described; a plateau or progressive pattern may also be observed.

Figure 3d Time-enhancement curve from 0 (precontrast) to 5 minutes demonstrates abrupt early enhancement (wash-in) with a peak of 159 % at 1 minute and a subsequent washout of contrast. The larger marks on the x-axis represent 1 minute intervals. This is a typically malignant curve obtained from a region of interest (ROI) placed at the point of maximal tumor enhancement. intravenous catheter with a bolus injection of a standard dose (0.1 mmol/Kg) of gadolinium-based contrast material. A 20 ml saline flush follows the gadolinium at a rate of approximately 2 ml/sec, and five serial post-contrast 60-second T1 FLASH acquisitions (Fig. 3b) are begun midway through the administration of the saline flush. Areas of maximal enhancement are identified (Fig. 3c) and contrast-enhancement. Following the dynamic exam, a highresolution sagittal 3-dimensional water-saturation image set (Fig. 3g) is acquired, either unilateral or bilateral (Protocol Table). These thin76

Clinical Cases
Neoadjuvant Case 1: A 53 year old woman presented with a large, firm, but poorly defined right breast mass and palpable axillary lymph nodes. MR examination for tumor size, as well as for staging, was requested. The extent of the tumor is well seen on an axial MIP image from the dynamic series at 1 minute (Fig. 4a). This demonstrates a bulky tumor involving the majority of the lateral right breast. A large asymmetrical draining vein to the internal mammary venous plexus was also present. This is a common observation in large, locally advanced breast cancers, and is readily appreciated with the bilateral 3D technique. There is no tumor visualized in the left breast. The latter is a clinically relevant finding of great importance, since MR has a very high negative predictive value. Considerable reassurance can be offered to the patient with this simultaneous bilateral exam. An advantage of the MIP technique is that a single MIP can summarize the

Figure 3e This “2-minute subtraction image” is the result of subtracting Figure 3a from Figure 3b. Subtraction improves the contrast and conspicuity of the lesion, suppresses background tissues, and corrects for non-uniformity of fat saturation.

Figure 3f The axial 3-dimensional MIP image demonstrates a solitary lesion in the left breast with a large asymmetrical draining vein, and a normal right breast. This image from the 2-minute postcontrast set shows approximately equal enhancement of the internal mammary artery and vein (small arrows). Additional MIP images are filmed in the coronal and bilateral oblique positions (not shown), and clearly document the absence of additional cancers.

WOMAN’S HEALTH

Figure 3g 1.2 mm thick VIEWS acquisition with an interpolated 512x512 matrix and a 180 mm field of view results in very high resolution and spatial detail. The fine spiculation of the mass, as well as its internal heterogeneity and relationship to the skin, is very well defined.

Sag>Cor -5

Figure 3h A composite “thin” MIP comprised of 6-8 individual slices is used to better demonstrate the relationship of the mass to the nipple-areolar complex. The multiple focal areas of nonspecific enhancement elsewhere are a reflection of the time delay from contrast administration for this sequence (5-10 minutes).

A coronal STIR image of the chest, done before the breast exam, reveals right axillary lymphadenopathy (Fig. 4c) and, more importantly, an abnormal lymph node is identified on STIR at the junction of the posterior cervical chain and the supraclavicular fossa. This had not been detected on clinical examination, and had potentially profound impact on the staging of this patient’s cancer. Ultrasound examination and fine needle aspiration (Fig. 4d) confirmed an abnormalappearing node with a positive cytology indicating Stage IIIC metastatic breast carcinoma, and the patient underwent neoadjuvant chemotherapy. A follow-up MR examination was requested following three months of neoadjuvant chemotherapy (Fig. 4e). As demonstrated, there is nearly complete resolution of the pathologic enhancement, and the abnormal venous drainage also returned to normal. However, punctate areas of mild contrast accumulation remain, and therefore multiple 14-gauge core biopsies were performed of this region, demonstrating scattered malignant cells and chronic inflammation. The enhancement curve after treatment can be compared directly to the pretreatment curve in Fig. 4f. There has been marked flattening of the contrast curve,

Figure 4c Coronal STIR chest image reveals right axillary adenopathy . The node is oval, enlarged, and there is replacement of the normal dark hilar fat by STIR-intense tumor. A STIR-hyperintense lymph node is also identified in the posterior supraclavicular fossa / posterior cervical chain (arrow).

Figure 4d Ultrasound-guided fine needle aspiration of the lymph node in Figure 4C yielded cytology consistent with metastatic breast carcinoma.

Figure 4a (Neoadjuvant Case 1): An axial MIP from the dynamic series (at 1 minute) demonstrates an 8 cm tumor as well as a large asymmetrical draining vein. Note the absence of abnormal enhancement in the left breast.

Figure 4b Peak enhancement is reached at 2 minutes (represented by the vertical line) and the curve shows rapid initial enhancement with a mild washout pattern thereafter. Peak enhancement is 156 % at 2 minutes. This is typically a malignant-like enhancement curve.

Figure 4e Axial MIP image after 3 months of neoadjuvant chemotherapy. Punctate areas of mild contrast accumulation are present, and may represent either underlying benign foci of enhancement or small islands of residual viable tumor at this time.

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which is still only slowly rising at the end of the dynamic acquisition (5 minutes), and no peak is seen. On the more delayed VIEWS images the mild mottled enhancement present in the area of previous tumor on these much-delayed post-contrast images is also consistent with substantially treated, but not eradicated, cancer. A follow-up coronal STIR image of the chest (Fig. 4g) reveals virtual resolution of the axillary and supraclavicular adenopathy, which is no longer palpable. The increased STIR signal intensity in the proximal right humerus is a reflection of marrow hormonal stimulation due to granulocyte colony stimulating factor (GCSF) treatment. The large field of view used on coronal STIR imaging allows visualization of most of the liver in most cases.

Figure 4f Pre- versus post-treatment enhancement curves. The vertical axis has been set at 200 units to match the pretreatment (upper) curve, and the ROI was placed as close as possible to the site of the pretreatment ROI. Post-treatment (lower curve) enhancement is now only 71 % at 2 minutes (compared to 156 %). The flattening of the curve is an important indicator of response to therapy.

Figure 5b Following 6 months of neoadjuvant chemotherapy the mass has diminished markedly and now measures 2.5 x 1.6 x 1.6 cm.

Neoadjuvant Case 2: This 47 year old woman noted increasing tenderness and swelling of her left breast and axilla, but had a history of a known ruptured left saline implant. The firmness and enlargement of the breast had been attributed by her and her physician to scarring from the implant rupture. The asymmetry of vascularity seen on the 3D MIP image (Fig. 5a) is striking, and a reflection of the extensive angiogenic ability of this tumor and its neovascularity. The patient received six months of neoadjuvant chemotherapy, and a follow-up MR examination shows a marked response to therapy (Fig. 5b). There is persistent rim enhancement and moderate lobulation and spiculation; however, the asymmetrical vascularity has virtually resolved. The contrast enhancement curve at this time demonstrates a peak enhancement at 2 minutes of 98 %, with a mild washout pattern thereafter, which is consistent with a substantial response. The changed shape of the curve is the most 78

Figure 4g Coronal STIR image (compare to Figure 4c). Note the increased STIR signal in the proximal right humerus (arrow) due to marrow hyperplasia secondary to granulocyte-colony stimulating factor (GCSF) treatment.

Figure 5c Axial MIP images at 9 months documents re-enlargement of the mass following a change in chemotherapy. The mass now measures 3.2 x 2.6 x 2.4 cm. and displayed a malignant curve.

Sag>Cor -17

Figure 5a (Neoadjuvant Case 2) Axial MIP image of a markedly enhancing heterogeneous and exceedingly vascular mass involves the majority of the left breast and has a 9 cm diameter, but it spares the skin and chest wall. Peak enhancement occured at 1 minute (259 %) with a malignant washout pattern thereafter. Note the curvilinear enhancement of the malignant left axillary lymph nodes (arrow).

Figure 5d Sagittal VIEWS image reveals a thickened, nodular rim enhancement with a central fluidic area of necrosis. The mass is spiculated, with morphologic features consistent with residual neoplasm. Notice the partially collapsed saline implant posterior to the mass but anterior to the pectoralis muscle.

WOMAN’S HEALTH

important indicator of response. The malignant lymph nodes had resolved. The decision was made to continue chemotherapy; however, the patient developed therapy related cardiotoxicity, and had a change of treatment protocol. Three months later a follow-up MR documents interval enlargement of the mass (Fig. 5c). The sagittal high-resolution VIEWS image (Fig. 5d) confirms the morphological features of malignancy, with a thickened, nodular rim of markedly enhancing material surrounding an area of central necrosis. At this point the decision was made to operate.

Acknowledgements
I would like to acknowledge the significant contributions of Helmuth Schultze-Haakh, PhD and Nancy Gillen from Siemens Medical Solutions for their longstanding support and creative contributions to this work, as well as Brandy Wolff and Steve Meyers, First Hill Diagnostic Imaging, and my colleague Justin P. Smith, M.D. Invaluable assistance for manuscript preparation was provided by Mildred Downey Broxon.

[ 7 ] Esserman L, Kaplan E, Partridge S, Tripathy D, et al. MRI phenotype is associated with response to doxorubicin and cyclophosphamide neoadjuvant chemotherapy in Stage III breast cancer. Annals of Surgical Oncology 8(6):549559. [ 8 ] Weatherall PT, Evans GF, Metzger GJ, Saborrian MH, et al. MRI vs histologic measurement of breast cancer following chemotherapy: comparison with x-ray mammography and palpation. Journal of Magnetic Resonance Imaging 13:868- 875 (2001). [ 9 ] Kuhl CK, Schild HH. Dynamic image interpretation of MRI of the breast. Journal of Magnetic Resonance Imaging 12:965-974 (2000). [ 10 ] Ikeda DM, Hylton NM, Kinkel K, Hochman MG, et al. Development, standardization, and testing of a lexicon for reporting contrast-enhanced breast magnetic resonance imaging studies. Journal of Magnetic Resonance Imaging 13:889- 895 (2001). [ 11 ] Schnall MD, Rosten S, Englander S, et al. A combined architectural and kinetic interpretation model for breast MR images. Academic Radiology 2001;8:591-597. [ 12 ] Kaiser W, Zeitler E. MR imaging of the breast: fast imaging sequences with and without Gd-DTPA. Radiology 1989;170:681-686. [ 13 ] Porter BA, Taylor V, Smith JP, Tsao V. Contrast-enhanced magnetic resonance mammography. Academic Radiology 1994; 1:S36-S50. [ 14 ] Porter BA, Smith JP, Borrow JB: MR detection of occult breast cancer in patients with malignant axillary adenopathy. Radiology 197(P):130, 1995. [ 15 ] Bydder GM, Young IR. MR imaging: clinical use of inversion recovery sequence. Journal of Computer Assisted Tomography 1985;9(4):659-675. [ 16 ] Porter BA. Marrow-infiltrating disorders. In Moss K, Gamsu G, Genant H,eds. Computed Tomography of the Body. Philadelphia: WB Saunders 1991. [ 17 ] Porter BA. Magnetic resonance imaging for advanced staging of breast cancer. CMRS Vision, December 1998: 1,5-13.

References Conclusions
MR technology has advanced to the point that it is possible to obtain a combined high temporal resolution dynamic exam and a high spatial resolution morphologic examination of both breasts using standard MR equipment and a dedicated breast imaging coil. The approach described in this paper combines the strengths of both examinations. The indications for breast MR are continuing to evolve. One unique application of this method is for initial staging of patients with locally advanced breast cancer and subsequent monitoring response to therapy. Being able to document changing morphological features and alterations of enhancement patterns provides a broad perspective on the staging and biology of breast cancer in vivo, while providing a clinically relevant basis for decision-making on management of these challenging patients. As treatment protocols for breast cancer continue to evolve and become more specific and effective, the availability of such a technique for monitoring day-to-day response to therapy will become all the more important.
[ 1 ] Trecate G, Ceglia E, Stabile F, Tesoro- Tess JD, et al. Locally advanced breast cancer treated with primary chemotherapy: comparison between magnetic resonance imaging and pathologic evaluation of residual disease. Tumori 85:220-228, 1999. [ 2 ] Gilles R, Guinebretiere J-M, Toussaint C, Spielman M, et al. Locally advanced breast cancer: contrast-enhanced subtraction MR imaging of response to preoperative chemotherapy. Radiology 1994; 191:633-638. [ 3 ] Tsuboi N, Ogawa Y, Inomata T, Yoshida D, et al. Changes in the findings of dynamic MRI by preoperative CAF chemotherapy for patients with breast cancer of stage II and III: pathologic correlation. Oncology Reports 6:727-732, 1999. [ 4 ] Drew PJ, Kerin MJ, Hahapatra T, et al. Evaluation of response to neoadjuvant chemoradiotherapy for locally advanced breast cancer with dynamic contrastenhanced MRI of the breast. European Journal of Surgical Oncology 2001;27:617-620. [ 5 ] Mumtaz H, Hall-Craggs MA, Davidson T, et al. Staging of symptomatic primary breast cancer with MR imaging. AJR 1997;169:417-424. [ 6 ] Abraham DC, Jones RC, Jones SE, Cheek JH, et al. Evaluation of neoadjuvant chemotherapeutic response of locally advanced breast cancer by magnetic resonance imaging. Cancer 1996;78:91-100.

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Thin-MIP Evaluation in 3D Mammographic Imaging
Greta Vandemaele, Ph.D. MR Applications, Belgium acquisition or from head to feet in axial exams (ima+/-). When a lesion is encountered, we apply the “projection views” key. 5 MIP projections appear on the screen, radially-oriented. The orientations correspond to the RX mammographic views: craniocaudal (axial), oblique and mediolateral (sagittal) views. We place the center point on the lesion and specify the extension of the MIP in “thickness” to cover the entire lesion. Orientation control should be applied to get correct orientation of the breast. Small lesions, trajectories of small intra-ductal carcinoma, can be seen with this evaluation (Fig. 3b, c). Galactophoric ducts can be detected with thin MIP on 512_T2_tirm or on T1_fatsat imaging (Fig. 4a). Depending on the constitution of the fluid in the ducts, they appear hyperintense (fluid, inflammation) or hypointense (containing lipids) on T2_tirm or hyperintense on T1_fatsat imaging. They will not be visible on the subtraction images, where only the obstructive papilloma (Fig. 4b) or intra-ductal carcinoma will be detected. Good results were obtained in other clinical applications: detection of small aneurysms in 3D TOF, evaluation of small stenosis in peripheral angio and thin MIP on 3D CISS images of the intra-acoustic ducts. Whenever the overlay of surrounding structures may hamper the 3D MIP evaluation, thin MIP might solve the problem and nicely depict pathology. Courtesy of Dr. M. A. Labaisse, ACCITAM Tournai, Belgium and Dr. Ch. Van Ongeval- KU Leuven, Belgium. Figure 1 MIP on a subtraction series of T1_fl3D_512

In MR breast imaging, gadolinium enhancement of lesions is followed with a high spatial resolution 3Dsequence (typically fl3d_512_in phase), covering the entire breast. A high temporal resolution is needed to detect the peak enhancement rate of the lesions. Subtraction of post minus pregado measurement shows the enhancing lesion. A 3D MIP of these subtraction images depicts the vascular structure of the breast, the extension of the pathology and shows the presence of multifocal lesions (Fig. 1). Very often, however, these MIP images suffer from artifacts. Slight patient movement makes subtraction of the fat incomplete which may mask lesions on the MIP image (Fig. 2a). Dense mammary glands may cover up small lesions in the overall MIP (Fig. 2c,d). That is why we always combine normal 3D MIP of the breast with thin-MIP evaluation in the 3D platform.

How is a thin MIP evaluation performed?
The subtraction series is loaded into the 3D MIP. The segment of the originally measured orientation (coronal or axial) is made active. “Thin MIP” is then pressed under “type” whereby the MIP-image changes to an MPR-image (here the originally measured slices). We screen all images for lesions, going from anterior to posterior in coronal 80

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Figure 2a MIP on a subtraction with incomplete fat subtraction and dense breast tissue.

Figure 3a The axial images with thin MIP orientations

Figure 4a Thin MIP on a gallactophorous duct in T2_tirm, filled with fluid.

Figure 2b The box of MIP evaluation on the right breast.

Figure 3b Sagittal thin MIP projection (medio-lateral view) with a width of 5mm.

Figure 4b Thin MIP on the subtraction T1_fl3D series, showing a small papilloma, obstructing the duct.

Figure 2c Sagittal MIP of the right breast.

Figure 3c Axial thin MIP (cranio-caudal view) with a width of 5mm. 81

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CP Breast Array Coil is compatible with iPAT parallel imaging applications for high resolution dynamic MRI of the breast.

iPAT Breast Imaging Examples Courtesy of Prof. Dr. med. H. Otto Evangelische Kliniken Gelsenkirchen GmbH Klinik für Radiologie, Nuklearmedizin und Radioonkologie

CP Breast Array Coil
■ 4 coil design with 4 integrated preamplifiers ■ Mediolateral compression capability ■ Circular polarized coil design offers up to 40% higher signal-to-noise ■ Array technology allows the coverage of large fields of view and high-quality breast imaging ■ No coil tuning ■ Size: 530 mm x 500 mm ■ Weight: 7.3 kg (16.094 lbs)

Second carcinoma on the right side of the breast. Subtraction result after dynamic high-resolution imaging with Flash 3D. True 512 matrix within 54 sec acquisition time.

STIR 512 matrix image showing fibroadenoma. TA : 2:24

STIR 512 matrix image showing DCIS TA : 2:24

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The MAGNETOM Family Leading the Innovations in MR

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When the choice is yours and you have gained a certain perspective on MR systems, your decision will be based on what‘s best for your patients and your business:

The MAGNETOM Open Class Open to everyone • MAGNETOM Concerto • MAGNETOM Rhapsody The MAGNETOM Ultra Class

The MAGNETOM® Maestro Class A new degree of perfection • MAGNETOM Harmony 1T • MAGNETOM Symphony 1.5 T • MAGNETOM Sonata 1.5 T

3T & beyond • MAGNETOM Allegra – the brain scanner • MAGNETOM Trio – the whole body scanner

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Case Report: Stroke Diagnosis with MR
Priv.Doz. Dr. med. Franz Fellner Institut für Radiologie Landesnervenklinik Wagner-Jauregg, Linz, Austria

81 year old patient suffered from stroke symptoms during coronary angiography procedure. Right hemiparesis and aphasia were the major findings in the physical examination. The patient was immediately transferred to our clinic and examined. Diffusion weighted images showed a lesion in the basal ganglia and perfusion weighted images showed decreased perfusion in a large area fed by left middle cerebral artery. This was a clear perfusion diffusion mismatch indicating an ischemic penumbra (Fig. 1,2). The neurologist decided for an immediate thrombolytic therapy with these findings. The next day, the patient could talk and move which was a dramatic quick response to the therapy. Followup MR examination showed adequate perfusion in the previously diagnosed hypoperfused area (Fig. 3).

Figure 1a Diffusion weighted image. B 1000

Figure 1b ADC map

Figure 2a Perfusion weighted image before therapy. (MTT, Mean Transit Time map)

Figure 2b Perfusion weighted image before therapy . (TTP, Time to Peak Map)

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Figure 3a Perfusion weighted image after intravenous thrombolytic therapy. (MTT, Mean Transit Time Map)

Figure 3b Perfusion weighted image after intravenous thrombolytic therapy. (TTP, Time to Peak Map)

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Application Package: Neuro Perfusion Evaluation

■ Color display of relative Mean Transit Time (relMTT) ■ Flexible selection of Arterial Input Function (AIF) for reliable quantification

■ Single shot and segmented EPI sequences for fast acquisition

■ Diffusion weighted imaging with b max of 10,000 s/mm2 ■ Single shot EPI for perfusion imaging ■ Multidirectional Diffusion Weighted (MDDW) imaging for diffusion tensor imaging

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Dream Machines and Getaway Speed…
Dream Machines and Getaway Speed –
This is What Siemens CMR and Harley Davidson Have in Common

For this year’s annual meeting in February 2003, the Society of Cardiovascular Magnetic Resonance in Medicine (SCMR) chose the birthplace of the legendary Harley Davidson motorcycle, Orlando, Florida. And again, this year the meeting saw a record attendance of over 800 SCMR representatives compared to ~600 last year and ~300 the year before. The exponentially growing interest and awareness of the power that Cardiovascular MR has as a diagnostic imaging tool, is reflected emphatically by these numbers. For Siemens, this year’s SCMR meeting broke many records, too: Siemens customers again presented the largest share of abstracts, with more than 40% of the total. A record, but no surprise, as this reflects the fact that Siemens partners lead the field in CMR. The huge potential of CMR was demonstrated throughout the SCMR meeting in many interesting talks and posters. And Siemens had some exciting new developments to share with its partners during the meeting. As special occasions require special places, we decided to come together with our MAGNETOM World CMR Ambassadors Friday night at The Harley Davidson First Historic Factory in Orlando. More than 240 people joined us at this 35,000 square foot motorcycle 86

Mecca that features the latest in Harley motorcycles, accessories and – for this one special night only – the latest in Siemens CMR. After a welcome drink, Dr. Stefan Assmann, CMR Product Manager, presented the new cardiovascular features, which will be part of the next syngo MR software version 2004A. Huge progress – focusing on workflow and ease of use – has again been made with the latest software version. Dr. Assmann highlighted the features which resulted from planning during our Annual Ambassadors meeting in New York last June. We can all look forward to working with great new features, such as Dynamic Signal, the perfusion evaluation tool, or with Phase Sensitive Inversion Recovery, or “AutoViability”, which eliminates the need for precise adjustment of inversion time in delayed enhancement imaging. Among many other new features, radial techniques for high resolution real time imaging, and new iPAT applications, will also form part of the new software, once again proving Siemens’ product leadership in CMR.

However, the highlight of the evening was the announcement of self-gated CMR, a revolutionary new technique proudly unveiled by one of its inventors, Dr. Orlando Simonetti.

Self-gated CMR – with Siemens, Innovation is Continuous
Siemens have brought CMR into clinical routine with Black-Blood turbo spin echo, TrueFISP cine, and Delayed Enhancement. Now we are continuing our leadership of the field in innovation with the announcement of Self-gated CMR, a new imaging technique, which eliminates the need for ECG during cardiac MR exams. For optimal cardiac image quality and highest resolution, MR imaging must be synchronized with the heartbeat. Self-gated MR is the innovative answer to this simple but complicated prerequisite. The ECG signal is typically used to synchronize MR imaging with the heartbeat. ECG triggering has several practical limitations:

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1. Proper placement of ECG leads takes a significant amount of the patient set-up and total scan time 2. Certain patient groups with poor physiological ECG signal can be difficult to image. 3. ECG signal is distorted by the static magnetic field and can also be distorted by switching of magnetic field gradients and RF pulses during scanning, making triggering difficult.

Self-gated CMR, simply stated, analyzes the acquired MR data itself, and is able to track the motion of the heart. It can also differentiate between cardiac and respiratory motion, and can use either motion to gate the images, or even use both in combination (Fig.2). The technique was developed by Andrew Larson of Northwestern University, together with Siemens scientists and Dr. Rick White, of the Cleveland Clinic Foundation. Initial clinical studies are underway at these sites, as well as at the NIH, where Andrew Larson is currently working. First patient studies and more detailed information on the technique will be shown in the next issue. After the talk, Andrew Larson was awarded the first MAGENTOM World CMR Research Student Of The Year Award for his significant contributions to self-gated CMR. However, it was not only Andrew who had a big smile on his face: all the participants were happy to experience the fun of test driving a great machine. Of course it was not possible to bring enough MAGNETOM scanners for everybody to the event. Therefore a substitute was provided – a real Harley – guaranteeing almost the same amount of fun. Every participant was given the opportunity to test drive a Harley, and nearly everybody did and enjoyed the experience. The next day at the SCMR meeting, the Siemens event and self-gated CMR were THE topics of the day on the show floor. Nomen est Omen: SCMR – Siemens Cardiovascular MR SCMR, a great meeting in any sense – thanks to the partnership with our customers !

The New Approach of Selfgated CMR
The self-gating technique extracts cardiac motion information from MRI data (Fig.1) and eliminates the need for wires and electrodes to be attached to the patient. No additional navigator echoes are acquired, and the high spatial and temporal resolution of segmented cine is achieved!

Figure 1 Comparison of conventional ECG trigger signal (black line) with self-gated signal (blue) shows excellent agreement of both methods

See you next year at the SCMR in Barcelona, Spain 13-15 February, 2004. Some customers comments

Figure 2 Four-chamber view of the human heart. No difference in image quality between the ECG gated (left) and self-gated (right) technique can be observed. Combined cardiac and respiratory gating was applied. (Courtesy: A. Larson, NIH, O.Simonetti, Siemens Medical)

“Best user event in years” ...and on self-gated CMR “Biggest thing in 5 years”, “Biggest scientific news of the meeting”
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MAGNETOM Trio MR Angiography Unlimited

MAGNETOM Trio is 3T Unlimited
3T MR systems are attracting great attention as new hardware and software become available for wholebody applications. In the area of MR Angiography, 3T benefits Time of Flight (ToF) techniques, as T1 of blood and stationary tissue become longer, thereby increasing the signal of the vessels and decreasing background signal. The increased SNR at 3T offers the potential to increase resolution with the same dose of contrast, for better diagnostic information. MAGNETOM Trio has been optimized at every level so that these advantages can be fully exploited in all applications. Maximal homogeneity, advanced coil technology, 8 RF channels in standard, iPAT applications and gradient speed are some of the many components that contribute to the quality of 3T MR on MAGNETOM Trio.

The benefits of MAGNETOM Trio in MR angiography ■ Advanced RF system with 8 independent channels is standard supporting the 8-channel torso array, 8-channel neurovascular array and 8-channel head array coils ■ iPAT is standard for fast acquisitions ■ Fastest gradients for a large FoV (200 T/m/s slew rate) ■ syngo ergonomic user-interface

Inline Technology in the syngo userinterface Automatic subtraction Automatic MIP in all orientations

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Time of Flight MRA of the hand with water excitation Without the use of contrast agent MAGNETOM Trio, CP wrist coil Longer T1 at 3T provides excellent inherent contrast for time-of-flight techniques. Excellent background suppression is enhanced by using the water excitation technique.

3D contrast-enhanced carotid MRA 3D FLASH, standard contrast dose

MAGNETOM Trio, iPAT-compatible 8-channel neurovascular array

Very high-resolution imaging: 80 partitions, 0.9 slice thickness, 512 matrix in only 35 seconds with the Trio gradients.

Peripheral MR Angiopgraphy MAGNETOM Trio, integrated SARoptimized body coil 3D FLASH acquisition in 1:30 min Acquired with 3 steps automatically with the panoramic table The design of the integrated body coil of MAGNETOM Trio shows excellent signal-to-noise, enabling the visualization of even small vessels of the lower leg.

2D Phase contrast image of the sagital sinus 2D FLASH, phase contrast, 4.5 sec / slice MAGNETOM Trio, CP head coil

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MRI Flow Quantification Techniques
Gary McNeal and Kevin Johnson Advanced Application Specialists Cardiovascular MRI R&D Team Siemens Medical Solutions USA

How does MRI flow quantification work ?
MRI flow quantification techniques actually measure the velocity (cm/sec) and then calculate the associated flow (ml/sec) by multiplying velocity times the cross-sectional area. How do we measure velocity? In contrast to stationary protons, any protons moving within a magnetic gradient generate a phase shift in the transverse magnetization. For protons with constant velocity, the phase shift is linearly proportional to the velocity. This fact can be exploited for velocity measurement by applying a very specific flow-encoded magnetic gradient in the desired direction. As seen in Figure 1, a flow-compensated magnetic gradient creates a reference phase (the phase of signal S1 is zero), then a flow-encoded magnetic gradient creates a different phase due to the constant velocity of the protons within the gradient (the phase of signal S2 is γ). The measured velocity is linearly proportional to the measured phase difference (γ).

What is the Phase Image and why is it important ?
In flow quantification techniques we are interested in both the magnitude and phase of the difference between signal S1 (flow-compensated) and signal S2 (flow-encoded). When an image is reconstructed it may be displayed as either a magnitude image in which the pixel intensity represents the length of the vector or as a phase image in which the pixel intensity represents the angle of the vector. ■ The phase image (Fig. 2c) represents a phase reconstruction of the difference signal (S2-S1). It looks grainy because it represents the phase of the signal rather than the magnitude of the signal. Blood is depicted as white if flowing in the positive direction (ascending aorta), black if flowing in the negative direction (descending aorta), or midgrey if stationary. This image represents not only the speed of flow, but also its direction. The pixel intensity is directly proportional to the velocity and its color indicates its direction. Both speed and direction information are extracted during post-processing to yield numerical and graphical flow results. Thus, the phase image is the most informative of the three different types of displayed images. ■ The rephased image (Fig. 2a) represents a magnitude reconstruction of the flow-compensated signal only (S2). This image is useful for drawing the regions-of-interest (ROI) for quantitative evaluation of the flow results. It looks like a typical gradient-echo image with flowcompensation. ■ The magnitude image (Fig. 2b) represents a magnitude reconstruction of the difference signal (S2-S1). This image may also be useful for drawing the ROI’s. In this image,

Why use MRI flow quantification ?
MRI is rapidly gaining acceptance as an accurate, reproducible, and noninvasive method for optimal assessment of structural and functional parameters in patients with heart disease.1 Diagnosis of cardiac disease requires accurate assessment of function as well as morphology of the heart. The acceptance of Cardiac MRI as a clinical diagnostic modality depends on its ability to demonstrate several important diagnostic features including cardiac morphology, regional and global ventricular function, cardiac perfusion, coronary arterial anatomy, and flow.2 It is the ability of MRI techniques to quantify flow that will be discussed in this article. Flow measurements using MRI can be used for examinations of blood vessels, cardiac valves, or cerebral aqueducts. The advantages of MRI flow quantification over Doppler echo include: ■ MRI contains both anatomical and functional information. ■ MRI allows access to all anatomical regions in all orientations. ■ MRI is sensitive to a broad range of flow velocities.

My S2

S1 Figure 1

Mx

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Figure 2 (a) Rephased Image

(b) Magnitude Image

(c) Phase Image

are marked with text “LPH” in the upper right corner as a reminder. ■ For velocity encoding along the x direction the pixel intensity will be white if moving toward the left or black if moving toward the right. ■ For velocity encoding along the Y direction the pixel intensity will be white if moving toward the posterior or black if moving toward the anterior. ■ For velocity encoding along the z direction the pixel intensity will be white if moving toward the head or black if moving toward the feet.

stationary tissue appears black and flowing blood appears bright regardless of the direction of flow. Thus, this image represents only the speed of flow and contains no information about its direction.

What is the VENC and why is it important ?
The velocity at which the phase difference (γ) reaches 180 degrees is known as the Velocity Encoding Factor (VENC). For example, if the VENC is set to 100 cm/sec then a velocity of 100 cm/sec will produce a phase difference (γ) of 180 degrees whereas a velocity of 50 cm/sec will produce a phase difference (γ) of only 90 degrees. Before running the scan the user must choose an appropriate VENC based upon his or her expectation of the peak velocity. If the VENC is too high or too low the pulse sequence can not accurately determine the velocity. Ideally, the VENC should be set just slightly greater than the peak flow.

the phase difference (γ) has reached its maximum negative angle (– 180 degrees) and therefore the pixel intensity has reached its maximum negative value (– 4096 = maximal black). Or, when the measured velocity is exactly zero, then the phase difference (γ) is also zero and the pixel intensity is zero (0 = midgrey halfway between white and black. Figure 3 shows how the phase difference is mapped to the pixel intensity.

+ 180 + 90

+ 4096

Why and how is cardiac gating used ?
To measure the changes in velocity and flow caused by the beating heart, data acquisition must be gated to cardiac motion, thereby resulting in a series of images evenly spaced throughout the cardiac cycle. Such images are typically played in a “cine loop” to visualize the flow in realtime. Figure 4 shows a series of cine images acquired in the axial plane with velocity-encoding applied in the through-plane direction (head-feet) to visualize pulsatile flow through the ascending aorta. See how the signal changes from white to midgrey as the blood pulses through the ascending aorta.

0 deg

0

– 90 – 180 - 4096

Figure 3 Remember that the positive directions are defined toward the patient’s left (L), and toward the patient’s posterior (P), and toward the patient’s head (H). In fact, all syngo images

How does the pixel intensity indicate speed and direction ?
Pixel intensities range from – 4096 to + 4096, independent of the VENC selected. When the measured velocity in the positive gradient direction has reached the chosen VENC, then the phase difference (γ) has reached its maximum positive angle (+ 180 degrees) and therefore the pixel intensity has reached its maximum positive value (+ 4096 = maximal white). Or, when the measured velocity in the negative gradient direction has reached the chosen VENC, then

Figure 4 91

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Chosing a VENC significantly greater than the actual peak velocity (>150 %) will result in sub-optimal SNR and sub-optimal measurement accuracy. The forward flow is not displayed as maximum white and the reverse flow is not displayed as maximum black (Fig. 7a). Chosing a VENC significantly less than than the actual peak velocity (< 90%) will result in severe velocity aliasing that may not be adequately compensated with the VENC Correction in post-processing (Fig. 7b). In some cases of highly turbulent flow, jets have been observed in which the peak velocity makes a transition from being too high

Figure 5 Figure 5 explains how a cine flow quantification sequence works. A trigger pulse derived typically from the ECG starts the process by acquiring a segment of data containing both signals S1 and S2. This process is repeated for as many heartbeats as needed to collect all the data (192 matrix x 20 images x 2 signals). Fourier Transforms are performed separately on the 2 different signals S1 and S2 to produce two different sets of phase images. Then the flowencoded images are subtracted from the flow-compensated images for subsequent cine display and quantitative analysis.

Acceptable results may be obtained if the VENC is only slightly less than the peak velocity (within 10%). In this case, a small amount of velocity aliasing will be present, but the VENC Correction in post-processing may be used to compensate for aliasing (Fig. 6b).

Figure 7a VENC too high

Figure 6a Optimal VENC

Figure 7b VENC too low (aliased) to near zero within one image pixel. In these cases the VENC Correction cannot properly report a velocity in the pixels that have a mixture of aliased and non-aliased signals. Therefore in these cases, it is best to avoid aliasing altogether rather than rely on the VENC Correction.

How to optimize the VENC ?
Optimal results may be obtained if the VENC is only slightly greater than the peak velocity (within 10 %). This will ensure the best possible signalto-noise ratio (SNR) and the greatest degree of measurement accuracy (Fig. 6a). 92

Figure 6b Acceptable VENC

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Rather than simply guessing at the optimal VENC, it may be prudent to run several quick test scans at several different VENC’s. This can be accomplished by temporarily reducing the matrix and the number of averages while increasing the number of lines per segment for the quick test scans (repeat at several different VENC’s). Determine the best VENC and reset the parameters back to their original values before performing the diagnostic scan.

Figure 8a Left-right shading

Figure 9a Coronal localizer

Figure 9b LVOT localizer

Figure 8b No shading

How to optimize measurement accuracy?
As discussed earlier, the pixel intensities in the phase images represent the velocities being measured. Moving protons are either white or black, whereas stationary protons should be homogeneously mid grey anywhere in the image. If there is any significant shading across the image the velocity measurements may be inaccurate. The shading in Figure 8a was caused by failure to follow one or more of these recommendations: 1. Ensure the equipment remains within its operational specifications by routinely performing preventive maintenance, especially the eddy-current and shim calibrations. 2. The measured region-of-interest must be as near isocenter as possible. Ensure the slice is within +/- 50 mm of isocenter along the head-feet direction. If the table or patient must be moved more than +/- 150 mm to meet this requirement, it is recommended to relocalize afterwards. 3. Normal or Whisper Gradient Pulses are preferred in the measurement protocols. Although Fast Gradient Pulses can be used, they could be more likely to contribute to shading effects, especially if recommendations 1 and 2 above are not followed.

Figure 9c Axial Ascending Aorta

How to align the velocityencoding gradient?
Accurate flow quantification requires that the velocity-encoding gradient is aligned primarily along the direction of the flow (use in-plane rotation of FOV if necessary). For example, a 20 degree misalignment between the velocity-encoding direction and the actual flow direction can cause up to 6 % error in the velocity measurement. The user must select the velocity-encoding gradient either through the slice (through-plane) or within the slice (in-plane), depending upon the slice orientation and the flow direction. In Figure 9 the ascending aorta is assessed with a flow quantification slice run in an axial oblique plane. Since the flow in the ascending aorta is pedominantly in the head-feet direction the velocity-encoding gradient must be applied throughplane (slice thickness direction). Localizers in the coronal and left ventricular outflow views are used to position the slice exactly perpendicular to the aorta. The aortic contour is shown in Figure 9c and will be described later. In Figure 10 the aorta is assessed with a flow quantification slice run in a sagittal oblique plane. In this case

the velocity-encoding gradient must be applied in-plane (readout direction, head-feet). Localizers in the axial view are used to prescribe the slice through both the ascending and descending aorta.

Figure 10a Axial localizer

Figure 10b Sagittal Ascending Aorta

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How to assess pulmonarysystemic shunts ?
To assess pulmonary-systemic shunts it is necessary to compare two separate flow measurements – one through the ascending aorta and another through the pulmonary artery. Refer back to Figure 9 for positioning through the ascending aorta and refer to Figure 11 for positioning through the pulmonary artery. The Net Forward Volume through the pulmonary artery is known as QP, whereas the Net Forward Volume through the ascending aorta is known as QS. The ratio QP / Qs represents the direction and amount of blood being shunted. Typical starting choices for VENC’s are about 120-250 cm/sec for the ascending aorta and about 80-140 cm/sec for the pulmonary artery, but these may vary from one patient to another and from one clinical scenario to another. ■ QP / QS = 1 no shunt. ■ QP / QS > 1 shunt is from systemic system into pulmonary system. ■ QP / QS < 1 shunt is from pulmonary system into systemic system. Figure 12 demonstrates an atrial septal defect (ASD) by using a dynamic first pass contrast enhanced scan in the four chamber horizontal long axis view of the heart. An ARGUS flow analysis was performed separately on the pulmonary artery and the ascending aorta using the steps listed below (Fig. 13). Analysis of the pulmonary artery yielded 131 ml Net Forward Volume (Qp) and analysis of the ascending aorta yielded 82 ml Net Forward Volume (Qs), thereby resulting in a QP / QS ratio of 1.6 (see Fig. 14 & 15). This indicates that blood was shunting from the left atrium into the right atrium. Figure 11a Pulmonary Outflow localizer

How to perform the Post-Processing ?
■ After running a flow quantification pulse sequence, load the resulting Rephased Images and Phase Images into ARGUS, select FLOW ANALYSIS. ■ Crop all images by about 50% – Window to best see flow in the Phase Images. ■ Enter the R-R interval as the Trigger Time from the last image in the series. Figure 11b Axial Pulmonary Artery ■ Enter the patient’s height and weight (used to normalize the results to BSA). ■ Select Active Contour 1 and draw a contour around the vessel of interest on a Rephased Image or a Phase Image (whichever best shows the full lumen – contour in Fig. 11) ■ Propogate Active Contour 1 by clicking on the bold-double-headed arrow. Figure 13

Figure 12 Atrial Septal Defect (ASD)

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■ Adjust Active Contour 1 on all images as needed to completely include the vessel lumen and exclude all stationary tissue – this is critical for accurate results so make your best guess if the edge definition of the lumen is uncertain – refer to earlier and later images in the series as a reference. ■ After verifying that all contours are correct click on Accept Generated Contours. ■ In the Results Taskcard click on the 1 to see the results for the vessel of interest. ■ Click on Velocity and Flow to get the curves – click on Temporal to get a table. Although not generally necessary, it is possible to perform a “reference correction” of the measured velocities within the region-of-interest relative to a zero baseline represented by stationary tissue with no flow. If the measured velocity within stationary tissue happens to be non-zero, it represents an offset error that should be corrected in the region-of-interest. Reference correction is generally unnecessary if the slice and regionof-interest are near isocenter and there are no nearby field inhomogeneity artifacts from stents, implants, prostheses, or air-tissue interfaces. However if desired, a reference region may be drawn in an area of stationary tissue near the region-ofinterest. It must contain homogeneous signal with no flow artifacts or field inhomogeneity artifacts. To draw the reference region click on the Ref button in the Contour toolbox (Fig. 13), click on the Circle button and draw a circle on a Phase image, and click on Simple Copy to propogate the reference region through all images. To apply the reference correction to the measured velocities, click on Flow Options and Use Baseline Correction.

Figure 14 Pulmonary Artery

Ascending Aorta

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How to assess flow jets through cardiac valves?
To assess stenotic or regurgitant jets through cardiac valves one can visualize the jets with in-plane velocity-encoding. This is not a “quantitative” approach, but rather an optional “qualitative” approach. As described earlier, it is always critical to align the velocity-encoding gradient to the direction of the jet (use in-plane rotation of the FOV if necessary). In this example of a stenotic pulmonary valve we begin with some images of the pulmonary valve to visualize the jet (Fig. 16). TrueFISP cine images (Fig. 16a) were acquired to confirm the location of the jet, followed by velocity-encoded images with inplane (head-feet) VENC of 500 cm/sec (Fig. 16b,c). We continued with some images of the pulmonary valve in a modified right ventricular outflow view (RVOT) that were planned directly through the jet from the previous images (Fig. 16d). Again we acquired velocity-encoded images with in-plane (head-feet) VENC of 500 cm/sec (Fig. 16e,f). At cardiac catheterization the peak velocity was estimated to be 403 cm/sec.

Figure 15 Pulmonary Artery

How to assess CSF flow in the cerebral aqueduct?
To assess CSF flow in the cerebral aqueduct it is necessary to acquire an axial slice through the aqueduct with very high spatial resolution (120-140 mm FOV, 256x256 matrix, 3 mm slice thickness, multiple averages). Refer to Figure 17 for positioning the axial slice perpendicular to the cerebral aqueduct from a midline sagittal localizer. Flow through the cerebral aqueduct is normally biphasic, with both cranial and caudal flow occuring during each heartbeat. Typically there is cranial component of flow occuring at the time of the

Ascending Aorta

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a

b

c ECG trigger (time=0), quickly thereafter it reaches a peak in the cranial direction, then it reverses direction toward caudal, and finally late in the cardiac cycle it reverses direction again toward cranial. The net cranial flow and the net caudal flow are almost equal under normal conditions (a difference of perhaps only a few microliters per heartbeat), but this may vary under abnormal conditions. A typical starting choice for VENC is about 10-15 cm/sec, but this may also vary from one patient to another and from one clinical scenario to another – stenosis generally requires a higher VENC due to the resulting flow jet. In the following example of a normal cerebral aqueduct an ARGUS flow analysis was performed on the data as described in Figure 13, except the contour of the aqueduct lumen was propagated as a simple circle with the command Simple Copy. The aqueduct contour is shown in Figure 17. A flow analysis of the cerebral aqueduct yielded a Net Flow of 0.013 ml in one heartbeat of this normal patient (the end-point of the curve in Figure 21).

d

e

f

Figure 16 (a) TrueFISP cine image through pulmonary valve shows the jet. (b) Rephased image with in-plane VENC 500 cm/sec shows the valve. (c) Phase image with in-plane VENC 500 cm/sec shows the jet. (d) Modified RVOT was planned directly through the jet. (e) Modified RVOT TrueFISP cine image through pulmonary valve shows the valve & jet. (f) Modified RVOT phase image with in-plane VENC 500 cm/sec shows the jet.

Figure 17a Midline sagittal localizer

Figure 17b Axial Cerebral Aqueduct

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Figure 18 shows the curve for Average Velocity versus Time (cm/sec). This curve represents the average velocity within the specified contour of the cerebral aqueduct. Velocities in the positive direction are displayed above the horizontal axis, whereas velocities in the negative direction are displayed below the horizontal axis. The velocity of CSF flow in a normal cerebral aqueduct is non-zero at the beginning of the cycle, returns to the same value at the end, and has both positive and negative velocity components (cranial and caudal flow). Figure 19 shows the curve for Peak Velocity versus Time (cm/sec). This curve represents the peak velocity within the specified contour of the cerebral aqueduct. In turbulent conditions the peak velocity may be considerably greater than the average velocity (as in the ascending aorta), but in laminar conditions the two are generally similar (as in the cerebral aqueduct). The peak velocity curve may provide a good indication of how well the chosen VENC matches the actual peak velocity of the measurement. If the VENC was chosen significantly too low, the Peak Velocity curve will be aliased – that is, it will appear to take a dip right at the peak of the curve. If this were the case and there was only minor aliasing, the VENC ADJUST feature would allow the user to shift the VENC in the positive or negative direction as needed to compensate for the aliasing. However, in this example the chosen VENC was 15 cm/sec and the peak velocity was only 2 cm/sec – that is, a VENC of 5 cm/sec would have been more appropriate.

Figure 18

Figure 19

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Figure 20 shows the curve for Flow versus Time (ml/sec). This curve represents the average flow within the specified contour of the cerebral aqueduct. This curve is derived by multiplying the Average Velocity curve by the cross-sectional area of the lumen as determined from its contour. Note in the example that the flow reached only 0.04 ml/sec in the positive direction (cranial) and only 0.10 ml/sec in the negative direction (caudal) – these are typical values for a normal patient. If you add up (integrate) all the area under the positive portions of the curve you will get the net volume of CSF (ml) that flowed in the cranial direction over a single heartbeat. Similarly, integrating the negative portion of the curve gives you the net volume (ml) of CSF that flowed in the caudal direction. Just a technical note: this flow curve is expressed in units of ml/sec, but flow is sometimes discussed in units of ml/min and would require that these numbers should be multiplied by 60. Figure 21 shows the curve for Net Volume versus Time (ml). This curve is derived by integrating the previously described Flow versus Time curve. Unlike all the other previous curves, this one typically does not end up at the same point that it started. The endpoint of this Net Volume curve represents the total volume of CSF that passed through the aqueduct lumen over a single heartbeat. In this example the net flow was 0.013 ml per heartbeat in the caudal direction. Furthermore, from the specified R-R interval of 900 ms we can calculate a caudal flow of about 0.87 ml/min (= 0.013 ml/beat *67 beats/min).

Figure 20

Figure 21

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Figure 22

Figure 22 represents a summary of the results and may be obtained by clicking on the Temporal button. This shows that the VENC is 15 cm/sec and the body surface area is 1.85 square meters (estimated from patient’s height and weight). The peak velocity is 4.35 cm/sec in the caudal direction (the peak of the curve in Fig. 19). The average velocity is 0.59 cm/sec in the caudal direction (the average of the curve in Fig. 18). The Average Flow is 0.02 ml/sec in the caudal direction (the average of the curve in Fig. 20). From these results the Average Flow Per Minute can be calculated as 0.0012 liter/min (= 0.02 ml/sec * 60 sec/min / 1000 ml/liter). Note that 0.0012 liter/min is so small that it is listed as zero in the table. For just one heartbeat the Forward Volume is +0.01 ml (in the cranial direction), the Reverse Volume is +0.02 ml (in the caudal direction), and thus the resulting Net Forward Volume is -0.01 ml (in the caudal direction).

Acknowledgements
We would like to thank our colleagues Dr. John Lesser, Dr. M. Tadavarthy, and Jana Lindberg, RT, at Abbott Northwestern Hospital who provided some of our data and advised us regarding the clinical interpretation of some of the finer clinical aspects of this technique.

References
Didier D, Ratib O, Lerch R, Friedli B. Detection and quantification of valvular heart disease with dynamic cardiac MR imaging. Critical Reviews in Diagnostic Imaging. 1999;40:1299-1301. Sakuma H, Takeda K, Higgins C. Fast magnetic resonance imaging of the heart. European Journal of Radiology. 1999;29:101-113.

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MAGNETOM Trio Cardiac MR Unlimited*
3T magnets offer double signalto-noise (SNR) compared to 1.5T. However, at 3T, artifacts, for example, due to the greater chemical shift can be very prominent. For these reasons, MAGNETOM Trio has been optimized at every level so that the increase in SNR can be fully exploited in cardiac MR. Maximal homogeneity, advanced coil technology and gradient speed are some of the many components that contribute to the quality of cardiac MR at 3T. The active ECG electrodes: Robust fiber optic signal transmission. High reliability at 3T. Cardiac Array Coil: Receive coil with integrated preamplifiers. No coil tuning. Used for high-resolution cardiac imaging. Coronary MR at 3T

Acquired with 1D PACE for motion correction and active ECG electrodes. MAGNETOM Trio, iPAT-compatible 8-channel cardiac array coil.

The benefits of MAGNETOM Trio in cardiac MR ■ Dedicated 8-channel cardiac array coil, iPAT compatible ■ Active ECG electrodes ■ Excellent homogeneity on a 40x40x40 cm FoV to ensure best fat saturation and TrueFISP imaging ■ iPAT standard for fast acquisitions ■ Fastest gradients on large FoV (200 T/m/s slew rate) ■ syngo ergonomic user-interface A B

A: 3D FLASH with fatsat, pixel size 0.9 x 0.9 x 1.2 mm B. 2D TSE dark blood, pixel size 1 x1.5 x 1.2 mm

Function – In-flow and out-flow tract at 3T Acquired in 12 s, 276x384 FoV

MAGNETOM Trio, iPAT-compatible 8-channel cardiac array Due to the high-homogeneity of the MAGNETOM Trio magnet, TrueFISP exhibits excellent signal and contrast-to-noise at 3T.

Morphology – 2D TSE dark blood of the heart MAGNETOM Trio, iPAT-compatible 8-channel cardiac array

Function with 2D cine TrueFISP of the heart Enhanced workflow with syngo user-interface Visualization of all views. Automatic loading and display of cine dataset. Ergonomic ECG display integrated into the interface.
* Cartain OEM coils with the MAGNETOM Trio System require 510 ( k ) review and are not commercially available in the US.

MAGNETOM Trio, iPAT compatible 8-channel cardiac array

Without iPAT (TA = 15 s)

With iPAT factor 2 (TA = 8 s) Temporal resolution: 25 ms, 256x256

The high SNR of the TrueFISP and 3T magnetic field strength of MAGNETOM Trio results in the very good SNR of the heart at 3T in extremely short acquisition times.

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Product Info
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Basic Cardiac Positioning and Terminology
Raleigh MRI Center, Raleigh, North Carolina, USA Margaret King, RT (R)(MR), Raleigh MRI Center, 3811 Merton Dr., Raleigh, NC, USA longer scanning, and conversely, a single breath-hold may be all that is needed on the shorter scans. Depending on the radiologist’s preference, images may be acquired on inspiration or expiration as long as it is consistent throughout the exam.

Introduction
Cardiac imaging can be intimidating. The heart is not a straightforward organ. However, cardiac imaging is not quite as difficult if you understand the basics and the terminology. HLA – Horizontal Long Axis-shows all 4 chambers (similar to oblique coronal) VLA – Vertical long Axis-shows 2 chambers, left atrium and ventricle (oblique sagittal) Short Axis – perpendicular to the ventricular septum

Localizer Images

Transverse scout

Sagittal scout

Coronal scout

Patient Preparation and Positioning
The patient is positioned head-first, supine, with leads attached. The body array coil is attached over the chest, centered approximately at the level of the nipples. Both body array elements should be activated, together with spine elements 2 and 3, unless one of the spine elements sufficiently lends enough signal to cover the heart in conjunction with the body array elements. The patient should be comfortable with the large leg cushion placed under their knees, and be offered detailed breathing instructions prior to entering the bore. It is productive to practice the breathing to ensure accurate, speedy inhalation and exhalation. Most imaging can be done on the second inspiration/expiration. Three breaths may be necessary for some of the 102

Utilizing the transverse image with the best depiction of the left ventricle (LV), position a slice parallel to the septum through the LV to generate a vertical long axis (VLA).

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Using the VLA, envision an imaginary line bisecting the mitral valve and exiting the apex of the LV. Position three short axis images perpendicular to the imaginary line to generate three short axis (SA) images.

Using the VLA and the short axis image which best demonstrates the apex of the right ventricle, position three slices parallel to the long axis of the LV on the VLA as well as perpendicular to the septum exiting the apex of the right ventricle on the short axis to generate a four chamber view. The mid slice should be the best four chamber image, with the anterior slice yielding an image of the Left Ventricular Outflow Tract (LVOT) .

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The anterior slice should yield a Left Ventricular Outflow Tract (LVOT) image. If you are trying to obtain a four chamber of the heart using single slice positioning, and your image demonstrates the LVOT where you can appreciate the aorta coming off of the left ventricle, you should then be able to move your slice more posterior to achieve a true four chamber.

Anatomy

E C D A B H F G J I

Horizontal Long Axis A. Right Atrium B. Left Atrium C. Right Ventricle D. Left Ventricle E. Tricuspid Valve 104

Vertical Long Axis F. Mitral (Bicuspid) Valve G. Left Ventricle H. Left Atrium I. Left Ventricle J. Right Ventricle

Short Axis

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Sequence Details
Cardiac imaging utilizes many sequences. Most of the images shown above are a single, phase image from a cine. Depending on the indications for the cardiac MR, a variety of sequences may be used. Morphology sequences include but are not limited to T1, T2, HASTE, IR, GRE and TrueFISP imaging. Cine imaging may include TrueFISP cine as well as FLASH cine. A list of the parameters for frequently used sequences are listed below.

TrueFISP, Single Slice or Multi-Slice (Morphology)
trufi_singleshot_15sl, #slices 1-15, slice thickness 5mm, TR 459, TE 1.56, TA ~9.9s, matrix size 256, 60% FOV 340, Rectangular FOV 82%, AC 1, BW 980, FA 62.

TSE T2, Single Slice (Morphology)
tse15_db_t2, #slices 1, slice thickness 5mm, TR 700, TE 70, TA ~8.4s, ETL 15, matrix size 256, 78% FOV 340, Rectangular FOV 82%, AC 1, BW 235, FA 180.

TSE T1, Single Slice (Morphology)
Tse9_db_t1, #slices 1, slice thickness 5mm, TR 600, TE 24, TA ~11s, TD 50ms, ETL 9, matrix size 256, 60% FOV 340, Rectangular FOV 82%, AC 1, BW 305, FA 180.

Most cardiac work-ups begin with the basic imaging described above. Commonly, a four chamber view is obtained and imaged with T1, T2 or IR, and Cine. From the four chamber image, a fine tuned VLA or two chamber image is made with T1, T2 and Cine. For various pathologies, the cardiac exam will be tailored from that point on. Functional analysis will require short axis cine through the left ventricle. Viability and perfusion can also be performed. The basic terminology and methodology for obtaining a four chamber, two chamber and LVOT will demonstrate the basic heart anatomy and cine will demonstrate basic contractile function. All cardiac exams will begin with basic imaging as described above. The radiologist will choose the type of imaging sequences. Once a four chamber view is achieved, the battle is half-won, as those basic images will be used for positioning and imaging for the remaining portion of the cardiac exam.

TrueFISP Cine, Multi-Phase (Function)
tf2d15_norm_HR, #slices 1 multiphase, slice thickness 5mm, TR 47.4, TE 1.58, TA ~11s, ETL 9, matrix size 256, 79% FOV 340, Rectangular FOV 82%, AC 1, BW 930, FA 60, segments 15.

Discussion
The imaging sequences used to obtain the four chamber of the heart are a matter of choice and may vary from facility to facility. Frequently, cine images are used to work up to the four chamber, since scan times are substantially shorter than in the past. The HASTE sequence in the localizer or morphology protocol tree will yield 7-15 slices in a breath hold, and are also used for multislice imaging in any given orientation.

Scanner
MAGNETOM Sonata

Coils used
CP Spine Array Elements 2&3 and CP Body Array Elements 1&2

Software Version
syngo MR 2002B

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Upper Extremity CE MRA with CARE-BOLUS Using syngo MR 2002B
Steve Rigsby RTR MR Senior MR Application Specialist Siemens Medical Solutions, Inc. USA

Objective:
■ To perform contrast enhanced MRA of upper extremity from the arch to distal portion of a single extremity

Materials used:
■ Siemens MAGNETOM Sonata with syngo 2002B software and panoramic table option ■ Receive coils used: CP Body Array, CP Spine Array, and the CP large Flex coil. ■ MR compatible power injector ** ■ Intravenous catheter **

MR Imaging Protocol:
1. II Scout_lower arm_0mm 3 plane scout with lateral offsets of the sagittal images to include both forearms 2. I Scout_chest_up arm_350mm 3 plane scout with lateral offsets of the sagittal images to include both humerii 3. I fl3d_chest_up arm _350mm 3D FLASH coronal sequence TR: 3.5 TE: 1.2 slice thickness: 1.8 no. of slices: 52 4. II fl3d_lower_arm_0mm 3D FLASH sagittal sequence TR: 4.4 TE: 1.5 slice thickness: 1.4 no. of slices: 60 5. Pause for contrast Trigger for inline pre/post subtraction 6. Carebolus-cor New inline subtracted gad bolus tracking sequence in the coronal plane Copy reference “adjust volume” from sequence 3 7. I fl3d_chest_up arm_350 Copy reference "everything” from sequence 3 8. II fl3d_lower_arm_0mm Copy reference “everything” from sequence 4 106 matrix: 416x512 FOV: 320x400 centric reordered k space filling large FOV filter matrix: 352x512 FOV: 280x400 fat sat selected large FoV filter

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Procedure:
* The patient is placed in the supine position on the MR table, in a head first orientation. The patient’s chest is positioned at the level of spine coil elements two and three, with the body array coil positioned parallel to these coils and off set to the extremity of interest. Next the large flex coil is wrapped around the forearm of interest in a spiral fashion and secured in place with the gray Velcro straps. This coil will cover from the elbow to the palm of the hand. The “tail” of the coil and the coil interface box are positioned to point into the magnet. The forearm and hand are positioned in a sagittal orientation (to stop the hips and body from aliasing into the image). The elbow and forearm is supported with sponges and all coils secured with table straps (Fig. 1). An intravenous line is inserted into the unaffected arm. This is now connected to the power injector with extension tubing. Center the laser light to the center of the large flex coil (forearm), then move the patient into the center of the magnet. The patient is registered and all sequences moved from the above protocol into measurement queue at one time. This will enable auto copy of parameters and tuning adjustments to take place. The first two scouts will run and the table will automatically move the required 350 mm as programmed in the sequences. When these are completed the table will be in the chest_upper arm location (350 mm) and the I fl3d_chest_up arm_350 pre-contrast scan is positioned on the localizer of corresponding table position (350 mm). This sequence is run using a breath-hold technique. After this scan is completed, the II fl3d_lower_arm_0mm pre-contrast

Figure 1 Patient positioning.

sequence is opened and this positioned on the localizer with corresponding table position (0 mm). This sequence is set up in a sagittal orientation to remove the possibility of aliasing from the hip/body anatomy. An injection pause is now the next step in the measurement queue. This pause serves an important purpose. After the contrast box has been selected on the “pop-up” menu, this will be the marker to the system that sequences of like names to the above fl3d scans should be “inline” subtracted and orthogonal MIP images should be created. The continue button should be selected, marking everything from this point post contrast. Next the Carebolus-cor Gadolinium bolus tracking sequence will open. This is positioned over the arch of the aorta. At this point a popup window will ask you to verify if further scan adjustments should be performed “automatically” or “manually”. Since these adjustments were done on the pre-contrast, and also since the post contrast have “copy adjust volume” selected, you do not need another adjustment. The postcontrast sequences have “copy references” installed in the parameters to automatically position everything including tuning values from the pre-scans.

Always choose “Manual”, otherwise the post sequences will perform tuning functions before actually running the scans, thus losing arterial phase and receiving only venous phase images. Commence the carebolus scan. “Online display” will open in the exam task card. This sequence also has inline properties for automatic subtraction (Maestro Class). After starting the scan no images will appear in the “online display” for 3-4 seconds as steady state must be reached first to rid inflow artifacts (bright blood with no contrast). Once the first image is seen in the online display, the contrast should be injected. Wait until the contrast reaches the arch and can be seen in the subclavian artery as well, then select the “stop and continue” icon in the online display window. This will stop the carebolus sequence and run the I fl3d_chest_up arm_350 and the II fl3d_lower_arm_0mm sequences. Thus they will scan and follow the contrast flow down the arm as the table moves. Each of these post contrast sequences are pre-defined to automatically subtract and create MIPs in the coronal and sagittal plane. The resulting images are seen in Fig. 2 and Fig 3.

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Notes
* The information presented 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. Figure 2 CP Body Array Coil ** Some of these non-Siemens devices described in the article may be pre-product prototypes that may not have completed US FDA, European CE Mark or other reviews for safety or effectiveness that are necessary prior to commercial distribution of these devices. Some devices may not be available in all countries where Siemens has systems.

CARE Bolus package

■ CARE Bolus for excellent ceMRA with optimum contrast useage

■ Fastest switching from 2D to 3D measurements for good results

■ Centric, elliptical phase reordering for excellent contrast

Figure 3 CP Large Flex Coil

Siemens makes no claims as to the patient/staff safety, MR compatibility, or clinical capability of any of the non-Siemens devices included in the article. Before introduction of any device into the MR suite, the device should be inspected by qualified hospital personnel, and the nonmagnetic properties of the device and its clinical operation in the magnetic field verified before it is used in a procedure. Use of these devices for animal or human procedures must comply with any applicable Governmental or local hospital safety and animal/human studies committee’s requirements.

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FAQs Cardiac Imaging
Michaela Schmidt Cardiovascular MRI Advanced Application Specialist Erlangen, Germany

1. How can I get the best image quality with dark blood sequences?
The dark blood (db) pulse is used to null the blood signal and improves the image quality for morphological imaging significantly. It consists of a non-selective inversion directly followed by a slice selective re-inversion pulse, played out directly after the trigger event. ■ For good image quality, it is necessary to shift the measurement to the time in the cardiac cycle when the heart has moved back to the same position it held when the dark blood pulse was applied. The measurement can be shifted with the parameter TR (Fig. 1). ■ For patients with long RR-Intervals a longer TR is required – but not higher than 800 ms. For patients with short RR-Interval a shorter TR is required.

Figure 1 TR – TRmin = waiting period

TR min = data acquisition period In case of poor image quality shift the TR in steps of 50 ms in either direction.

Figure 2a TR is too long, there is already signal from the blood

Figure 2b TR is too short, the slice which has seen the re-inversion pulse hasn’t moved back to its original position. No signal from the myocardium.

TIP:
When you cannot optimize both the myocardial signal and the black blood, the image with better myocardial signal is preferred (TR too long).

Figure 2c Optimal TR.

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aVR (-150 deg.)

aVR (-30 deg.) I (0 deg.)

-aVR (30 deg.) III (120 deg.) aVR (90 deg.) II (60 deg.)

2. How can I get a good ECG trace?
■ Prepare the skin Clean wet or oily skin with a dry paper towel and remove hairs. Never use alcohol to clean the skin as this would remove the electrolytes. ■ Use appropriate electrodes Do not use old or dry electrodes, or MR-incompatible electrodes. If you have to reposition the leads, always use new electrodes. ■ Position electrodes with care Avoid positioning the electrodes on the breast muscle, or remote from the heart. ■ Check the ECG trace If necessary, reposition the electrodes until you get a robust signal with a high and clear QRS complex, and a small flow artifact (at location of T- wave).

The projection of the electrical vector of the myocardial activation onto the body surface depends on the orientation of the heart. The best result is achieved when the electrodes are positioned along the heart electrical axis (usually the same as the long axis of the left ventricle) Figure 4 The heart axis of tall and/or young patients is more likely to be vertical.

Figure 5 The heart axis of older and/or big patients is more likely to be horizontal.

Figure 6 There are two ways of positioning standard leads. Figure 6a shows frontal positioning on the chest which allows better signal and higher patient comfort but sensitive to patient positioning. Figure 6b is the positioning on the back which is a bit further from the heart compared to the frontal positioning and thus giving less signal but is not as sensitive to the respiratory motion as the frontal positioning. Figure 7 During positioning of the active leads you have to keep in mind that the amplifier can vibrate during scanning so the ECG leads should be positioned within the cushion. On women with large breasts, the ECG may also be positioned above the breast or directly on the sternum. Figure 6a

Figure 6b

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3. How do I perform flow quantification measurements at the Isocenter?
The accuracy of quantitative flow measurements is improved significantly by scanning at the isocenter (Fig. 8).

Figure 8 Note the change in signal intensity in the stationary chest wall tissue from left to right in the off-center image (Fig. 8a), and the significant reduction of this effect when scanning at the isocenter (Fig. 8b).

Figure 8a

Figure 8b

STEP BY STEP: A. Perform examination as usual and position your slice for flow quantification. B. On the Routine card, look for the Head-Feet position (Position mode LPH) of your slice, note it, and change it to 0. (Fig. 9)
Figure 9

C. On the System card, type in the old Head Feet slice position as new Scan Region Position. The scan assistant will inform you that the reference images will be unloaded from the GSP. Click OK. (Fig. 10)

Figure 9

Figure 10

D. Start scan

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4. How do I localize the coronary arteries? STEP BY STEP: A. Acquire a multi-slice TrueFISP localizer B. On a coronal slice, position a transverse HASTE localizer (Fig. 11). If HASTE image quality is poor, try a FLASH sequence with fat sat. The localizers must be acquired in the same way as the subsequent 3D measurements i.e. in inspiration or in expiration. For free breathing navigator measurements, use localizer in expiration. C. On the transverse HASTE images, position a stack of coronal HASTE slices (Fig. 12) D. Examine the images and identify the coronaries. In case you cannot find them, repeat the localizers with thinner slices (4 mm, no gap), when you have to deal with very small arteries. Check the timing of the HASTE acquisition.

Figure 11

RCA

LAD

Figure 12

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In patients with fast heart rates, better quality localizer images might be obtained with a FLASH sequence with fat saturation than with a HASTE sequence (Fig. 13).

RCA

Figure 13

Instead of transverse slices, one can use a stack of 4-chamber views to localize the RCA (Fig. 14).

Figure 14 RCA

E. It is important to scan during that period of the cardiac cycle when the coronaries are not moving. The localizer should be acquired at a similar time in the cardiac cycle as the 3D images. In most patients, the time of least motion is during diastole (Fig. 15).
CINE Figure 15

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F. Use the 3 point localizer to define the orientation and position of your slab/ slice on suitable localizer images. It is recommended to perform first a fast breath-hold 3D acquisition to check for correct positioning (Fig. 16).

Figure 16a

Figure 16b

Figure 16c

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G. What is the difference between prospective triggering and retrospective gating?

Prospective triggering The measurement is driven by the ECG. Data is acquired after a trigger signal (R-wave) is detected by the PMU. The acquisition window should be set about 5-10 % less than the average R to R interval. Only during this time is data acquired. No data is acquired during the time between the end of the acquisition window and the next R-wave.

R

R

Acquisition window Data acquisition

Acquisition window Data acquisition

Acquisition window Measurement

Acquisition window

Retrospective gating The measurement runs continuously and independent to the ECG.Each measured line gets a PMU time stamp relative to the trigger event. The data is sorted after the measurement is finished. The acquisition window should be set 10-20% higher than the average R to R interval. Advantages: the entire cardiac cycle can be imaged; the number of phases can be defined by the user and this is independent of the measurement time.

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Peripheral MRA with iPAT
R. Banach – Planchamp M.D. Institut fur Angiologische – Kardiologische Kernspintomographie, Krefeld, Germany system which causes strong enhancement with only a little amount of the CM. The real revolution in peripheral MRA was the introduction of iPAT. Slice thicknesses between 1.7 and 1.3 mm in plane resolutions ranging from 1.56x1.56 to 1.39x1.25 increases the certainty in diagnosis of most pathologies including renal artery stenosis (Fig. 1). The very fast table motion which optimizes the workflow is also another positive factor which has affected our decision in shifting to MRA from diagnostic DSA in the diagnosis of peripheral arterial diseases. In addition to the use of non-nephrotoxic contrast material and the absence of radiation, MRA images also allow 3D post-processing so that oblique projections can be generated and vessel diameters in stenosis can be more accurately measured. Only a very little amount of CM that passes through sub-total stenosis is required for a detailed visualization of the distal segment, whereas in such situations DSA is generally unsuccessful (Fig. 2). A certain amount of information about plaque composition can also be obtained. Target organs like the kidneys can also be evaluated with 3D techniques. The success of MRA is dependent on the coordinated efforts and works of clinicians, surgeons and radiologists. The surgeon who is to operate has to understand the details of this cross sectional imaging technique and related post-processing, where the need for radiological experience is apparent.

In this article we shall discuss practical experiences with iPAT technique in the area of “Stepping Table Peripheral MRA”. Today when we talk about peripheral MRA, thanks to the Large FoV adapter, we think of a coverage starting from the aorta and reaching down to the distal vessels of the leg. Our institution has possessed a MAGNETOM Sonata system since December 2001. In an environment where different clinical departments make use of the system, the major use of the system has been for cardiovascular imaging. It is a pleasure here to say that thanks to the very convincing image quality from day one, the 1200 bed “Klinikum Krefeld” – our major clinical partner – has replaced diagnostic digital substraction angiography (DSA) with MRA. This decision has of course been influenced by the fact that MR is a modality without any x-ray exposure. We have been using Gadovist 1M (Schering, Berlin) which allows use of a smaller amount of bolus in comparison to the 0.5 M contrast medium. It is also worth mentioning here that the control of the CM is a little bit difficult with 1M. For most applications, a small amount of Gadovist in MRA allows the visualization of distal and collateral vessels in cases of complete occlusion and severe stenosis. Timing errors, hyperemia or slow table movement can cause an overlapping signal from the venous system. The high concentration of Gadovist has the same impact in the venous system as in the arterial 116

How do we achieve this?
MRA has been in routine radiological practice for quite a long time. One of the most important challenges of this application is the prevention of Figure 1 Peripheral MRA covering from aorta to distal vessels showing left renal artery stenosis.

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Figure 2a/b Peripheral MRA showing multiple occlusions and distal filling through collaterals.

Figure 2c/d/e show the same patient’s DSA results.

venous enhancement which creates an obstacle by the overlapping of veins over arteries. This carries more importance in peripheral MRA examinations where you have to follow the contrast bolus. This can only be achieved by fast table motion and shorter acquisition times. Another important factor is that the sequences for distal parts should have the ability to measure the central Fourier lines first, followed by the peripheral lines which will also help obtaining arterial information in a timely manner. 3D data can be obtained between 10 and 20 secs. The contrast arrival time can be estimated by test bolus techniques, or another solution for timing is to use the real time CAREBolus technique. The first step of the angiography is the decision point for Care Bolus, which is the aorta in our peripheral MRA examination. This means that after real-time visualization of the arrival of the CM and filling of the aorta, the examination is commenced with an automatic scan of 3 or 4 sequential steps. The examination time for each region is 15-20 secs. The distal leg is scanned in 40 to 50 secs from the start of the examination, which is generally sufficient for viewing the “only arterial” phase. Whenever the circulation time of the patient is shorter or there is early venous enhancement due to arterio-venous shunts (especially with infections in extremities), you need shorter scan times. With 2002B Software, there is increased speed in table motion and iPAT also decreases the examination time by 50%, which helps provide a more accurate diagnosis.

iPAT in Peripheral MRA
In contrast to traditional sequential measurement techniques, mSENSE and GRAPPA are parallel imaging techniques. The spatial resolution of 117

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the image is no longer determined solely by the acquired, gradientencoded echoes. With mSENSE and GRAPPA, additional spatial information is obtained from the spatial variation in the coil intensity profiles during measurement with array coils. Thus, fewer echoes are measured with mSENSE and GRAPPA than would be needed to obtain the desired resolution with a traditional technique. In simple terms, this is nothing more than a measurement with a rectangular field of view (RecFOV). The only “trick” with mSENSE and GRAPPA is the elimination of the aliasing that occurs with traditional techniques. This is the result of the additional information that one can gain from the intensity profiles of the individual coils during measurement with array coils. In peripheral MRA, we prefer GRAPPA as it is less sensitive to foldover (aliasing) artifacts.

patients with contractions which do not permit the placement of coils are also unable to be examined with MR.

Patient Preparation
The patient has to be comfortable but at the same time must not move: this is very important as motion artifacts can cause additional diagnostic problems. We use the combination of CP Peripheral Angio Array Coil, CP Body Array coil and CP Body Array Extender. The use of Large FoVAdapter allows the extended coverage of the aorta. For iPAT applications it is important that there should be a gap between the examined part and the array coils, so we use flat cushions between and under the coils. Anxious patients should be sedated. We also use spasmolytic agents to prevent bowel motion artifacts which can hinder diagnosis in the abdominalpelvic area. The use of elastic material above the ankle joint to prevent the filling of superficial veins can cause early filling of the deep venous structures which is very difficult to get rid of in post-processing. We generally prefer the cubital vein access and inject 15 ml Gadovist with an injection rate of 0.7 ml/sec and follow this with 20 ml NaCl at the same rate. The patient condition must always be kept in mind: for example, the injection rate must be higher in patients with heart failure. Use of 1M in comparison to conventional CM will allow you to decrease the volume injected, as mentioned before it is a little difficult to control injection and optimum enhancement with 1M agents. Of course the bolus time will be extended due to the circulation through the heart and pulmonary circulation. Here you must be very careful with the timing and we advise you to start scanning after optimal filling of the aorta.

Indications
Indications for peripheral MRA are all arterial diseases, including fistulas and postoperative states. For the planning of MRA it is very important to know about existing bypasses like femoro-femoral or more important axillo-femoral bypasses which have to be included in the scout images: additional slices or oblique projections may be required. Furthermore, certain stents should not be confused with stenosis or occlusion due to the signal loss created by metallic artifacts (Fig. 3). We prefer to allocate part of the day for the examination of peripheral angiography patients and our department employs two technologists dedicated exclusively for this examination. In addition to the usual contra-indications for MR, such as pacemakers and stimulation systems,

Figure 3 Stents in the right common iliac and left external iliac arteries. 118

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Examination
The Siemens protocols are directly applicable in routine practice with just patient-specific small changes and they allow the examination of each step in 8-10 secs with an iPAT factor 2, which is almost twice the speed of conventional techniques. The inclusion of all vessel segments is sometimes difficult due to bypasses (Fig. 4) and sometimes at the pelvic level the iliac arteries can make a deep curve. In both situations you need to add additional slices and maybe change the number and orientation of the ToF 2D scout slabs. Particularly in patients with aneurysms, we use additional TrueFISP sequences at each level to be able to show the thrombosis and vessel wall in detail. With Care Bolus technique in patients with aneurysms it is important that the para-sagittal slab also covers the parts distal to the aneurysm so that you can adapt your timing to the delays caused by CM pooling in these aneurysmal sacs (Fig. 5). The Care Bolus technique allows real time observation of the arriving contrast bolus and it would be wise to place the coronal slab over the whole aorta including part of the heart. You should commence with breathing orders as the right ventricle and pulmonary arteries fill with contrast. The examination should start when you see the filling of the aorta. In the Siemens protocol tree with “Care Bolus”, the sequences for the distal leg vessels are centrically reordered which allows you to hinder venous filling. These centrically reordered sequences might also be used for examination of other vessels where the early filling of venous structures might cause problems: a good example would be the hand vessels. 119

Figure 4a Y prothesis and femoro-popliteal by-pass on the right side.

Figure 4c Y prothesis and occlusion of the left superficial femoral artery

Figure 4b Crossover by-pass

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Figure 5 Aneurysm of distal aorta and iliac vessels.

Post-processing
Post-processing includes the steps of subtraction, volume rendering or MIP. The detailed evaluation of suspicious areas, such as stenosis evaluation, may be achieved by dedicated MPR and volume rendering techniques (Fig. 6). Another step in evaluation could be the stent size planning by an exact measurement of the vessel’s diameter and the length of the stenosis by state of the art post processing tools like “Vessel View”. A useful tip would be that total dependency on post-processing results is not the right way to go as there is very useful information in raw data images which can be overseen only by looking at the MIP images. Another advantage of raw data images is that they allow you to see plaques and thrombosis which do not cause any stenotic changes in the MIPs. Peripheral structures seen by raw data images will also bring useful information, especially in the abdominal-pelvic area where there might be hidden pathologies in the kidneys or liver.

Initially, we always kept in touch with our vascular surgeons and referring clinicians in order to develop a common way for evaluating and grading stenosis. They were used to DSA images and we had to find a way to encourage them to understand the MRA results in line with their previous experiences. Accordingly, we had and still have regular consultations with our clinician colleagues where we compare the DSA results with those of MRA. Our grading is as follows: non-stenosing plaqueminimal – middle – high grade stenosis and total occlusion. Highgrade stenosis should be evaluated with 2D ToF sequences to be able to see the minimal flow through those stenotic areas and its direction.

Future Directions
iPAT has been a giant step in MRA of the peripheral vessels as, thanks to its speed, venous overlap seems not to be a big issue in examination of the aorta, iliac vessels, femoral and distal vessels. Of course, in the future we anticipate solutions very similar to DSA practice today, which means that each step is triggered after the arrival of the bolus and starts scanning centrically allowing real-time evaluation of the anatomical area. The greatest problem we face today is due to possible motion artifacts caused by the time difference between the non contrast enhanced images of each step and the contrast enhanced images (in MRA each step is scanned first without contrast, then the table returns to its original position and after contrast injection the examination starts with the arrival of the contrast and followed by automatic movement of the table). A motion correcting post processing algorithm based on 3D pixel shift would be extremely useful.

Other Applications
iPAT with moving table might also be used for the evaluation of the upper extremity. Dynamic MRA with iPAT can be used to evaluate the circulation in the pulmonary vascular system. Showing perfusion characteristics in aortic dissections and evaluation of dialysis shunts are other possible applications.

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Figure 6 Volume rendered images from peripheral MRA examination.

Acknowledgements:
I would like to thank our technicians A.Hünnekens, W.Kaartz, M.Nitsche, N. Zimmermann and of course W.Chwilka.

Institut für Angiologische – Kardiologische Kernspintomographie, Krefeld, Germany
PD Dr. V. Fiedler, Diagnostic Radiology Prof. Dr. HG. Klues, Internal Medicine/Cardiology Dr. R. Banach – Planchamp, Diagnostic Radiology Dr. R. Ott, Internal Medicine/Cardiology The Institute for Cardiovascular MRI was established on December 12, 2001. The objective of this private initiative was to install the latest generation magnetic resonance imaging (MRI) system in Krefeld. In addition to patients from private practice, patients from the hospital in Krefeld are also being examined in the institution, enabling all to benefit from this latest diagnostic technology. 121

Figure 7 Dynamic MRA showing anomalous drainage of upper veins of the lung into superior vena cava.

Future developments in technology will hopefully allow high resolution examinations of the micro and macro-angiopathies in the hands and feet.

Image examples: examinations were performed with the combination of CP Body Array, CP Body Array Extender, CP Peripheral Angio Array Coil, Large FoV Adapter and CP Spine Array Coil. At each step the phase encoding direction was from right to left. The PAT factor was chosen as 2 to minimize the examination time to approximately half that of routine exams. Each table movement was 333 mm, FoV 380-400mm. 4 different table positions with 3 table motions are preferred. For the abdomen, Body Array Elements 1-2 and spine elements 3-6 were chosen. For the pelvis, Body Array Elemets 3-4, Spine 3-4 and PR 3-4 and PL 3-4 were chosen. For upper leg PR 2-4 and PL 2-4 and lower leg PR 1-2 and PL 1-2 were chosen.

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MAGNETOM World Summit
South Beach, Miami September 17–19, 2003

Agenda
MAGNETOM World Summit 2003, South Beach, Miami Wednesday, September 17th 06:00–8:00P.M. Thursday, September 18th 07:30–8:30 A.M. 08:30–9:30 A.M. Block A: 3 T Imaging 09:30–10:00 A.M. 10:00–10:30 A.M. 10:30–11:00 A.M. Block B: Neuro Imaging 11:00–11:30 A.M. 11:30–12:00 A.M. 12:00–12:30 P.M. 12:30–1:30 P.M. Block C: Cardiac Imaging 01:30–2:00 P.M. 02:00–2:30 P.M. 02:30–3:00 P.M. 03:00–3.30 P.M. Block D: Business Models 03:30–4:00 P.M. 04:00–4:30 P.M. 04:30–5:00 P.M. 05:00–5:30 P.M. 05:30–6:00 P.M. 07:30–11:00 P.M. Optimizing Clinical Throughput Tech, Tips & Tricks for Optimizing Clinical Throughput Whole Body Screening Technology – Parallel Imaging – Benefits Outpatient Imaging (Non-Hospital Segments) Evening Social Cardiac Viability Radiologists and Cardiologist – Working Together Self-Gated Cardiac Imaging Coffee Break Trends in Neuro Imaging iPAT Neuro Applications Spectroscopy in Clinical Practice Lunch 3T Clinical Imaging (incl. Orthopedics) Safety in 3T Imaging Coffee Break Breakfast Opening Welcome Reception

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Friday, September 19th 07:30–8:30A.M. Breakfast Block E: Body Imaging 08:30–9:00 A.M. 09:00–9:30 A.M. 09:30–9:45 A.M. 09:45–10:00 A.M. 10:00–10:30 A.M. 10:30–11:00 A.M. 11:00–11.30 A.M. 11:30–12:00 A.M. 12:00–1:00 P.M. 01.00–1.30 P.M. 01.30–2.00 P.M. Pediatric Imaging Tech, Tips & Tricks (Pediatric Imaging) State-of-the-art in Breast Imaging Advances in Breast Imaging with iPAT Coffee Break Angiography in Clinical Practice Musculoskeletal MR Virtual Colonoscopy Lunch iPAT Imaging in Clinical Practice Perfusion of Kidneys and Lung with MRI

EVENTS


Registration Form

Please complete this form below. If several people from your institution will be participating, please complete this form for each attendee. Forms must be received before July 20, 2003. You may either fax it to 610-448-1534 or mail it to Raya Dubner, Siemens Medical Solutions, USA, Inc., 51 Valley Stream Parkway, Malvern, PA 19355, USA.

(Please Print Clearly) Name: Title: Institution:
Terms & Conditions

Mailing Address (Include Country):

Telephone (Include Country Code): E–mail address: Will you be bringing a guest ❏ YES ❏ NO Departure Date: ❏ Double Occupancy

Upon submission of the registration form attached, or completion of registration through SiemensMedical.com/MAGNETOMWorld, you will automatically be registered for the MAGNETOM World Summit 2003 Meeting on September 17–19, 2003, in South Beach, Miami. You do not have to call the hotel to reserve a room, it will automatically be reserved for you. Please register no later then August 1, 2003. If you need to cancel, please do so by August 31, 2003.

Arrival Date: ❏ Single Occupancy

Name of roommate, if also Ambassador attendee:

Please indicate specific issues that you would like addressed by Siemens during this session:

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20 Years of Development and a Constantly Improving Performance = MAGNETOM
Peter Kreisler, Ph.D. Collaborations and Applications , Erlangen, Germany An 0.2T prototype system was the first Siemens MR to be installed in a clinical environment. The system – based on a resistive 0.2T magnet – was installed at the Medizinische Hochschule of Hanover (MHH), Germany. In 1983, the first MAGNETOM with a super-conducting 0.35T magnet was delivered to the Mallinckrodt Institute in St. Louis/ USA. This system was the first member of a product family that has increased in size and in technical and clinical performance. Let’s look at some of the components and subsystems. more than a year. One interesting developmental step was the introduction of a magnet system with an integrated helium liquefier: the Helicon. However, because of new magnet designs and helium saving developments, the direct integration of a liquefier turned out to be no longer economically beneficial and the development was discontinued. Today’s magnet trends are towards increased openness, lower helium consumption and lower total costs.

Space requirements
The magnet’s fringe field is one of the parameters that define the space requirement of an MR system. Another parameter is the amount of hardware needed. The first systems in the 1980s comprised a total of 12 cabinets fully packed with electronics. As we all know from the revolutionary changes in computer technology, electronics became integrated to a very high degree. The entire system electronics and supplies can be put into two cabinets today, with a much higher performance than in the past.

Magnets
Figure 1 The first MR image from Siemens: Red pepper Working in the field of MR for almost 20 years, it has been really impressive to see the developmental steps that have taken place over this time. Siemens’ involvement with MR development began in the late seventies, but it was the first images of a red pepper in1980 which were to some extent the “starting signal” to set Siemens off to a flying start in the field of MAGNETOM product development (Fig. 1). The early super-conducting magnets were relatively large (2.55 m long) and heavy (~8 tons for 1.5T), they had a large fringe field since they were not shielded at all, and they required very frequent liquid gas refills (nitrogen every two weeks and helium every 6 weeks). Over the years passive iron shielding was introduced – with weights of 21 t and 31 t (Fig. 2); active shielding was created; the magnets became smaller and lighter; additional nitrogen was no longer needed and the refill intervals for helium were extended to

Gradients
The gradients used for spatial encoding – as for several contrast mechanisms – are one of the essential components for MR imaging. Tremendous improvements have been developed and implemented over the last two decades. The following table summarizes the main steps.

Figure 2 Magnets with passive shielding. 21 t or 31 t of iron was needed to reduce the magnetic fringe field. 124

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MAGNETOM Trio MAGNETOM Maestro Class MAGNETOM Rhapsody MAGNETOM Harmony, Symphony, Sonata (syngo based), Concerto MAGNETOM Allegra MAGNETOM Harmony, Symphony, Sonata MAGNETOM Vision Plus, Open Viva MAGNETOM Impact Expert MAGNETOM Vision, Open MAGNETOM Impact, P8 MAGNETOM SP and SP 4000 MAGNETOM 42/63 (GBS 2) MAGNETOM M/H (GBS 1)

1983

0.2T Prototype
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1983
MAGNETOM M 3 mT/m 1.5 ms

RF System
The first units were delivered with an integrated body coil and a head coil – nothing more. Knowing that a higher signal-to-noise ratio was essential for the future success of MR, our physicists and engineers started the development of dedicated surface coils and smaller volume coils: they created the 10 cm eye/ear coil (Fig. 3), a breast coil and an extremity coil, and a spine coil would follow. also soon be available.

1986
MAGNETOM SP 10 mT/m 1 ms

Some of you will remember the manual tuning of these special coils with the two long sticks, whilst staring at the small digital display. All these coils were based on an LP (linearly polarized) design. With MAGNETOM 42 and 63 (GBS2 systems), CP coils (circularly polarized) were introduced, with a gain in signal-to-noise of 40%. In 1991, the first prototypes of array coils were delivered, a development which resulted in the Integrated Panoramic Array (IPA) concept, introduced with MAGNETOM Harmony and Symphony (Fig.4). And today, the IPA coils form the basis for the parallel imaging techniques like mSENSE and Grappa which are now integrated into the MAGNETOM Maestro Class product line. All these developments have helped to broaden the range of applications by increasing the signal-to-noise and/or by increasing the speed of the examinations.

1991
MAGNETOM Vision 25 mT/m 0.6 ms

1999
MAGNETOM Sonata 40 mT/m 0.2 ms

1999
MAGNETOM Allegra 40 mT/m 0.1 ms

And the development continues. In 2002, the prototype of a gradient insert coil, especially for head and small animal studies, has been created with a gradient strength of 80 mT/m and a rise-time as short as 0.1 ms (800 T/m/s). Figure 3

Even more important than these horse power numbers are the improved and advanced applications that became available based on this powerful hardware. Think about the fast imaging techniques in ce-MRA and abdominal imaging, think about EPI in diffusion weighted scans, or look at all the “bread and butter scans” – like the fast T2-weighted sequences routinely used today.

Figure 4 IPA Coil Combinations, iPAT compatible!

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Computer configuration and data handling
As already mentioned, computer development has been terrifically fast. This has also been reflected in the changes of the computer configuration in the MAGNETOM systems: VAX11/730 and VAX 11/750 together with a BSP11 image processor in the GBS1 systems, MicroVax2 and later Microvax 4000 in the MAGNETOM SP systems, then replaced by Sparc2 and turboSparc in combination with the SMI 5 for fast image reconstruction and today the combination of high performance PC systems with GHz processors. Just remember the increase in speed for the image reconstruction by using the 2D Fourier transformation. 1984: 6.8 seconds per image in full 2562 matrix, and today less than 6 ms. Or consider the amount of data generated. In 1983, typically much less than 100 images per patient were measured. The images were filmed with analog monitor based cameras like the MULTISPOT M. Some of the “most interesting” images were stored digitally on a floppy disc (three images per side). Today hundreds to thousands of images are the result of a complete patient examination with new challenges for processing, networking and archiving.

variability between the human tissues, and additional contrasts and parameters are used for diagnosis. Scan times were rather long in the early 80’s. A T2 weighted scan using a spin-echo sequence took easily a quarter of an hour. All developers sought faster sequences. Let’s look at some steps:

using Gadolinium-based contrastagents and CARE-Bolus techniques. A 3D scan of the carotid arteries takes only a few seconds. Dynamic angio scans can be performed with good temporal resolution. Today, MRAngio is applied from head to toe. Over the years, therefore, Siemens has been the first to develop unique sequences and imaging techniques that increased speed and resolution, or offered new contrasts or new applications, such as MP-RAGE, CISS, DESS, HASTE and TrueFISP. And finally, let’s not forget spectroscopy, the oldest MR technique. Spectroscopy has been a tool for chemical research since the 1940’s. And the MAGNETOM systems offered spectroscopy capabilities almost from the start. In 1984, 1.5T MAGNETOM systems allowed phosphorus spectroscopy, in 1985 a sodium head coil was available as a product together with sequences for imaging, and shortly after fluorine spectroscopy was put into the product. Today, clinical spectroscopy is mainly done with hydrogen protons, but there is still a lot of interest in the use of other nuclei. To bring spectroscopy to clinical routine, its use – scanning and post-processing – must be easy. With the syngo based software, a lot of effort has been put into a stream-lined workflow for spectroscopic examinations. Overall, we can look back over twenty years of exciting and fascinating developments. And we are looking forward to further developments that will make the future even more exciting.

1983:
Spin Echo

1985:
Half Fourier

1987:
Gradient Echoes FLASH and FISP

1989:
Turbo-FLASH

1990:
Turbo Spin Echo

followed by hybrid-techniques like Turbo Gradient-Spin-Echo, and the single shot techniques , tse240, HASTE, segmented gradient-echo sequences, and finally EPI. In the meantime, EPI has become an indispensable tool in brain-imaging and brain-research. The single shot scan times can be cut down to less than 50ms for a single image. Or remember the steps in MR-Angiography, starting in 1985/86 with FLASH2D for sequential slice-by-slice measurement in a time-of-flight manner. The technique became extended to 3D, to automized 3D multi-slab and to the faster TurboMRA. No contrast agent is required. Nevertheless, the MR-angio scan of the carotids typically took more than 10 minutes. And now? More and more MRA scans are performed with fast 3D-gradient-echo sequences,

Sequences
The NUMARIS software for the first MAGNETOM system enabled the user to perform Spin-Echo measurements – T1 and T2 weighted – and T1 weighted Inversion-Recovery scans. Virtually from the start, quantitative T1 and T2 calculations could be performed, hoping that by knowing T1 and T2, all tissue types were characterized. But there is a larger

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The information in this document contains general descriptions of the technical options available, which do not always have to be present in individual cases. The required features should therefore be specified in each individual case at the time of closing the contract. Siemens reserves the right to modify the design and specifications contained herein without prior notice. Please contact your local Siemens Sales representative for the most current information. Original images always lose a certain amount of detail when reproduced. This brochure refers to both standard and optional features. Availability and packaging of options varies by country and is subject to change without notice. Some of the features described are not available for commercial distribution in the US.

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Letters to the Editor – We welcome your comments about the content of MAGNETOM Flash. Please send comments to the Editor. Include your name, address, and phone number or e-mail. World Wide Web – Visit us at www.siemensmedical.com and www.siemensmedical.com/MAGNETOM-World This sites provides information about all Siemens medical products. Publish articles? – You are invited to publish articles in the newsletter to share your experience with MAGNETOM MR users all over the world. To submit an article please contact the Editor. Subscription – You have seen the newsletter and want to get it on a regular basis? In the US, please contact the Applications Helpline (phone 800-888-SIEM) and give us your name and business address (no home addresses, please). Outside the US, MAGNETOM Flash is distributed through the local Siemens offices. Please contact the Editor and we will make sure that you are included on your local support office’s distribution list. Editor Ali Nejat Bengi, M.D, AliNejat.Bengi@siemens.com Published by Siemens AG Medical Solutions P.O.Box 3260, D-91052 Erlangen Correspondence and International Distribution Ali Nejat Bengi, M.D., Editor in Chief MAGNETOM FLASH Siemens AG Medical Solutions, MR Marketing Allee im Röthelheimpark 3 D-91052 Erlangen Phone: 49 - 91 31 - 84 - 75 99 Fax: 49 - 91 31 - 84 - 21 86 US Distribution MR APPLICATIONS HELPLINE Siemens Uptime Service Center 110 MacAlyson Court Cary, NC 27511 Phone: 800 - 888 - SIEM Fax: 919 - 319 - 28 64 All articles represent the techniques and opinions of the authors and may not represent specific recommendations or endorsements from Siemens Medical Solutions. Contact the authors directly for further information about their techniques and opinion.

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