Overview

The simplest way to think about the multitude of sequences available on modern scanners
is to divide them according to the dominant influence on the appearance of tissues. This
leads to a division of all sequences into proton density (PD) weighted, T1 weighted, T2
weighted, diffusion weighted, flow sensitive and 'miscellaneous'. A number of 'optional
add-ons' can also be considered, such as fat or fluid attenuation, or contrast enhancement.
This leads to a broad categorization as follows:
 T1
o gadolinium enhanced
o fat suppressed
 T2
o fat suppressed
o fluid attenuated
o susceptibility sensitive
 proton density
o fat suppressed
 diffusion weighted
 flow sensitive
o MR angiography
o MR venography
o CSF flow studies
 miscellaneous
o MR cholangiopancreatography (MRCP)
 a special T2-weighted sequence
o MR spectroscopy
o MR perfusion
o functional MRI
o tractography
Terminology
Intensity
When describing most MRI sequences we refer to the shade of grey of tissues or fluid
with the wordintensity, leading to the following absolute terms:
 high signal intensity = white
 intermediate signal intensity = grey
 low signal intensity = black
Often we refer to the appearance by relative terms:
 hyperintense = brighter than the thing we are comparing it to
 isointense = same brightness as the thing we are comparing it to
 hypointense = darker than the thing we are comparing it to
Annoyingly these relative terms are used without reference to the tissue being used as the
comparison. In some instances this does not lead to any problems; for example, a
hyperintense lesion in the middle of the liver is clearly hyperintense compared to the
surrounding liver parenchyma. In many other situations however use of relative terms
leads to potential confusion. Imagine a lesion within the ventricles of the brain described
as "hypointense". Does this denote a lesion darker than CSF or than the adjacent brain?
As such it is preferable to either use absolute terminology or, if using relative terms, to
acknowledge the comparison tissue e.g. "the lesion is hyperintense to the adjacent
spleen".
NB: the word density is for CT, and there are few better ways to show yourself as an MRI
noob than by making this mistake.
Diffusion
When describing diffusion weighted sequences, we also use the term intensity but
additionally we use the words restricted diffusion and facilitated diffusion to denote
whether water can move around less easily (restricted) or more easily (facilitated) than
expected for that tissue. Again many use these words as if they are absolute terms and
this leads to confusion (more on this issue here).
*
Why routine measurement of ADC values is important
By A.Prof Frank Gaillard
Most of us know that intracranial epidermoid cysts demonstrate restricted diffusion, and we look for high signal on DWI to make the diagnosis. What I
have repeatedly encountered, however, is confusion when the ADC maps are reviewed and the cyst content has signal similar to white matter, rather
than being as black as an acute ischemic stroke. This leads many to start doubting the diagnosis, despite all imaging being characteristic. So in this
quick post I will try and address the question "what do we mean when we say that epidermoid cysts demonstrate restricted diffusion", and to more
generally address the use of the term "restricted diffusion".

When we say "epidermoids demonstrate restricted diffusion" what

we mean is "compared to arachnoid cysts"

The problem arises from the fact that we grow up being exposed to the concept of restricted diffusion in the context of ischemic stroke. We are used to
saying "restricted diffusion is present consistent with an acute infarct". What we forget is that actually what we meaning is "this bit of brain restricts
diffusion of water more than it should, were it to be normal". Because of this we think of diffusion restriction dichotomously (ie present or absent) rather
than as a measure of a physical parameter, similar to say density on CT. So, when we say "epidermoids demonstrate restricted diffusion" what we
mean is "compared to arachnoid cysts" which is usually their differential. The presence of a degree of restricted diffusion categorically tells you that
this very high T2 signal lesion with low T1 and at least partial suppression on FLAIR does not contain CSF. In reality epidermoid cysts only moderately
restrict, roughly similar to white matter. Most of the high DWI signal is due to T2 shine-through.

Case 1

CASE 1: Typical right CPA epidermoid cyst, demonstrating vivid high DWI signal, and ADC value of 839 x 10-6 mm2/s (see whole
case)

Become familiar with normal ADC values and routinely measure them
and include them in reports.
Normal values
 I have been trying to encourage my registrars to become familiar with normal ADC values and routinely measure them and include them in reports.
You should become as familiar with these values as you are with CT Hounsfield units (HU). So below are a few typical values (see ADC article for
references; all values in x 10-6 mm2/s) followed by case examples:

 white matter: 670 - 800

 cortical grey matter: 800 - 1000

 deep grey matter: 700 - 850

 CSF: 3000 - 3400

Case 2

Case 2: Normal posterior fossa, cerebellar white matter ADC of 766 x 10 -6 mm2/s and CSF of 3498 x 10-6 mm2/s.

Case 3

Case 3: Typical middle cranial fossa arachnoid cyst with ADC values of CSF 3136 x 10-6 mm2/s (see whole case)

Case 4
 Case 4: Middle cranial fossa epidermoid cyst with ADC values of 720 x 10-6 mm2/s, similar to adjacent white matter (see whole
case)

If you compare the ADC values from an epidermoid cyst of say 700 to 800 x 10-6 mm2/s, to those obtained from acute infarcts or cerebral
abscesses then you will note that the ADC values in both of those situations are much much lower (more restricted).

Case 5

Case 5: Two day old infarct, with ADC values of 344 x x 10-6 mm2/s.

Case 6

Case 6: Cerebral abscess with ADC values of the pus of 500 x 10-6 mm2/s (see whole case)

Take home message

So what is the take home message? Diffusion restriction is a continuous scale ranging from approximately 3400 for CSF all the way down to 0, and to
say merely "restricted diffusion is present" is as meaningless as saying in a CT report that "density is present". Get used to the values you expect to
encounter and remember that invariably when you are talking about the presence of restricted diffusion it is relative to some other tissue. As you
become more comfortable with these values, you will find that you start using them in many other scenarios, such as predicting grade of gliomas and
assessing treatment response in high grade tumors.

T1 weighted sequences

T1 weighted sequences are part of almost all MRI protocols and are best thought of as the
most 'anatomical' of images, resulting in images that most closely approximate the
appearances of tissues macroscopically, although even this is a gross simplification.
The dominant signal intensities of different tissues are:
 fluid (e.g. urine, CSF): low signal intensity (black)
 muscle: intermediate signal intensity (grey)
 fat: high signal intensity (white)
 brain
o grey matter: intermediate signal intensity (grey)
o white matter: hyperintense compared to grey matter (white-ish)
Read more about T1 weighted sequences.
Contrast enhanced
The most commonly used contrast agents in MRI are gadolinium based. At the
concentrations used, these agents have the effect of causing T1 signal to be increased
(this is sometimes confusingly referred to as T1 shortening). The contrast is injected
intravenously (typically 5-15 mL) and scans are obtained a few minutes after
administration. Pathological tissues (tumors, areas of inflammation / infection) will
demonstrate accumulation of contrast (mostly due to leaky blood vessels) and therefore
appear as brighter than surrounding tissue. Often post contrast T1 sequences are also fat
suppressed (see below) to make this easier to appreciate.
Fat suppression
Fat suppression (or attenuation or saturation) is a tweak performed on many T1 weighted
sequences, to suppress the bright signal from fat. This is performed most commonly in
two scenarios:
Firstly, and most commonly, after the administration of gadolinium contrast. This has the
advantage of making enhancing tissue easier to appreciate.
Secondly, if you think that some particular tissue is fatty and want to prove it, showing
that it becomes dark on fat suppressed sequences is handy.
Read more about fat suppressed sequences.
T2 weighted sequences
T2 weighted sequences are part of almost all MRI protocols. Without modification the
dominant signal intensities of different tissues are:
 fluid (e.g. urine, CSF): high signal intensity (white)
 muscle: intermediate signal intensity (grey)
 fat: high signal intensity (white)
 brain
o grey matter: intermediate signal intensity (grey)
o white matter: hypointense compared to grey matter (dark-ish)
Read more about T2 weighted sequences.
Fat suppressed
In many instances one wants to detect edema in soft tissues which often have significant
components of fat. As such suppressing the signal from fat allows fluid, which is of high
signal, to stand out. This can be achieved in a number of ways (e.g. chemical fat
saturation or STIR) but the end result is the same.
Read more about fat suppressed sequences.
Fluid attenuated
Similarly in the brain, we often want to detect parenchymal edema without the glaring
high signal from CSF. To do this we suppress CSF. This sequence is called FLAIR.
Importantly, at first glance FLAIR images appear similar to T1 (CSF is dark). The best
way to tell the two apart is to look at the grey-white matter. T1 sequences will have grey
matter being darker than white matter. T2 weighted sequences, whether fluid attenuated
or not, will have white matter being darker than grey matter.
Read more about FLAIR sequence.
Susceptibility sensitive sequences
Being able to detect blood products or calcium is important in many pathological
processes. MRI offers a number of techniques that are sensitive to these sort of
compounds. Generally these sequences exploit what is referred to as T2* (T2 star) which
is highly sensitive to small perturbations in the local magnetic field. The most sensitive of
these sequences is known as susceptibility weighted imaging (SWI) and is also able to
distinguish calcium from blood.
Read more about susceptibility weighted imaging (SWI).
PD weighted sequences
Given that nuclear magnetic resonance of protons (hydrogen ions) forms the major basis
of MRI, it is not surprising that signal can be weighted to reflect the actual density of
protons; an intermediate sequence sharing some features of both T1 and T2.
Proton density images were extensively used for brain imaging, however they have
largely been replaced by FLAIR. PD however continues to offer excellent signal
distinction between fluid, hyaline cartilage and fibrocartilage, which makes this sequence
ideal in the assessment of joints.
The dominant signal intensities of different tissues are:
 fluid (e.g. joint fluid, CSF): high signal intensity (white)
 muscle: intermediate signal intensity (grey)
 fat: high signal intensity (white)
 hyaline cartilage: intermediate signal intensity (grey)
 fibrocartilage: low signal intensity (black)
Diffusion weighted sequences
Diffusion weighted imaging assess the ease with which water molecules move around
within a tissue (mostly representing fluid within the extracellular space) and gives insight
into cellularity (e.g. tumors), cell swelling (e.g. ischemia) and edema.
The dominant signal intensities of different tissues are:
 fluid (e.g. urine, CSF): no restriction to diffusion
 soft tissues (muscle, solid organs, brain): intermediate diffusion
 fat: little signal due to paucity of water
Typically you will find three sets of images when diffusion weighted imaging is
performed: DWI, ADC and B=0 images.
DWI
When we say "DWI" we usually are referring to what is in better terms an isotropic T2
weighted map as it represents the combination of actual diffusion values and T2 signal.
It is a relatively low resolution image with the following appearance:
 grey matter: intermediate signal intensity (grey)
 white matter: slightly hypointense compared to grey matter
 CSF: low signal (black)
 fat: little signal due to paucity of water
 other soft tissues: intermediate signal intensity (grey)
Acute pathology (ischemic stroke, cellular tumor, pus) usually appears as increased signal
denoting restricted diffusion. However (and importantly), because there is a component
of the image derived from T2 signal, some tissues that are bright on T2 will appear bright
on DWI images without there being an abnormal restricted diffusion. This phenomenon is
known as T2 shine through.
ADC
Apparent diffusion coefficient maps (ADC) are images representing the actual diffusion
values of the tissue without T2 effects. They are therefore much more useful, and
objective measures of diffusion values can be obtained, however they are much less
pretty to look at. They appear basically as grayscale inverted DWI images.
They are relatively low resolution images with the following appearances:
 grey matter: intermediate signal intensity (grey)
 white matter: slightly hyperintense compared to grey matter
 CSF: high signal (white)
 fat: little signal due to paucity of water
 other soft tissues: intermediate signal intensity (grey)
Acute pathology (ischemic stroke, cellular tumor, pus) usually appears as decreased
signal denoting restricted diffusion.
B=0
If you see these, do not worry. They are only used to calculate ADC values. They are
essentially T2 weighted images with a bit of susceptibility effects.
Read more about diffusion weighted imaging.
Flow sensitive sequences
One of the great advantages of MRI is its ability to image physiological flow (e.g. blood
flow) often without the need for intravenous contrast. This allows for the imaging of
arteries, veins and CSF flow.
Read more about MR angiography.
Read more about MR venography.
Read more about CSF flow studies.
Miscellaneous sequences
In addition to the aforementioned sequences, novel applications have been developed
over the years, largely beyond the scope of this introductory article.
MR spectroscopy
Different compounds interact with the magnetic field of MRI scanners slightly differently
and the amounts of these compounds can be detected in a quantifiable way in a
prescribed region of tissue. These can be used to help characterize the tissue to aid in
diagnosis or grading of tumors.
Read more about MR spectroscopy.
MR perfusion
The amount of blood flowing into tissue can also be detected and relatively quantified,
generating values such as cerebral blood volume, cerebral blood flow and mean transit
time. These values are useful in a number of clinical scenarios, including defining the
ischemic penumbra in ischemic stroke, assessing histological grade of certain tumors, or
distinguishing radionecrosis from tumor progression.
Read more about MR perfusion.
Functional MRI
The brain controls its blood flow very tightly and locally. Active tissue demonstrates
elevated blood flow and this can be detected.
Read more about functional MRI.
Tractography
The structure of tissue (e.g. axons tightly packed together) influences how easily
diffusion of water occurs in various directions. This can be detected and the direction of
white matter tracts can be implied.
Read more about tractography.