The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists

, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized.

Revised 2008 (Res. 19)*

PREAMBLE These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from these guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these ACR PRACTICE GUIDELINE guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective. I. INTRODUCTION

This guideline was revised by the American College of Radiology (ACR) in collaboration with the American Society of Neuroradiology (ASNR). Magnetic resonance spectroscopy (MRS) is a proven and useful method for the evaluation, assessment of severity, therapeutic planning, post-therapeutic monitoring and follow-up of diseases of the brain and other regions of the body. It should be performed only for a valid medical reason. While MRS can be useful in the diagnosis and management of patients, findings may be misleading if not closely correlated with the clinical history, physical examination, laboratory results, and diagnostic imaging studies. Adherence to these guidelines optimizes the benefit of MRS for patients. II. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL

See the ACR Practice Guideline for Performing and Interpreting Magnetic Resonance Imaging (MRI). The physician supervising and interpreting MRS must understand the specific questions to be answered prior to

MR Spectroscopy / 1

g. the following: 1. and Huntington’s disease.. especially temporal lobe epilepsy. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Evidence or suspicion of an inherited metabolic disorder such as Canavan’s disease and other leukodystrophies. e. The request for the examination must be originated by a physician or other appropriately licensed health care provider. Suspicion of acute brain ischemia or infarction. Seizures. Evidence or suspicion of spinal cord disorders such as tumors. Evidence or suspicion of neurotoxicity disorders. Peer-reviewed literature pertaining to MR safety should be reviewed on a regular basis. particularly high grade versus low grade glioma. especially cerebral abscess (pretreatment and post-treatment) and HIV-related infections. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patient’s clinical problem or question and consistent with the state scope of practice requirements. INDICATIONS 22. IV. SPECIFICATIONS OF THE EXAMINATION A. 2. 12. Evaluation of response neurological disorders. Evidence or suspicion of a demyelination or dysmyelination disorder. and schizophrenia. adopted in 2006) Reasonable efforts should be made to ensure that all prior imaging of the region in question is available to the interpreting physician/spectroscopist at the time of the study. demyelination. Evidence or suspicion of other neurodegenerative diseases such as amyotropic lateral sclerosis. III. B. 6. Written Request for the Examination The written or electronic request for MRS of the central nervous system should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. and trauma. 17. 16. 21. 19. abscess versus cystic metastasis or cystic primary neoplasm. but are not limited to. Evidence or suspicion of chromosomal and inherited neurocutaneous disorders such as neurofibromatosis and tuberous sclerosis. Grading of primary glial neoplasm. 5. Evidence or suspicion of cerebral vasculitis. 15. (ACR Resolution 35. 20. 10. Patient Selection The physician responsible for the examination shall supervise patient selection and preparation and be available in person or by phone for consultation. indications for MRS in adults and children include. Evidence or suspicion of chronic pain syndromes. systemic lupus erythematosus (SLE). 7. Patients shall be screened and interviewed prior to the examination to exclude individuals who may be at risk by exposure to the MR environment. Parkinson’s disease. 18. to treatment of SAFETY GUIDELINES AND POSSIBLE CONTRAINDICATIONS When conventional imaging by magnetic resonance imaging (MRI) or computed tomography (CT) is inadequate to answer specific clinical questions. 8. 13. Evidence or suspicion of neurodegenerative disease. See the ACR Practice Guideline for Performing and Interpreting Magnetic Resonance Imaging (MRI) and the ACR Guidance Document for Safe MR Practices. Evidence or suspicion of subclinical or clinical hepatic encephalopathy. infection. 9. IV contrast enhancement should be performed using appropriate injection protocols and in accordance with the institution’s policy on IV contrast ACR PRACTICE GUIDELINE 2 / MR Spectroscopy . Differentiation between recurrent tumor and treatment related changes or radiation injury. Evidence or suspicion of traumatic brain injury. V. Evidence of neuropsychiatric disorders such as depression. Certain indications require administration of intravenous (IV) contrast media. 4. post-traumatic stress syndrome. Differentiation of cystic lesions. 14. Evidence or suspicion of brain infection. 3. Evidence or suspicion of brain developmental abnormality and cerebral palsy. Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination.the procedure in order to plan and perform it safely and effectively. Evidence or suspicion of primary or secondary neoplasm (pretreatment and post-treatment). and neuropsychiatric systemic lupus erythematosus (NPSLE). 11. especially Alzheimer’s disease. Evidence or suspicion of hypoxic brain injury.

Other basic pulse sequences for spectral data acquisition are available commercially. No artifactual NAA. 135 to 144 ms) Intermediate TE has a number of advantages over short TE MRS but provides information on fewer metabolites. More reproducibility and accuracy.g. Peak in the 2. This is the recommended TE if only one MRS sequence is considered for the examination. e. and hence the signal to noise is lower than at short and intermediate TE measurements due to the T2 decay of metabolites. after the short TE acquisition for the following reasons: a. The physician and/or spectroscopist should understand the differences between the PRESS and the STEAM techniques. however. PRESS (point-resolved spectroscopy) that uses a 90degree excitation pulse plus two 180-degree refocusing RF pulses for volume selection. particularly for quantifying Cho and NAA peaks. For example. chronic pain syndrome. In differentiating lactate and alanine from lipids around 1. D. The recommendation is that this would be a second acquisition. including the Choice of Echo Time 1. in the characterization of neurodegenerative disorders such as Alzheimer’s disease. Better-defined baseline and less baseline distortion compared with short TE. and other emergency support must also be appropriate for the range of ages and sizes in the patient population. c. Administration of moderate sedation may be needed to achieve a successful examination. (See the ACR Practice Guideline for the Use of Intravascular Contrast Media. Long echo time (e. Short echo time (e.05 range can only be attributed to NAA rather than superimposed Glx complex peaks in the 2.utilization.. and disorders of myelination. The physician and/or spectroscopist performing the study should understand how the history and physical examination affect the choice of technique (including location of voxel placement). MR Spectroscopy / 3 . ACR PRACTICE GUIDELINE 3.4 ppm by Jmodulation/inversion of the lactate and alanine doublet peaks. Cho. If moderate sedation is necessary. d.) Patients suffering from anxiety or claustrophobia may require sedation or additional assistance. These metabolites are useful in characterizing most neurological diseases. All examinations are interpreted by physicians. C. Presence of lipids may infer more significance than at short TE. the choice of TE would also depend on the clinical indication. short TE MRS is recommended to ensure obtaining information on metabolites only detected with short TE MRS. Examination Technique E.5 ppm range.3 to 1. These include the following: STEAM (stimulated echo acquisition mode) that uses three 90-degrees RF pulses for volume selection. medications.g. Facility Requirements Appropriate emergency equipment and medications must be immediately available to treat adverse reactions associated with administered medications. to include an intermediate echo time acquisition for the reasons stated above. Long TE can be 2. The recommendation is to acquire MRS data at short TE and. as well as the spectra that could be anticipated for the diagnostic entities being considered in the patient. The equipment. b. repetition time (TR). glutamine/glutamate (Glx) complexes and lipids. and Cr relative to the baseline noise. metabolic and neurodegenerative disorders. time permitting. refer to the ACR Practice Guideline for Adult Sedation/Analgesia or the ACR Practice Guideline for Pediatric Sedation/Analgesia. The physician and/or spectroscopist performing and the physician interpreting the examination should be knowledgeable about the normal metabolites and their relative concentrations. and echo time (TE) for the examination and how the metabolite peaks are affected by changes in the TE.g. Intermediate echo (e. 270 to 288 ms) At longer TE (longer than 144 ms) there is less signal from NAA.05 to 2. MRS involves the application of various MR pulse sequences that are designed to provide a range of capabilities. 20 to 40 ms) Short TE is useful in demonstrating myoinositol (MI).. such as tumors.. Guidelines for Performing MRS. Physicians and/or spectroscopists using MRS shall understand the artifacts and limitations of the MR pulse sequences. They are also useful in monitoring therapy for these diseases. such as myoinositol and the Glx complexes. The equipment and medications should be monitored for inventory and drug expiration dates on a regular basis. seizures.0 to 2. time permitting.

6. f. due in part to the necessity for hardware modifications (coils). the relatively large volumes of tissue required (resulting in partial volume effects through necrotic regions) and the sometimes subtle metabolite changes when the spectra are reviewed visually. fluorine-19 (19F). As expected HGGT will express higher levels of phosphatidylcholine compared with low grade glial tumors. voxel bleeding. and a decrease in PDE/α-ATP with no significant changes in PCr/ α-ATP or PCr/Pi ratios. PCr. oxygen-17 (17O).5 T. Phosphorus-31. obtains spectroscopic information from multiple adjacent volumes over a large volume of interest in a single measurement.field spectroscopy is likely to have a place in the near future. g. facilitating evaluation for focal as well as global neurological processes. Ultra-high-field MRS (beyond 3-T) Currently MRS is FDA approved and can be performed at 3-T. there is alkalization (pH 7. either 2D or 3D. The phosphodiester (PDE) and phosphormonoester (PME) compounds are from membrane phospholipids. phosphorus-31 (31P). There are technical challenges. Compared with proton spectroscopy (1H MRS).employed if the user has experience and normative data for comparison. Cellular energy metabolism is represented by ATP. The report should describe the peaks visualized in the spectrum. sodium-23 (23Na).16). This technique has better resolution and samples metabolites over a larger region of interest. The safety and clinical application of MRS for ultra-high field spectroscopy (beyond 3-T) are still under investigation. It also allows for comparison and normalization of pathologic spectra to spectra in normal tissue. and 13C have demonstrated some utility in neuro-oncologic MRS. Multinuclear MRS Besides proton hydrogen-1 (1H) MRS. and xenon-129 (129Xe) can be used. an increase in PME. 4. and decreased phosphodiesters. 19F. 5. Multiplets – needing to decouple to demonstrate the metabolites adequately. c. It is recommended that multinuclear MRS be performed using a 3-tesla MR system. other nuclei for MRS that include helium-3 (3HE). and voxel contamination when using commercially available CSI sequences. There are a number of reasons for this compared with 1H MRS: a. multi-TE approach to neurologic diseases. e. the clinical utility of 31P MRS has been limited. however. and/or poor voxel placement. In high grade glial tumors (HGGT) such as glioblastoma multiforme. Reporting should be in accordance with the ACR Practice Guideline for Communication of Diagnostic Imaging Findings. Phosphorus-31 MRS (31P MRS) provides information on cellular energy metabolism. the ability to resolve metabolites not usually demonstrated at lower field strengths and only when using proton MRS suggests that ultrahigh. CSI can be combined with conventional MR imaging. Meningiomas are characterized by an alkalinity (pH 7.5 T resulting in poorer signal-to-noise (SNR) at 1.12). Lower sensitivity at 1. It should attempt to address the potential etiologies suggested by any abnormities found. membrane phosphates and intracellular pH. Proton-decoupled 31P (31P. b. a decrease in phosphocreatine. Low spatial resolution. The physician and/or spectroscopist performing the examination must understand how voxel placement affects diagnostic accuracy. or relative concentrations of the metabolites. Lower abundance of the nuclei. improper water suppression. Chemical shift imaging (CSI) or MR spectroscopic imaging (MRSI) MRSI or CSI. carbon-13 (13C). lithium-7 (7Li). Lower spectral resolution. The metabolite resonances in HGGT may sometimes be reduced by the presence of necrosis. Longer measurement times. and Pi. However caution must be exercised when using CSI regarding artifacts such as chemical-shift artifact. lipid contamination. chemical shift artifact/misregistration.[1H]) and 1H MRS may eventually be used in a multinuclear. the relative heights of the peaks. since spectral patterns and metabolite concentrations can be overlaid on grayscale conventional imaging to compare voxels containing normal parenchyma and voxels containing pathology and also to obtain distributional patterns of specific metabolites. 4 / MR Spectroscopy ACR PRACTICE GUIDELINE . d. Lower gyromagnetic ratio. The physician and/or spectroscopist performing and the physician interpreting MRS shall recognize artifacts due to poor shimming. DOCUMENTATION VI.

MD Jeffrey R. Van De Kerckhove T. ACKNOWLEDGEMENTS This guideline was revised according to the process described in the ACR Practice Guidelines and Technical Standards book by the ACR Guidelines and Standards Committee of the Commission on Neuroradiology in collaboration with the American Society of Neuroradiology (ASNR). Value of single-voxel proton MR spectroscopy in temporal lobe epilepsy. Metabolism of human gliomas: assessment with H-1 MR spectroscopy and F-18 fluorodeoxyglucose PET. Cendes F. MD. NMR Biomed 1990. Liebscher. Infection Control. Follow-up pathology and laboratory results and diagnoses are needed for correlating radiology and pathology findings and should be actively sought whenever possible as part of any quality control or quality improvement program. Aas TC. MD Alan D. Petrella. 2. Li LM. Russell. maximum rate of change of magnetic field strength (dB/dt). CSC R.128:2933-2940. Costallat LT. Chair. SAFETY. MD Michael I.3:184-189. MD Eric J. Specific policies and procedures related to MR safety should be in place with documentation that is updated annually and compiled under the supervision and direction of the supervising MR physician. Sherry. Bizzi A. MD Comments Reconciliation Committee Lawrence A.18:1131-1139. infection control. Matthews PM. Villemure JG. AND PATIENT EDUCATION ACR Guidelines and Standards Committee Suresh K. 6. maximum radiofrequency power deposition (specific absorption rate). Arnold DL. Aasly J. Larson. Evidence of reversible axonal dysfunction in systemic lupus erythematosus: a proton MRS study. VIII. MD John E. Ulmer. Proton and phosphorus magnetic resonance spectroscopy of human astrocytomas in vivo. MD Eric J. patient education.177:633-641. MBBS 1. Nick Bryan. MD. Reed Murtagh. EQUIPMENT SPECIFICATIONS The MR equipment specifications and performance shall meet all state and federal requirements. MD Edward J. Brain 2005. CSC Cynthia S. Appenzeller S. Equipment monitoring should be in accordance with the ACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of MRI Equipment. Safety. Kieffer. MD Daniel C. These requirements include. Sundren. et al. MD Meng Law. PhD Meng Law. Mukherji. MD F. Epilepsy Res 1999. Russell.VII. O’Brien. MD Stephen A. Jordan. specifications of maximum static magnetic field strength. 3. Co-Chair. Francis GS. Rothman. Chair Carol A. Boon P. Radiology 1990. Jr. Garner. Commission ASNR Guidelines Committee Erin S. INFECTION CONTROL. Schwartz. Principal Reviewer: Pia C. MD Sachin Gujar. De Reuck J. Proton magnetic resonance spectroscopic MR Spectroscopy / 5 ACR PRACTICE GUIDELINE . Shoubridge ES. MD. and safety should be developed and implemented in accordance with the ACR Policy on Quality Control and Improvement. MD Patrick A. MD. 4. 5. Alger JR. Pollack. Antel JP. Caemaert J. Arnold DL. Co-Chair. Turski. Preliminary observations on tumor grading. MD. Achten E. MD R. and Patient Education appearing elsewhere in the ACR Practice Guidelines and Technical Standards book. Screening forms must also be provided to detect those patients who may be at risk for adverse events associated with the MR examination. MBBS Suresh K. Nick Bryan. MD Paul A. MD Suggested Reading Policies and procedures related to quality. MD David C. Kushner. Mukherji. MD. et al. Proton magnetic resonance spectroscopy of brain biopsies from patients with intractable epilepsy. Feindel W. AJNR 1997.. MD Matthew S.35:211-217. QUALITY CONTROL AND IMPROVEMENT. Kaye. Frank JA. and maximum acoustic noise levels. MD Pia Sundgren. MD. MD John L. Guidelines should be provided that deal with potential hazards associated with the MR examination of the patient as well as to others in the immediate area. Silfvenius H. but are not limited to. Dolinskas. O’Connor J. Kunnen M.

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