CT AND MRI
81. CT and MRI
A transfer to the CT or MRI scanner with an anaesthetised patient is not a task to be undertaken lightly. There is
good reason why the CT scanner is sometimes referred to as the ‘doughnut of death’. When answering a question
on scan transfers, it is important to show the examiners that you are well prepared to cope with the potential pitfalls
that may occur on your journey.
What are the principles behind
computed tomography (CT)
scanning?
What are the principles behind
magnetic resonance imaging
(MRI)?
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The name comes from the Greek ‘tomo’, meaning slice and ‘graphein’, to
write. CTs take a series of X-ray images around a central axis, either in a
discontinuous ‘shoot and step’ process, or in a continuous ‘spiral’ manner.
The latter are much quicker and so may reduce motion artefact, and enable
better 3D reconstruction of images.
> MRI is an alternative way of producing images of the body.
> MRI visualises soft tissues much better than does CT, and therefore is
more useful in the study of the brain, spinal cord and musculoskeletal
system.
> Atoms with unpaired electrons or protons are in a state of spin that can be
affected by the application of an external magnetic field.
> Hydrogen ions found in water and fat molecules (which make up 60–70%
of the body) are affected in this way and so, when the patient enters the
powerful magnetic field of the scanner (1–2 tesla), their protons align in the
direction of the field.
> The protons then begin to resonate at their ‘precision frequency’.
> The powerful magnet is called the ‘primary magnet’ and its magnetic field
is generated by an electrical current passing through coils of wire, which
are cooled with liquid helium.
> Once the atoms have lined up, a radiofrequency coil is turned on,
generating a second current at right angles to the first.
> The energy generated by this coil is absorbed by the hydrogen ions and
disrupts their alignment.
> When the radiofrequency coil is turned off, the protons release energy (in
the form of low-frequency radiation) and return to their original position.
> It is this low-frequency radiation that is detected by the scanner, and
reconstructed into images.
> Different tissues will give out different amounts of energy and return to
their equilibrium position at different rates, allowing for differentiation
between them. This exchange of energy between spin states is called
‘resonance’.
> Another component of the MRI scanner is the ‘gradient magnet’. These
are smaller magnets that are applied to allow fine-tuning and focusing of
the image on the area being studied. The banging noise in the MRI is the
sound of these magnets being turned on and off.
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> MRIs are either T1 or T2 weighted and this refers to the amount of time
elapsed between the radiofrequency magnet being switched off and the
image being taken, i.e. the ‘relaxation time’. T1 images are taken earlier
than T2. In T1 images fat is bright and water is black, in T2 images fat is
black and water is bright.
> The entire scanner is housed in a room lined with copper or aluminium,
and this room is referred to as the Faraday cage.
> What are the indications for general anaesthesia in the scanner?
> Unstable patient (e.g. for airway protection or from ITU)
> Young child if they cannot cooperate and lie still
> Patient with learning difficulties, as above
> Very anxious or claustrophobic patient
> Patients with movement disorders or who are unable to lie still for
sufficiently long.
What are the problems associated > Generic problems:
with anaesthesia in the scanning • Patients are removed to an often remote and isolated area:
department? This area may be unfamiliar to the responsible doctor. It is important,
therefore, to consider who will be available to help should there be an
emergency during the trip and if possible, to familiarise oneself with the
department and the equipment available there before the transfer.
• Cold and noisy environment: Ambient temperature in an MRI
scanner is cool in order to prevent the magnet from overheating. The
magnets produce a lot of noise and earplugs must therefore be used
and patients covered in order to minimise risk of hypothermia.
• Claustrophobic environment: Space within scanners is extremely
limited, more so in the MRI scanner, and some patients can find this
very distressing.
• Limited space for anaesthetic equipment
• Limited access to the patient: Once the patient is in the scanner it
can be practically impossible to get to them. Before the scan begins it
is important to satisfy yourself that all the leads reach far enough, that
the patient is stable and that you can see the monitor. The scan may
take some time, especially if it is an MRI.
> Specific problems related to the MRI scanner: The magnet in the MRI
adds a whole new layer of problems.
• Ferrous implants: Within the magnetic field, ferrous implants (e.g.
pacemakers, defibrillators, cochlear implants, some aneurysm clips
and foreign bodies) are prone to displacement or torque forces, which
can lead to serious patient injury. Patients with any such implants must
not enter the MRI scanner. Non-ferrous implants are prone to heating
and patients must be warned of this. Both types of implants can cause
image artefacts.
• Ferrous equipment: Ferrous-containing equipment such as
laryngoscopes, stethoscopes, pagers, and gas cylinders are prone to
significant movement within the 50 G line and should therefore not be
taken beyond this point unless securely fastened. Magnetic strips on
identity badges and credit cards will also be wiped if taken within the
magnetic field. Ideally, only ‘MR safe’ and ‘MR conditional’ equipment
should be used within the scanner.
• Monitoring: Special ‘MR safe’ ECG electrodes, BP cuffs and pulse
oximeters are required. ECG leads are short and plaited to minimise
the risk of magnetically induced currents within them, which can burn
the patient (burns are the most common MRI-associated injury). If
a standard anaesthetic machine is used, this is housed outside the
Faraday cage with an extra long Bain circuit connecting it to the
patient. Long gas analysis sampling lines cause a delay in monitoring.
Monitoring equipment can introduce stray radiofrequency currents,
which can degrade the image quality.

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How are items to be used within
an MRI scanner classified?
What is the standard international > SI unit for magnetic flux is the weber (Wb)
unit of magnetic strength?
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CT AND MRI
• Delivery of anaesthesia: ‘MR conditional’ infusion pumps should
ideally be used. However, standard pumps can also be used outside
the 100 G line (see below). Volatile agents can be administered using
an ‘MR conditional’ anaesthetic machine. If this is not available, a
standard anaesthetic machine can be used outside the cage with an
extra-long Bain circuit.
The old term ‘MR compatible’ is no longer suitable and the ASTM
International and FDA have introduced the following classification system:
> MR Safe: Items are completely free of all metallic components. They are
non-metallic, non-conductive and non-radiofrequency reactive. They pose
no hazard in any MR environment.
> MR Conditional: Items are safe under certain tested magnetic
conditions, which should be enumerated on the product (i.e. the magnetic
field strength in which the product can be safely used is stated).
> MR Unsafe: Items pose a hazard in any MR environment.
> SI unit for magnetic flux density is the tesla (T), which is used for large
densities. For smaller densities, a smaller unit, the gauss (G) is used. An
average MR scanner produces between 1 and 1.5 T (although newer
machines can now generate up to 3–5 T), while earth’s magnetic field is
about 1 G.
1 T = 1 Wb/m2
1 T = 10 000 gauss
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