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HOW I DO CMR SCANNING SAFELY

Elisabeth Burman
Research Sister
Royal Brompton Hospital, London UK
This presentation is posted for members of scmr as an
educational guide it represents the views and practices of
the author, and not necessarily those of SCMR.
2011 update: some updates added to terminology, MR conditional
devices, and contrast with renal failure. JMoon

Magnetic Resonance
One of the safest imaging modalities but there
are still safety issues
Advantages
Non-invasive

No ionizing radiation
Repeat studies present no problem
Fewer ethical problems imaging volunteers

Why are there safety issues?


Potential for accidents and even fatalities

Damage to equipment / cost

Safety issues centre around the 3 electromagnetic fields


and issues indirectly related
Static magnetic field

biological effects
mechanical effects

Gradient Field

induced currents (PNS)


auditory damage

RF Field

RF power deposition
Burns

Other issues

contrast agents
critically ill patients/resuscitation
monitoring
quench
claustrophobia

Static magnetic field


Measured in Gauss or Tesla (10,000G equivalent to 1T)

1.5 T is 30,000 x the strength of earths magnetic field

Static Magnetic Fields


A superconducting magnet is always switched on!
1.

Biological effects (potential risk)


- exposure to static magnetic fields of up to 4T are not thought
to be harmful

Biological effects relevant to clinical imaging


- distorted ECG (magnetohydrodynamic effect)
- consider prudency with pregnancy

2.

Mechanical effects (very real risk)


- translational or attractive forces on metallic objects when
brought into the field

Static Magnetic Field


Biological effects
Magnetohydrodynamic effect augmented T wave
Outside field
0.5 Tesla

1.5T

Magnetohydrodynamic effect
seen as augmentation of T-wave
Caused by the effect of the static magnetic field on moving
blood (systole) as a conducting fluid.
The gradient and RF fields also affect the configuration of the
ECG
Morphological ECG changes are therefore difficult to detect
and diagnose, but rhythm is usually recognised
Any concern regarding rhythm, remove patient from scanner
and perform 12 lead ECG

Static Magnetic Field


Pregnancy
Patients
1st trimester prudent to avoid CMR where possible
2nd and 3rd trimester decision made on a risk versus benefit
determination. For example if it avoids the patient being
subjected to x-rays.

Health Care Workers


May enter MR scanning room regardless of trimester
Should not remain in the room when scanner is operational,
avoiding exposure to gradient and radiofrequency fields

Static Magnetic Field


Mechanical effects

Projectile or missile effect


- the attractive forces exerted by the static magnetic

field present the greatest potential for patient injury


- objects will be pulled out of hands, pockets etc, and fly into
magnet which has caused injury and death.

Effect on ferromagnetic implants


- electro-mechanical eg pacemakers
- biomedical eg valves, stents

What is typically ferromagnetic?


EQUIPMENT
Oxygen cylinders
Wheelchairs
Trolleys
IV stands
Monitoring equipment
Ventilators

PERSONAL ITEMS (leave outside)


Keys, pens
Bleeps
Mobile phones
Coins
Stethoscopes
Scissors

It is easy to forget objects, particularly when


responding to an emergency!
Remember also magnetic strips will be wiped (credit cards)

Warnings to minimise accidents?


OUTSIDE THE SCANNER ROOM

Signage

Barrier cords to scanner room

Restricted access - swipe card / coded entry system


INSIDE THE SCANNER ROOM (fringe field 5 Gauss line)
Older systems
- passively shielded
- extensive fringe field gave a warning
Newer systems
- actively shielded
- small fringe field

greater hazard because there is no gradual warning

field strength increases hundreds of gauss in a few inches

Never be complacent accidents do happen!


Oxygen cylinder

Infusion pump

Floor buffer

Contraindications to CMR*
Implants & metal

Electromechanical implants

Cerebral aneurysm clips


Metallic foreign body in the eye
Shrapnel, bullets (in critical area)
Ocular implants (containing metal)
Swan-Ganz

Pacemakers /ICDs
Pacing wires
Cochlear implants
Neurostimulators
Hydrocephalus shunts

Any device electrically or mechanically activated


* In some circumstances MR has been performed despite contraindications, especially in specialist centres.
Work is in progress to make some devices safe. For example, some cerebral aneurysm clips may now be scanned.

Implants
Cerebral clips

modern clips are considered safe (titanium, elgiloy)


older clips (martensic steel is highly ferrous)
obtain operation notes with serial number of clip
radiologist to consent patient
seek advice from specialist centre

Foreign bodies
Maybe situated near vascular or nervous tissue
If in doubt x-ray

Pacemakers
Highly specific guidelines are required

General rule has been absolute contra-indication

All 3 electromagnetic fields effect pacemaker


function

Non-pacemaker dependent patients have been


scanned in specialist centres in exceptional cases

Future: new pacemaker/lead designs may be MRI safe


**2011 update: MR-conditional Medtronic pacemaker and leads now available

Potential effects of MRI on pacemakers


excessive heating / induced currents in the
pacemaker lead
temporary or permanent modification of
pacemaker function
inappropriate sensing or triggering of the device
movement of the pulse generator or lead
pacing the heart

What can be safely scanned at 1.5T?


Lists of approved implants are available

BIOMEDICAL IMPLANTS
OTHER

CARDIAC
sternal wires
heart valves & annuloplasty rings
coronary stents
epicardial wires (cut short and taped)
other vascular stents, coils and filters

orthopaedic implants

contraceptive devices
dental implants

If unsure, best to check at check: www.mrisafety.com

occlusion devices
catheters (without guidewire)
Effects of implants on imaging - signal void / local distortion

Safety Checklist comprehensive but concise


Essential to know
Cardiac pacemaker?

Important to know

Previous neurosurgery?
Implants or metal in the body?
Pregnant (prudent approach)?
Drug patch with foil backing?

Previous heart surgery?


Diabetic or epileptic?
Asthmatic or allergies?
(in relation to contrast)
Tattoos or permanent eye liner

Essential preparation

(iron oxide)?

Removal of accessories - watch, jewellery (except


wedding rings), body piercing rings, hearing aids, glasses,
false teeth, artificial limbs and prostheses
Removal of clothes containing metal eg zips, bras

Preparation of patient

Remove watches / jewellery except gold wedding rings


Remove hearing aids, false teeth, glasses, prostheses
Remove all clothes except socks and underpants
Patient gowns - no pockets
- no metallic fastenings
- length sleeves for IV access
- wrap round for easy chest access
Brass changing room keys
Screen all accompanying personnel
Check any suspicious item with small bar magnet

Gradient fields - Induced Currents


Gradient fields induce an electric field and thus
a current in the patient, potentially this can be of
sufficient intensity in modern systems to
produce a physiological response
- peripheral nerve stimulation (PNS)
- cardiac stimulation is not considered possible

Gradient fields Auditory damage


Hearing protection mandatory above 90dB
time averaged for:
patients
staff remaining in the scanner room
relatives accompanying children or patients

Radiofrequency (RF) fields


Thermogenic effects - health & safety concern
Physiological tissue heating response

most of the transmitted RF power is transferred into heat


within the patients tissue

all MR systems have safety thresholds to avoid


dangerous levels

Patients with compromised thermoregularory systems are


at greatest risk

Specific Absorption Rate (SAR)


SAR is the RF power absorbed per unit mass of tissue
(expressed in W/kg)

complex function of numerous variables

calculated by software from the average forward


power passing into the RF transmitter coil and the body
mass situated in the RF transmitting field
Therefore an accurate patient weight is vital

SAR increases 9 fold from 0.5T to 1.5T

Radiofrequency (RF) fields


Potential for burns
1, 2, 3 burns have occurred in the past in
patients undergoing MRI
This is a result of excessive heat developing in the
devices or objects
ECG system is often the culprit
Interventional MRI poses greater risk

Prevention of burns
Electrodes

- carbon fibre studs


- placed close together
ECG leads
- carbon fibre
- fibre optic
- high impedance
- short as possible (plaited if necessary)
All conductive leads should be placed in a linear fashion
coming out of bore of scanner
Avoid crossed limbs where possible

RF Burn from non-Carbon Electrode

Other Issues

Contrast agents

Critically ill patients / resuscitation

Monitoring and equipment related hazards

Quench of superconducting magnets

Claustrophobia

Contrast agents
all gadolinium chelates
overall patient tolerance high
incidence of adverse reactions very low

Possible reactions: headache, nausea and vomiting, pain if extravasation occurs


anaphylaxis 1:100,000

Contraindications
GFR<30ms/minute
pregnancy (risk versus benefit ratio)
breast feeding mothers
infants < 2 years

Caution
asthmatics, history of previous reactions

Critically ill patients


AICU and High Dependency Patients

Assess patient the day before


Lengthen and prime IV lines on ward
Replace electrodes - carbon studs
Lengthen chest drains
Check intubation circuits for metal
Educate nursing staff in preparing patient
Ensure status of patient has not changed since referral
Screen all accompanying personnel

Sedated patients
Departmental sedation protocol with anaesthetic
approval
Nil by mouth for 6 hrs (food & milk) 2 hrs water
Medical examination
Informed consent
Tipping trolley, piped oxygen, full resuscitation
equipment
Responsible adult to collect from department and remain
with for 24 hours

Resuscitation

Alert cardiac arrest team


Call for help
BLS only can be performed in scanner room
Keep MR Compatible tipping trolley adjacent to
scanner
Patient must be moved to designated resuscitation area as
quickly as possible
Appoint non-clinical person to prevent access to scanner
room
Practice regular cardiac arrest scenarios to identify
potential problems

Monitoring
Equipment must be MR Safe or MR Conditional
MR Safe
Device when used in the MR environment, has been demonstrated
to present no additional risk to the patient BUT may affect the
quality of diagnostic information

MR Conditional
The object may or may not be safe for the patient undergoing an
MR procedure or an individual in the MR environment, depending
on the specific conditions that are present.
Ie can be used if certain device specific conditions met.
See http://www.mrisafety.com/list.asp for definitions
2011: MR conditional replaces MR compatible as terminology

Quench
Cryogens maintain the magnetic field - helium
QUENCH = the liquid helium boils off and becomes a gas

Causes

- physical
- human error (accidental)
- intervention (elective)

Effects

- ratio of gaseous to liquid helium 760:1


- should vent to the outside, but this can fail
- pressure build up
- asphyxiation/frostbite

Elective Quenching
The magnet should only be quenched in two
situations:
If someone is trapped to the scanner by a
ferromagnetic object and is
injured and/or
distressed (eg O2 cylinder, piece of equipment)

If there is a fire in the immediate vicinity on


order to reduce risk to the Fire Brigade

Action to be taken in the event of


a Quench

Evacuate the room as quickly as possible


Ensure the door is kept open during evacuation
Close door after evacuation
If trapped in room stay close to floor level
Seek the advice of a senior physicist immediately
Call scanner engineer

Claustrophobia
Affects 5-10% of patients
Causes
restrictive dimensions of the interior of the magnet
duration of the examination
gradient coil induced noises
the ambient condition within the imaging bore

Factors to reduce anxiety

education and explanation


trial visit to the department
maintaining physical and verbal contact
presence of a relative or friend
use of a mirror, prism glasses
good communication system
alarm
good light and ventilation
music
pleasant thoughts

Ensuring Safe Practice


Safety Checklist comprehensive but concise
Restricted access to magnetic field area
MR Compatible equipment monitors, wheelchairs,
syringe pumps, stethoscopes
Awareness of medication common to patient area
contrast agents, stress agents
Staff Induction
Education and training of staff of all disciplines
Risk Assessments
Policies and Procedures cardiac arrest, quench

This could be you!

References
Shellock F.G. and Kanal E. (2001)
- Magnetic Resonance Bioeffects, Safety, and Patient
Management
Health Protection Agency (HPA)
(was National Radiological Protection Board -NRPB)
International Electrical Committee (IEC)
Medical and Healthcare products Regulatory Agency
(MRHA) (was Medical Devices Agency - MDA)
http://www.mrisafety.com (Shellock and Kanal)
http://www.imrser.org/
http://www.magneticresonancesafetytesting.com/