Magnetic resonance

Imaging/Nuclear medicine

Prof Dr Phrabhakaran K.N. Nambiar

BDS(Mysore), BSc Dent (Hons)(Adelaide), MSc Dent [Forensic Odontology](Adelaide),MSc Dent
[Dental Radiology] (Western Cape),
Postgrad Dip Dent [Maxillofacial Radiology] (Stellenbosch), FFOMP(Forensic Odontology)
RCPA.
Magnetic Resonance Imaging (MRI)
and Nuclear medicine
Learning outcomes:

Principles involved in acquiring the MRI scans/

nuclear imaging and their various manipulations.

List the indications and contraindications of

MRI/nuclear medicine in head and neck pathology

List their advantages and disadvantages

List their safety concerns

Magnetic Resonance Imaging (MR)
Non-ionising radiation:
radiofrequency (RF) end of the
electromagnetic spectrum
High contrast sensitivity to tissue
differences- depends on protons (hydrogen
nuclei) density

Patient placed in large magnet (0.5

to 7 Tesla (Mayo clinic 14 Tesla)
-1 Tesla is 10,000 times the earth’s magnetic field
Paul Lauterber and Peter Mansfield-
MRI first described in 1973. Clinical use around 1980.
Nobel prize in 2003.
 Magnetic Resonance Imaging (MR)
The magnitude of the received RF signal relates to the overall
concentration (proton density/spin density) of hydrogen protons (nuclei) in
the tissues
Loosely bound hydrogen proton (eg in soft tissues/liquids) do all this more
easily than those in tightly bound situations (e.g. bone)

In magnet
 Loosely bound
hydrogen atoms,
the stronger the
excitation, the
more intense the
recovered signal-
lighter the recovered
image.

Proton/Spin Density- Indicates the distribution of protons in the tissues. Increase in protons,
increase in transverse image thereby increased intensity of the recovered signal-brighter the MR
image
• The patient’s hydrogen protons which normally
spin on an axis behave like small “magnets” to
produce the net magnetization vector which
aligns itself readily to the long axis of the
magnetic field-longitudinal magnetic
force/moment.
• The RF pulses cause the excitation of the
protons;
• a) from longitudinal magnetic moment they
become transverse magnetic moment
• b) The spins synchronize, spinning like tops in
phase with each other
Spin-
up,
spin
down
Radiofrequency
 Magnetic Resonance Imaging (MR)
Once RF pulse is turned off, energy
released by hydrogen nuclei and return to Different tissues
original spin state (relaxation)- recorded by have different T1
coils in the scanner. and T2
Relaxation results in: relaxation times
•transfer of energy to a state of equilibrium. Time
constant required to do this is called T1 relaxation
time
NB: Variance in T1
•Along with loss of transverse magnetization,
there is dephasing of the hydrogen proton. Time and T2 between
constant describing this rate of loss is the T2 tissues is higher
relaxation time than differences in
x-ray absorption
Magnetic Resonance Imaging (MR): optimising
image appearance
T1 weighted images: short
RF pulse repetition time
[TR] and short signal
recovery(echo) time [TE]:
‘fat image’ (e.g red
marrow)- high
signal/bright on image
High anatomic detail
Magnetic Resonance Imaging (MR): optimising
image appearance
T2 weighted images: long RF
pulse repetition time [TR] and
long signal recovery time [TE]:
‘water image’ (e.g CSF, TMJ
fluid) high signal/bright on
image
Generally, abnormal tissues are
brighter on T2 images (good for
pathology)
• Techniques such as turbo spin echo and gradient
echo, allow images to be captured rapidly.

• Other techniques-fat or fluid enhanced or

suppressed. “Fat saturation”-no signal from fat.
Similarly fluid signals too can be suppressed so
that better visualization of pathology adjacent to
CSF.
Disavantage of MRI- bone, teeth and metallic objects appear
black-making appearance difficult.
Magnetic Resonance Imaging (MR):
optimising image appearance
Contrast enhancement possible
using Gadolinium i.v. it reduces TR
& TE i.e. shortens T1 relaxation time and gives
high signal on T1 weighted image
Danger of gadolinium- nephrogenic systemic
fibrosis.

Multiplanar imaging possible

with no loss of image
resolution, unlike CT
 Magnetic Resonance Imaging (MR): uses and
contra-indications
•All soft tissue imaging
Metal restorations/titanium will
•but maybe everything? not move but cause minor image
•TMJ show both the bony and soft tissue components of the joint degradation
including the disc position.

•salivary glands
•implant planning? No ionizing radiation
Contra-indications:
. replace anything ferromagnetic (gold is considered
ferromagnetic??susuk??)
•cardiac pacemakers; cerebral aneurysm clips
•Claustrophobia
•1st trimester of pregnancy
•• Electronically operated stapedial implants
Stainless steel brackets, bands, and fixed
retainers should be checked to ensure secure
attachment, and may be left in place if secure,
unless they interfere with the region of the
image being examined.
Nuclear Medicine
• Radionuclide (radioisotope) imaging relies upon
altering the patient by making the tissues
radioactive and the patient becoming the source
of ionization radiation. This is done by injecting
certain radioactive compounds into the patient
that have affinity for particular tissues-so called
target tissues.

• Radionuclides or their labelled tracers

(radiopharmaceuticals attached to the chemical
or biological material) are used in quantities well
below amounts that are lethal to cells.
Nuclear Medicine
:

Radionuclides are administered to patients for mostly

a) diagnostic purposes - that is to get imaging scans or scintigrams.

b) non-imaging procedures-including determining function of organs and therapy.

Radionuclides are actually isotopes with unstable nuclei (unstable balance of

neutrons and protons) which undergo radioactive disintegration.

The important radioactive emissions includes:-

• Alpha particles

• Beta – (electron) and beta + (positron) particles

• Gamma radiation

The main emissions used in imaging are gamma ray and beta + (positron) particles.

Alpha particles are banned from use in nuclear medicine and beta – (electron) particles have very
limited use in diagnostic imaging.
Nuclear Medicine (for imaging)
Many radioisotopes
used, e.g:
131
Iodine
67
Gallium
74
Selenium Salivary gland imaging:
99m
Technetium 99m
technetium pertechnetate

Bone scanning:
Technetium methylene
99m

diphosphonate (MDP)
Nuclear Medicine (Non-Imaging)
• Iodine-131 with a half-life of 8 days – Used for thyroid function
and with beta emission also provided a therapeutic potential for
treatment of hyperthyroidism (Graves disorder, multinodular
toxic goitre, toxic solitary nodule or adenoma) and thyroid
carcinoma with local and distal metastases.
• Thallium-201 with a half-life of 3.1days – for myocardial
visualization.
• Xenon-133 and Krypton – 81m for determining lung ventilation.
• For other therapeutic purposes, yttrium-90 is used for acromegaly
and bone tumours.
• cobalt -90 for external radiotherapy and phosphorus -32 for
polycythaemia rubra .
Nuclear Medicine
Uses ionising radiation, mainly
gamma rays, from radioactive
sources
Radioactive gamma emitter
introduced into body attached to a
pharmaceutical or in a form that will
concentrate in the tissue/ organ/ cell
of choice
Gamma rays detected by gamma
camera
Images really relate to physiological
activity rather than anatomy
Nuclear Medicine
• The gamma camera which is most commonly used now is the
Anger scintillation camera. It was invented by Hal Anger of
Donner Laboratory, University of California, at Berkeley,
United States of America in the late 1950s . The principle of
the instrument lies in the ability of a large sodium iodide
crystal, contained within the detector head, to respond to the
gamma rays emitted from the radioisotope by the emission of
tiny scintillations of light (or flourescence). These
scintillations are magnified by a photomultiplier tube and
altered electronically into electric signals. From the positions
of the scintillations which occur within the crystals, the
picture of the isotope distribution in the organ is built up. The
use of a scintillation crystal for the acquisition of the data for
image formation has led to the labelling of this technique as
scintigraphy and the images scintigrams.
Nuclear Medicine
• However, nuclear medicine techniques are
known for their sensitivity to changes of function
induced by disease but not for the specificity in
determining the nature of the disease process.
Nuclear Medicine
• Radionuclide images are obtained by injecting radionuclide
intravenously into a patient, waiting about two hours for it to be
taken up in the target tissue, and assessing its uptake in that tissue
by measuring the gamma radiation given off by means of the
gamma camera.

• These radionuclides have rapid rate of decay. Decay is a process

whereby a radioactive material changes from radioactive state to
non-radioactive condition.

• The process of decay is associated with spontaneous loss of energy

in the form of gamma radiation. Most radiopharmaceuticals used
today have biological half-life of 12-24 hours. This means that
through the process of decay combined with biological elimination
of material from the body, the radioactivity of these substances is
reduced by 50% within the 12 hours, by another 50% within the
next 12 hours and so on until the substance is completely eliminated
or decays to an inert form.
Nuclear Medicine
• Gallium is taken up rapidly at sites of
infection (especially cellulitis) and only
weakly so in the presence of malignant
disease. Good for evaluating the response of
osteomyelitis to treatment, as gallium study
ceases to be positive when inflammation
becomes quiescent.
Nuclear Medicine
• According to Basset, Gold and Weber (1981) gallium
scan use must be restricted as it yields higher radiation
dosage and poorer image resolution when compared to
technetium scan.
 Nuclear Medicine
Salivary gland imaging:
technetium pertechnetate, i.v. injection, imaging
99m

immediately/continously for 30 minutes

Uses:
Sjogren’s syndrome
Possible gland aplasia
 Parotid

Submandibular

Thyroid
Nuclear Medicine
99m
Technetium
According to Maisey (1980)the advantages of 99mTc are:

• It decays with short half-life (approximately six hours) ensuring

minimal radiation dose.

• During this decay it emits only gamma photons and not beta particles
(which are responsible for the larger radiation dose incurred by other
radionuclides such as Iodine-131).

• The gamma photons have a an energy of 140 KeV which is particularly

well suited to the characteristics of the main imaging instrument-the
gamma camera.

• It is easily produced, as and when required on site.

• The relative ease with which it can be attached to many varied chemical
compounds. It may be used to perform scans of virtually every organ of
 Nuclear Medicine
Bone scanning:
99m
Technetium methylene diphosphonate
i.v injection. Imaging after 3 hours
Uses:
•Detecting bony metastases in malignancy
•Bone dysplasias/fibroosseous lesions to assess activity
•Paget’s disease to identify sites
•TMJ: condylar hyperplasia
•Osteid osteoma- skeletal pain not detected for years.
Nuclear Medicine-bone scanning
• The radionuclide may be taken up in areas where there is increased
blood flow (hyperemia) because of increased metabolic activity
within the bone (e.g. tumour growth) or rate of production of new
hydroxyapatite crystals (osteogenesis) - especially reaction of the
bone at the margins of the tumour. Decreased activity is associated
with metabolically inactive bone, a lack of osteogenesis, or an absent
vascular supply. Areas of increased uptake are referred to as “hot
spots”, whereas zones of diminished or absent activity are called
“cold spots”.

• Radionuclide bone imaging is important in the

evaluation of several acquired bone diseases but not for
congenital bone diseases. The acquired bone disease can
be classified as traumatic, neoplastic, inflammatory,
metabolic, degenerative, vascular and other bone
diseases
 Nuclear Medicine
SPECT: single photon
emission computed
tomography
Gamma camera capable of
rotating around the patient
through 360o
-image acquisition takes about 30-45 minutes

Uses technology similar to CT

to derive transaxial
slices(cross-sectional) and
reconstructed multiplanar
images
 Nuclear Medicine
PET: Positron emission
tomography

Uses isotopes of atoms that

occur in natural organic
molecules (e.g. C, N, O,F)-
emits positron
Highly sensitive method
Need medical cyclotron
Wide range of clinical uses:
limited availability
Nuclear Medicine
•PET, which is reported to have a sensitivity nearly 100 times that of
gamma camera, relies on positron-emitting radionuclides
generated in a cyclotron.

•A positron is emitted within the tissue, it meets a free electron and

mutual annihilation occurs, resulting in the production of two
551keV photons (gamma rays) emitted 180 degrees to each other.

•When electronically coupled opposing detectors simultaneously

identify this pair of gamma photons, the annihilation event is
known to have occurred along the line joining the two detectors.
•
•The utility of PET is based not only on its sensitivity for functional
imaging techniques but also on the fact that the most commonly
used radionuclides (11C, 13N, 150, 18F) are isotopes of elements that
occur naturally in organic molecules.
Detector
crystals made
of bismuth
germinate
Nuclear Medicine
• PET can be used to investigate disease at the molecular level, even in the
absence of anatomical abnormalities being apparent on the CT or MRI. The
radioisotopes can be used on their own or incorporated into diverse and
biologically important compounds (e.g. glucose or amini acid) and then
administered in trace amounts to study the following :- tissue perfusion;
substrate metabolism- often using 18F- fluorodeoxyglucose (18FDG); cell or
tumour receptors; neurotransmitters; cell division; and drug
pharmacokinetics (especially drug uptake in tumours).
•
• Furthermore it is also possible to superimpose a PET scan on a CT scan, by
the technique known as co-localization, to determine the exact anatomical
position of a lesion. Clinically it has been used in the management of
patients with epilepsy, dementia, malignant tumours, cerebrovascular (e.g.
stroke) and cardiovascular diseases, staging and treatment of squamous
cell carcinoma in the head and neck..

• At the present time the use of PET is somewhat limited because of high cost.
PET facilities cost US$ two million and require more space, electricity and
air-conditioning than conventional nuclear units. Additionally, PET
requires an on-site cyclotron because of the short half-life of positron
emitting radionuclides (for example the half-life of 150 is 124 seconds).
Cyclotron cost a minimum of US$ one million and are quite expensive to
install and operate.
Nuclear Medicine
•Hofer and colleagues stated that although the combination of scintigraphic
and radiologic investigations does not facilitate differential diagnosis, the two
modalities support each other in offering valuable information on the rate of
growth of jaw lesions. Furthermore they concluded the following:-

•Although the radiographic assessment is more specific, the nuclear bone scan
is more sensitive.

•Scans are especially useful in determining surgical margins. This is because the
bone scans were more accurate than radiologic examination in delineating the
true limits of a lesions.

•Scintigrams alone are especially useful in detecting early inflammatory lesions.

•Radiographs alone are adequate for the study of cysts and benign tumours.

•Malignant neoplasm and osteomyelitis should be carefully followed using both

imaging methods. The disease process may extend considerably beyond the
zone of visible bone destruction as shown in the radiograph.
Nuclear Medicine
• In the near future, new pharmaceuticals will undoubtedly appear and
improve the sensitivity, and thus increase bone uptake relative to the
surrounding tissue. Also there is likely to be increased emphasis for
specificity of bone or soft tissue tumours on the scans with greater
research being advocated on this area.

•Molecular imaging of individual gene expression is being performed.

•Although the radionulcide imaging is noninvasive, the radiation dose

to the patient as a result of the intravenous injection of radionulide-
labeled tracers should be considered. The injection of 740 MBq of
99mTc-pertechnetate delivers a whole body radiation dose of 2 mGy.
This quantity is however less than the average annual effective dose
resulting from natural radiation.