MAGNETOM

Issue no. 1.2003

F L A S H

MAGNETOM World Meeting

Sheraton Perdana Hotel
Langkawi, Malaysia
17-18 Jan 2003

s
medical
MAGNETOM FLASH

Content
Topic Page
EDITORIAL
Seeing is Believing:
Phoenix Protocol Exchange Platform and
Virtual Siemens MR Booths at the RSNA 2002 & ECR 2003 4

PHOENIX
MAGNETOM World
Phoenix Quick Guide 6

MAGNETOM WORLD MEETING

Sheraton Perdana Hotel
Langkawi, Malaysia, 17 -18 Jan 2003 10

OPEN SYSTEM
Cervical Spine Examination with MAGNETOM Concerto 14

ULTRA HIGH-FIELD
MRI of the Knee Joint:
Comparing Sequences at 3 T and 1.5 T 16
High Field Brain Imaging: Clinical Implications 20

PEDIATRIC IMAGING
MT Tissue Contrast Effect and its Role in Pediatric MR Imaging 24
Pediatric MR Workshop 28
MRI and US in Diagnosis of Facial Angiodysplasia in Children 36
Fetal MR Imaging 44

MUSCULOSKELETAL
Magnetic Resonance Imaging of the Elbow 48
Topic Page

The information presented in MAGNETOM® Flash is for illustration only and is not intended to be relied upon by the
reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded
that they must use their own learning, training and expertise in dealing with their individual patients. This material
does not substitute for that duty and is not intended by Siemens Medical Solutions, Inc. to be used for any purpose in
that regard.

2
GASTROINTESTINAL IMAGING
MR Enteroclysis: a New Diagnostic Approach
for Small Bowel Imaging 54

TECHNOLOGY CORNER
All You Want to Know About “HASTE” 62

MRI SAFETY
Medical Devices and Accessories Developed for Use in
the MR Environment and Interventional MRI Procedures 68
Accessories and Supplies from Siemens 72

WOMEN’S HEALTH
Contrast-Enhanced 3–Dimensional Dynamic Breast MR:
Monitoring of Neoadjuvant Chemotherapy 74
Thin-MIP Evaluation 3D Mammographic Imaging 80

NEURO IMAGING
Case Report: Stroke Diagnosis with MR 84

CARDIO VASCULAR
Dream Machines and Getaway Speed… 86
MRI Flow Quantification Techniques 90
Application Tip
Basic Cardiac Positioning and Terminology 102
Upper Extremity CE MRA with CARE-BOLUS Using syngo 2002B 106
FAQs Cardiac Imaging 109
Peripheral MRA with iPAT 116

EVENTS
MAGNETOM World Summit 122

TECHNOLOGY CORNER
20 Years of Development and
a Constantly Improving Performance = MAGNETOM 124

3
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Editorial

Seeing is Believing:
Phoenix Protocol Exchange Platform
and Virtual Siemens MR Booths
at the RSNA 2002 & ECR 2003

“Protocol exchange through images on the internet, the exact

examination parameters from the images on
www.SiemensMedical.com/MAGNETOM-World directly
to the MAGNETOM and voila! your scanner is replicating what a
scanner in Massachusetts General Hospital or New York
University (NYU) is doing, or a scanner in the University of
Wuerzburg or anywhere else...”
Nobody believed us when we said these ambitions would
become a reality at RSNA in 2002. We were looked at as though
we were giving away the plot of the latest Star Trek film,
so far-reaching were our aims.
In 2002, we at MR were proud to reveal Phoenix, simply the
easiest protocol exchange method ever. Phoenix allows you to
click on an image, drag it into the measurement queue
and instantly duplicate the exact protocol-TR, TE, bandwidth,
number of slices, echo spacing, etc. Phoenix extracts these
values from the DICOM header and you are ready to scan.
If your system has a different gradient strength configuration
from the source image, Phoenix “adapts” the protocol in less
than 30 seconds. To convert images, simply press the shift key
while dragging the image into the queue.
The queue of MR users by the internet demonstration console
at the Siemens MR Booth waited patiently but full of anticipation
to see and believe what, to our competitors, remains in the
realms of science fiction. We have created a virtual RSNA and
ECR MR booth on our community web page
www.SiemensMedical.com/MAGNETOM-World containing
the panels from the RSNA and ECR, the images with Phoenix
functionality (syngo MR 2002B ) from the booths and the
presentations. Our advice is: You do not have to leave the
comfort of your home to see the MR show in the congresses.
Simply log on to our web page and see the results in a fascina-
ting and simple virtual booth full of images containing the
Phoenix icon. These are downloadable with parameters by just
clicking on the images. We don't believe we could have made
it easier.

4
Editorial Team

Tony Enright, Ph.D. Laurie Fisher, B.S.R.T., R, MR

Asia Pacific Collaboration, US Installed Base Manager,
Australia Malvern, PA

Our virtual booth was not the only focus of attention:

our community web page also attracted much attention as a
source of state-of-the-art clinical applications’ and new technical
developments’ demonstration platform. The technology corner Marion Hellinger, MTRA David Thomasson Ph.D.
MR Marketing- US R&D Collaborations
demonstrated the latest technical steps taken by MR: Application Training, Malvern, PA
Maestro Class, iPAT, TrueFISP lung imaging, viability imaging and Erlangen
more.
Case reports are available from reference sites all around the
world: VIBE MR Cholangiography from NYU, diffusion tensor
imaging from Brisbane…
Application tips will help you in your routine practice:
Cardiac perfusion imaging from Royal Brompton, MR Angio- Milind Dhamankar, M.D. Michael Wendt, Ph.D.
graphy from Essen.... MR Marketing- US R&D Collaborations,
Applications, Erlangen Malvern, PA
Clinical methods help you understand the new techniques
being developed and used by other clinics : Imaging Acute
Ischemia from MGH, MR demonstration of thoracic central veins
from Auckland.
Clinical protocols will help you improve your exam quality to
the levels of internationally renowned clinics:
Renal Mass protocol from NYU, MRCP with contrast from NYU…
Dagmar Thomsik- Helmuth Schultze-Haakh,
The future will bring our customers the complete protocol trees Schröpfer, Ph.D. Ph.D.
MR Marketing-Products, US R&D Collaborations,
from different reference sites for different anatomical examina- Erlangen Malvern, PA
tions, together with the opportunity to download them all with
one click. The future will bring out Phoenix books on Neuro MR
and Orthopedics MR where you can read text books and apply
the techniques referred to with one simple click on the images.
The future will bring case reports, application tips, clinical
methods with the Phoenix option which allows you to download
images which you believe offer solutions to your immediate Peter Kreisler, Ph.D. Judy Behrens,
questions. Collaborations & R.T. (MR) (CT)
Applications, Erlangen Adv. Clinical Applications
Our competitors may think of Phoenix books, Phoenix protocol Specialist
trees and Phoenix application tips as pure science fiction.
However, we at MAGNETOM world know, and our customers
know, that we do not deal in fiction. We deal in fact, pure and
simple. Seeing is believing.

Charlie Collins, B.S.R.T. Raya Dubner

Enjoy this issue of Flash. Market Manager (USA), Design Editor,
Erlangen Malvern, PA

Gary R. McNeal, MS(BME) Achim Riedl

A. Nejat Bengi, M.D. Advanced Application Specialist Technical Support,
Editor in Chief Cardiovascular MR Imaging Erlangen
Siemens Medical Solutions USA
5
www.SiemensMedical.com/MAGNETOM-World We thank Harald Werner, Lawrence Tallentire and
Iman Staab for their editorial help.
MAGNETOM FLASH

MAGNETOM World
Phoenix Quick Guide
Marion Hellinger, MTRA
MR Marketing-Application
Training, Erlangen

Phoenix is a unique syngo-tool that

allows you to click on an image, drag
it into the measurement queue,
and instantly duplicate the extracted
protocol – TR, TE, bandwidth, number
of slices, echo spacing, etc..
The Phoenix Quick Guide gives
a step-by-step description of how to
extract sequence protocol data from
DICOM images worldwide via net-
work, CD, or Internet using Phoenix. For additional copies of this CD, visit our web-site at
The Quick Guide is also included www.siemensmedical.com/MAGNETOM-World.
in the Phoenix CD attached to this Please click on „Contact“ on the right upper side of
MAGNETOM Flash issue. the page, give your name/address and the number
of copies that you would like to receive. The CDs
All images acquired with software will be sent to you as soon as possible.
syngo MR 2002B and all subsequent
versions can be utilized to exchange
parameter from clinical images
amongst different MAGNETOM
users. On the MAGNETOM World
page in the internet the Phoenix logo
indicates those images that are
suitable for downloading on a PC.
After transferring them to a CD these
images can be used directly on your
MAGNETOM scanner. We invite you
to visit our MAGNETOM World.
Go to www.SiemensMedical.com/
MAGNETOM-World and download
interesting clinical images from
hospitals all over the world.

6
 PHOENIX

Step 1
Click on the wing of the red
Phoenix logo

Step 2
Press the “Save” button in the pop up
window in order to save the images
on the hard disc of your PC.
As soon as the desired images are
transferred to a CD they can be taken
to your MAGNETOM scanner.
The next pages explain how
to continue with Phoenix on your
MAGNETOM scanner.

7
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Step 3
Insert the CD with the desired
images acquired with syngo MR
2002B software into the CD-ROM
drive. These may be DICOM images
that have been downloaded
e.g. from the MAGNETOM World
Internet page.

Step 4
Call up the start menu by pressing
<Ctrl> and <ESC> on your keyboard
simultaneously. Select the entry
“Program/Load images from CD”
(Fig. 1).

Figure 1

Step 5
A window named “Load images from
CD” shows up indicating the loading
progress of the images from the CD
to the browser. (Fig. 2)

Figure 2

8
 PHOENIX

Step 6
The images will be available in the
patient browser after a few seconds.
From here you can select a single
image, press the shift key
simultaneously when performing
drag & drop into the exam explorer.
The protocol conversion takes
place immediately and a pop up
window informs you about the
progress. The new generated
protocol will be inserted under the
desired program (Fig. 3)

Figure 3

Step 7
In some cases it can occur that the
new inserted protocol is underlined.
This indicates that protocol
adaptations were made during the
conversion (e.g. the original image
had been acquired on a MAGNETOM
Harmony and is now downloaded
to a MAGNETOM Sonata).
You can display the changes on the
upgrade info sub card under the
protocol properties (Fig. 4).

Figure 4

9
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MAGNETOM World Meeting

ASEAN, Malaysia, 17-18 Jan 2003
MAGNETOM World Meeting The aim was to demonstrate dealers, representing eight countries.
in ASEAN the MAGNETOM Concerto’s range of Of particular interest was the diver-
clinical applications and image sity of applications and the extremely
quality. There were two guest spea- high image quality.
kers, Dr. Craig Platenberg, MedTel
International, USA and Dr. Kenneth Shaun Seery also gave a presentation
Tan, Cardinal Santos Medical Centre, on marketing concepts and how
Philippines. marketing could be used to streng-
then a business model. This was
Dr. Platenberg gave two presen- greeted with enthusiasm by the
tations, one focusing on the clinical attendees.
The ASEAN region covers countries
outcomes of low field MR and the
like Indonesia, Malaysia, Philipines, other on the business model of his The event concluded with a “jungle
Singapore, Thailand and Vietnam. corporation. party”, including a barbeque and
We recognize a growing interest in
Dr. Tan also presented low field native Malaysian dancing (support
1.5T as well as in low field systems in
clinical outcomes and also a compa- by some of the attendees), conduc-
this area. Our Asian business centre ted in a true tropical rainforest within
is located in Singapore. Marivic rison between 1.5T and Concerto
image quality and clinical results. walking distance of the hotel.
Santos (ASEAN MR Modality Mana-
ger) and Shaun Seery (General Both speakers were extremely well All attendees gave the overall event
Manager MR Asia Pacific) organized received by the audience, which a big “thumbs up” and look forward
the event over two days on the consisted of radiologists, administra- to future events to stimulate infor-
Malaysian Island resort of Langkawi. tors, Siemens sales staff and Siemens mation exchange.

10
 MAGNETOM WORLD SUMMIT MALAYSIA

11
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

12
 MAGNETOM WORLD SUMMIT MALAYSIA

“The customers were convinced

at the end of the meeting that
MAGNETOM Concerto was a real
open system with great images.
For me this was an important
outcome of the meeting”
Shaun Seery
General Manager of Asia Pacific
Region

13
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Cervical Spine Examination with

MAGNETOM Concerto
Dudge, John C., MD
Meredith, Lawrence A., MD
Mullins, Patrick, RT
Longmont United Imaging Center
1380 Tulip Street, Suite B
Longmont, Colorado 80501

Examination was done with sagittal

T1 pre and post Gadolinium (Fig. 1),
sagittal T2 with TSE and STIR (Fig. 2, 3).
MEDIC and CISS axial images (Fig. 4, 5)
were also obtained. The bone signal
Figure 1 Sagittal T1 Figure 2 Sagittal T2
intensity is unremarkable. No acute
cervical spine cervical spine using TSE
loss of vertebral height or disk space
narrowing is seen. There is noted to
be a central subligamentous disk
protrusion at C5 and C6, extending
posteriorly by perhaps 3-4 mm and
with probably some mild pressure on
the canal. Also of note is a syrinx
beginning at approximately the C6-
C7 interspace and extending caudally
to approximately T1-T2, with maxi-
mum diameter approaching 6 mm.
There is no increased signal intensity
noted on the post-gadolinium T1
sequence.

1. Significant syrinx measuring up

to 6 mm wide from approximately
C6-C7 to approximately T1-T2.
2. Central subligamentous disk
protrusion, C5-C6, with perhaps
minimal pressure on the cord.

Figure 3 Sagittal cervical spine with STIR

14
 OPEN SYSTEM

Figure 4 Axial cervical spine images

using MEDIC

Figure 5 Axial cervical spine images

using CISS

15
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MRI of the Knee Joint:

Comparing Sequences at 3 T and 1.5 T
B.M. Wietek MD and J. Machann the objective assessment in clinical cal sequence parameters. SNR at
Section on Experimental trials of new pharmacological both field strengths were measured
Radiology, Department of and surgical treatments for articular and tissue contrast was compared
Diagnostic Radiology, cartilage lesions. qualitatively between 1.5 and 3 T. As
Eberhard-Karls University chemical shift doubles from 1.5 to
High-field MRI systems enable small 3.0 T, particular attention was given
Tübingen, Germany
field-of-view images with improved to the evaluation of chemical shift
spatial resolution due to an increased artefacts at 3.0 T.
SNR. Factors such as B0 homogeneity
and the increased chemical-shift
artefacts can, however, reduce the
Introduction gains offered by a higher magnetic
MRI of the knee performed at con- field. Given this situation, the aim of Results
ventional field strengths is sensitive our study was the direct comparison
for the detection of cruciate and of sequences with identical para- SNRs were found to be nearly
collateral ligament tears as well as for meters at different field strengths two-fold higher in the 3 T images for
the detection of meniscal tears. The with respect to SNR, image contrast, all sequences using identical para-
spatial resolution and excellent soft- and artefacts. In a second step, the meters. In this pre-clinical study, T1-
tissue contrast provided by 1.5 Tesla adaptation of sequence parameters weighted images demonstrated no
clinical MRI scanners are perfectly for optimal imaging at 3 Tesla has striking difference in tissue contrast
satisfactory. The signal-to-noise ratio been initiated. between 1.5 versus 3.0 T (see Fig. 1).
(SNR) and spatial resolution at this In the proton density and T2 weigh-
standard field strength, however, ted images, only a slightly improved
remain inadequate for the study of tissue contrast could be demonstra-
Methods ted for higher field strength (see Fig.
fine structural details in certain
critical joint components such as 2). However, in the additional carti-
MR imaging of the knee was perfor-
articular cartilage. Consequently, the lage sensitive sequences with fat
med on healthy volunteers, aged
introduction of high-field whole suppression, such as DESS (i.e.,
31-45 years, with a 1.5 T MAGNETOM
body magnetic resonance imaging sequences which were not disturbed
Sonata Scanner (Siemens, Germany)
systems, such as 3.0 T and above, is a by the more pronounced chemical-
using a circularly polarized extremity
consecutive step to achieve a higher shift artefacts at 3.0 T), a significantly
coil. The routine protocol included
spatial resolution in vivo. Applica- higher spatial resolution with similar
a T1 weighted spin-echo sequence
tions for this technology in musculo- SNR could be demonstrated using the
(TR = 450 ms, TE = 15 ms, FOV = 180
skeletal systems include the imaging same measuring time (see Fig. 3).
mm) and a turbo spin-echo sequence
of small joints and of morphologically (TR = 5000 ms, TE = 15 ms and 100 ms) In the multi-echo technique recorded
complex and vulnerable structures for simultaneous recording of proton with a higher bandwidth (MEDIC),
such as articular cartilage. density- and T2-weighted images. the images revealed a higher SNR for
The accurate imaging of articular Additionally, two special techniques the same spatial resolution (see Fig.
cartilage is of major clinical dedicated to depict cartilage were 4). In the inversion recovery images
importance as cartilage degeneration applied: a dual echo steady state (TIRM), fat suppression enabled
is a significant cause of morbidity. (DESS) sequence (TR = 21 ms, TE = 6 obtaining artefact-free (i.e. chemical-
ms) and a multi-echo sequence with shift) images. Furthermore, a
Diagnostic arthroscopy is still a high bandwidth: MEDIC (TR = 120 significant 2.5 increase in SNR was
frequently used for articular cartilage ms, TE = 21 ms). Finally a TIRM (TR = achieved at 3.0 T.
assessment despite the fact that only 7000 ms, TE = 58 ms, TI = 180 ms)
the surface condition of the cartilage sequence and a standard gradient The GRE sequence images revealed
can be directly evaluated by this echo sequence (GRE) with different a clear signal loss in regions with
method. In particular, cartilage repair TE’s were applied (TR = 120 ms, spongy bone marrow. This was
and degeneration cannot be monito- TE = 10 and 20 ms, FOV = 180 mm). particularly clearly visible in the
red over time by such invasive Examinations were repeated on a 3.0 epiphysis of the distal femur (see Fig.
methods. Such monitoring becomes T whole body imager (MAGNETOM 5, small arrow), even when a rela-
particularly important, however, for Trio, Siemens, Germany) with identi- tively short TE of 10 ms were used.
16
 ULTRA HIGH-FIELD

Figure 1 T1-weighted SE-images

revealed no striking differences
between 1.5 T (a) and 3 T (b) regar-
ding to tissue contrast. Measurement
parameters: TE = 15 ms, TR = 4500,
FOV=180 mm, Matrix 256x256,
BW 130 Hz, in plane resolution
0.7mm2, slice thickness 4 mm,
Acq. time 4:20 min.

Figure 1a Figure 1b

Figure 2 PD/T2-weighted fast

spin echo images show a slightly
improved tissue contrast at
3 T Measurement parameters:
TE = 15 and 100 ms, TR = 5000,
FOV = 180 mm, Matrix 256x256,
BW 130 Hz, in plane resolution
0.7 mm2, slice thickness 4 mm,
turbo factor 5, Acq. time 4:27 min
[1.5 T T2-weighted (2a), PD-weigh-
ted (2c), 3.0T T2-weighted (2b),
PD-weighted (2d)]
35 year old healthy male volunteer,
without knee joint pain or trauma in
his medical history.
Figure 2a Figure 2b

Figure 2c Figure 2d

17
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

In summary, the usual T1 and T2

weighted spin echo and turbo spin
echo sequences led to very similar
contrast characteristics and showed
increased chemical shift artefacts at
3.0 T compared to 1.5 T. To overcome
this effect, larger bandwidth needed
to be used, thereby decreasing the
Figure 3a 1.5 T FOV 205, in plane Figure 3b 3T FOV 205, in plane
SNR. Consequently, such sequences
resolution 0,8 mm isotropic resolution 0,8 mm isotropic
used in MR articular imaging did not
profit from the increased SNR at 3.0 T. Figure 3 3D Dual echo steady-state
Gradient echo sequences showed (DESS) sequence, TR = 21, TE = 6ms,
similar increased chemical shift FOV = 205 mm, Matrix 256x256, BW
artefacts as well as a faster signal 130 Hz, Flip Angle = 25° , in plane
decay with TE, especially in regions resolution 0.8 mm2, partition thick-
with trabecular bone structures, ness 0.8 mm, Acq. time 7:31 min
which are likely to be related to In these cartilage sensitive sequences
reduced T2*. – especially fat suppressed images –
no pronounced chemical shift
However, new acquisition strategies artefacts disturb the improved SNR
such as the MEDIC-sequence perfor- by the same spatial resolution (a)
med with relatively high bandwidth 1.5 T and 3.0 T (b). A significantly
resulted in high SNR, high image higher spatial resolution (in plane
quality at 3.0 T. This applied also to resolution 0.6 mm2) with similar SNR
fat suppressed imaging of cartilage – could be demonstrated using the
same measuring time (c). Figure 3c 3T FOV 154, in plane
DESS-sequence- where improved resolution 0,6 mm isotropic
SNR without any chemical-shift
artefact was achieved. For these
sequences the increase 3.0 T SNR Figure 4 Multiecho-data-image- The ‘MEDIC’ images revealed
could be exploited and lead to combination sequence (MEDIC), a higher SNR and an improved tissue
decreased acquisition time or increased TR = 120, TE = 21ms, FOV = 180 mm, contrast by the same spatial
resolution. Matrix 256x256, BW 390 Hz, flip resolution. 1.5 T (a), 3.0T (b)
angle = 50°, in plane resolution
0.7mm2, partition thickness 0.7 mm,
slice thickness 4 mm,
Conclusion Acq. time 0:32 min
This preliminary study investigated
the potential of 3.0 T field strength to
improve diagnostic imaging of
articular cartilage. Due to increased
chemical shift, standard imaging did
not show 3.0 T benefits. However,
fat-suppressed and large bandwidth
acquisitions (DESS, MEDIC) clearly
profited from the increased 3.0 T
SNR. These results show promise for
faster or high resolution imaging
at 3.0 T when using appropriate
sequences.

Figure 4a Figure 4b

18
 ULTRA HIGH-FIELD

Figure 5a Figure 5b Figure 5c

Figure 5 2D gradient echo (GRE) In the gradient echo sequences the

sequences, signal show a faster decay with TE
TR = 120 ms, TE = 10/20 ms, especially in regions with trabecular
FOV = 180 mm, Matrix 256x256, bone structures (e.g. epiphysis) and
BW 130 Hz, flip angle = 48°, in plane more pronounced chemical-shift
resolution 0.7mm2, partition thick- effects at 3.0 T: TE 10ms (a),
ness 0.7 mm, slice thickness 4 mm, TE 20 ms (b), MEDIC sequence (c).
Acq. time 0:32 min

Figure 6a Figure 6b
Figure 6 IR TSE-Sequence (TIRM)
TR = 7000 ms, TE = 58 ms,
TI = 180/190 ms, FOV = 180 mm,
Matrix 256x256, BW 130 Hz, flip
angle = 150°, in-plane resolution
0.7mm2, partition thickness 0.7 mm,
slice thickness 4 mm, Acq. time 4:28
min. Suitable T1 Relaxation times
for the complete fat suppression are
between 180-190ms indicating
a slightly higher T1 time for fat at 3T:
a) TI = 180ms,
b) TI = 190ms,
c) TI= 200ms,
d) TI= 220ms
Figure 6c Figure 6d

19
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

High Field Brain Imaging:

Clinical Implications
A. Gregory Sorensen, M.D. ■ The investigation of microscopic additional SNR is available, how best
Massachusetts General Hospital, anatomy with diffusion imaging and to use it is for the radiologist to
USA perfusion imaging is just beginning decide.
to achieve widespread clinical accep-
It is also important to note that
tance. However, such images are
increasing field strength is not the
markedly limited by signal to noise
only way to improve the ratio of
constraints. This is one reason for the
signal to noise. A four-fold increase
lower spatial resolution of diffusion
in imaging time will lead to a doub-
and perfusion MRI compared to
ling of the signal to noise ratio (SNR).
conventional imaging.
This means that when one refers to
Introduction ■ Spectroscopy and spectroscopic SNR, it always assumes a fixed
imaging have had limited success in amount of imaging time, since one
Magnetic resonance imaging has
the clinical arena, despite marked can improve SNR simply by imaging
changed medical practice, particularly
success in the laboratory setting. One longer. SNR can also be improved
in the brain. Diagnosis of anatomic
key reason is the time needed to by utilizing improved receiver coils
diseases has become possible with a
acquire clinically useful information. (such as surface coils, singly or in
level of precision that was previously
arrays); in some instances by shorte-
unthinkable: tumors, aneurysms,
ning echo times (made possible
congenital abnormalities, and trau-
In each of these scenarios, a funda- by improved gradient hardware); or
matic injuries are now routinely
mental limitation that current MRI by utilizing novel pulse sequences
diagnosed with a higher degree of
techniques suffer from can be (these often optimize contrast to
accuracy than ever before.
thought of as simply too low a ratio noise, or CNR, but sometimes boost
of signal to noise. As users look for SNR as well). However, most new
Nevertheless, the full potential of
ways to get more signal, an increa- 1.5T systems in use today are already
MRI remains to be realized. In a
sing number are using higher field using optimized hardware and
number of clinical applications in the
strengths. This article will illustrate software. While longer imaging times
brain, MRI might be able to offer
some of the benefits we have recog- might provide better SNR, increasing
significantly more benefit than it
nized in our practice by moving from the imaging time by a factor of four is
currently offers. Take these four
1.5 Tesla (the current standard simply not possible in many situa-
examples:
premier clinical system) to 3.0 Tesla. tions for a variety of patient related
We have found significant benefit by reasons. For example, the exam may
■ Most psychiatric diseases have already be as long as feasible, or the
little if any gross anatomic change moving to 3T in a variety of routine
and investigative settings. patient is not stable, or there may be
detectable by MRI. Instead, such economic reasons, e.g. throughput
diseases appear to be caused by of patients. Therefore, using a higher
incorrect functioning of normal- field strength is an option that merits
appearing tissue. Functional MRI – an Signal to noise: exploration.
approach that may be able to change the “currency” of MRI
this shortcoming – has been limited
by the lack of signal relative to the An important concept in considering
biologic noise present (as well as the benefits of high field imaging is Areas of Potential Benefit
other problems). that signal to noise can be viewed as We will briefly explore each of the
a type of “currency” that the radiolo- above listed areas of MRI limitation to
■ Magnetic resonance angiography, gist can choose to “spend” in a num- see what benefit higher field imaging
though steadily improving, has not ber of ways. Improved SNR might be might bring.
yet replaced catheter-based x-ray used to increase the imaging matrix,
angiography as a gold standard. or to choose thinner slices, or to
From a health care policy point of reduce the number of signal averages, Conventional Anatomic
view, the sensitivity and specificity or in some cases to decrease the
Imaging
are too low; from a technical point of amount of contrast agent administe-
view, coverage and spatial resolution red. This flexibility of improved SNR is Conventional MRI already provides
are both insufficient. one of its greatest advantages. Once high quality imaging in many
20
 ULTRA HIGH-FIELD

settings. There are, however, some graphy. Diseases that could benefit
instances in which finer detail from this improvement in spatial
would be desirable, particularly if the resolution include both aneurysms
imaging time is not increased. and atherosclerotic disease. Impro-
Figure 1 shows an example of the ved diagnostic confidence in MRA
intracranial vasculature near the could preclude even more catheter
Cirlce of Willis, demonstrating small x-ray angiography studies and, for
perforating arteries not typically example, allow more confident
visible. While the increased matrix screening of patients with congenital
size here would be possible at 1.5T, or other predisposition to form
the resulting voxel size would lead aneurysms.
to a grainy image. Such fine level of
With the recent focus on dynamic Figure 1 Ultra-high-resolution T2
detail is appealing to surgeons,
contrast-enhanced angiography, the weighted images showing the Circle
radiologists and radiation therapists,
benefit of improved SNR at 3T will be of Willis. Note the high level of detail
as well as neuroscientists. Remember evident, in particular the lenticulo-
even more apparent. This is because
that most CT images are 512x512 striate and perforating vessels arising
these contrast-enhanced techniques
over a 20 cm field of view; this is a from the middle and posterior cere-
are inherently SNR-limited:
voxel size that is one quarter that of a bral arteries (arrows). While a similar
these techniques depend on acquiring
typical MR image, or smaller. While matrix could be used at 1.5T, it
multiple images during the rapid would produce images with increased
MRI provides superior contrast to
passage of contrast through noise (a grainy appearance), and
noise (CNR) for most lesions, increased
the arterial tree, and increasing the less diagnostic confidence. Courtesy
spatial resolution would be welcome
imaging time is not an option. Larry Wald, PhD. Images acquired on
in most arenas. Specific diseases in
a Siemens Allegra 3T with a 4 channel
which increased spatial resolution of
array coil. Acquisition parameters:
conventional images might prove to 15 echo Turbo Spin Echo: TR/TE =
be cost effective include tumors, in Functional MRI
4000/90ms, FOV = 156 x 180 mm,
which pre-surgical planning could be The area of functional MRI is perhaps 450 x 512, 2 mm slice thickness
assisted; and epilepsy and congenital where high-field will be of greatest 0.35 x 0.35 x 2.0 mm3 voxels,
abnormalities, which are often subtle impact. Blood-oxygenation level 9 min 16 sec scan time, 15 slices.
and difficult to detect. dependent (BOLD) imaging gains an
additional boost from high field
because susceptibility effects gene-
Magnetic Resonance rally increase as the square of the
Angiography field strength. Hence, at 3T the level
of signal change can be up to 7%,
We have found substantial improve- compared with 1.5% or less at 1.5T.
ment in the appearance of MRA This benefit is particularly apparent
images at higher field, and are when investigating subtle changes,
currently investigating the specific or when utilizing paradigms that
cause of this improvement. Figure 2 require extra SNR, such as single trial
shows 1.5T and 3T images demon- designs or event-related studies. One
strating the high level of detail way to measure the apparent benefit
available at 3T. Note in this case that of higher field is to determine the Figure 2a 1.5T Figure 2b 3T
the matrix sizes are the same (both extent of activation for a given
1024 MRA); the improvement in SNR paradigm. With better SNR, additio- Figure 2 performed at 1.5T on
shows as a reduction in the graini- nal areas should be resolved from the a MAGNETOM Sonata; image (b)
at 3.0T on a MAGNETOM Allegra.
ness of the image, and in increased background noise. Figure 3 demon-
Note the increasing vessel conspicuity
conspicuity of the fine vasculature. strates results from a visual stimula- and the level of detail. Both were
We anticipate that with additional tion paradigm at 3T and at 1.5T, and 1024 x 384 matrix sizes; the 3T
work to optimize parameters for 3T, indicates that extensive additional image took approximately 7 minutes
MRA will improve further, and may information is available at higher and the 1.5T approximately
eventually rival catheter x-ray angio- field. 16 minutes.
21
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Paradigms to investigate dementia,

drug addiction, migraine, and other
human diseases are underway at
our institution, as well as others, and
have demonstrated benefits at 3T.
Two potential drawbacks of the
higher field should be remembered
when considering fMRI, however:
often, the echo-planar sequences on
higher field instruments are substan-
tially louder than on 1.5T systems
and require additional hearing pro-
tection. Also, as noted in the previous
paragraph, the increased field
strength increases susceptibility
effects. This is why the BOLD signal
change is improved. However,
susceptibility artifacts are also increa-
sed. This can be of particular concern
if the area of interrogation is prone
to such artifacts, such as the inferior
temporal lobes. Nevertheless, most
investigators find that these draw- Figure 3 fMRI at 1.5T and at 3.0T.
These images are computed eccentri-
backs are manageable and worth the
city phase maps, used for mapping
benefits.
retinotopy in the visual field.
The images are on flattened visual
cortex, taken from the calcarine
Diffusion and Perfusion fissure (area circled on small image
MRI of brain cortex at top left).
The subject is shown expanding
These relatively new techniques, rings, and the delay from the onset
which use echo planar imaging and of the stimulus is mapped as a phase
typically push SNR requirements to change. Colors represent isophase
regions, with the white areas
the limit, also benefit from higher
representing one particular phase
field strength. Perfusion-weighted value. Note that at 3T, the signal
imaging has an additional way to strength is higher and allows map-
“spend” the increased SNR that 3T ping of a larger area of visual cortex,
yields. The susceptibility changes whereas at 1.5T, many areas are
that are the basis of perfusion MRI simply not visible, since the noise
can be obtained with a lower dose of hides the reaction of the brain tissue.
Gd-based contrast agents compared Many more white areas are present
with lower fields. In effect, the at 1.5T, indicating that the ability
higher field strength means half the to distinguish noise from signal is
decreased. Figures courtesy of
dose can be used compared with
Anders Dale and Bruce Fischl,
1.5T for the same effect. Figure 4 MGH-NMR Center.
shows perfusion MRI images obtai-
ned at 3T, and indicates that creating
maps of relative cerebral blood flow
as well as relative cerebral blood
volume is easily done with the higher
SNR available. Perfusion measure-
ments have often been limited by
22
 ULTRA HIGH-FIELD

SNR, since the first pass of a contrast

agents occurs so quickly and therefore
there are relatively few data points to
compute hemodynamic parameters
from. The additional SNR boost
(assuming the same dose of Gd is
given) can allow more precise mea-
surement of hemodynamics, particu-
larly in disease states such as stroke
where hypoperfusion is present and
only a small amount of contrast
agent might be arriving into a voxel.

Diffusion MRI is also limited by SNR:

many sites typically acquire multiple
signal averages at 1.5T, and still have
insufficient SNR to fully study pheno-
mena such as anisotropy and behavior
of the full diffusion tensor in disease
states such as stroke. The additional
SNR boost should help these studies
as well.
Figure 4 Perfusion MRI at 3.0 T*
Maps of relative cerebral blood
volume (rCBV) and relative cerebral
blood flow (rCBF) can be created The Future
from dynamic data acquired at 3.0T.
These images demonstrate abnor- We anticipate that the quest for
mally elevated rCBF and rCBV in higher field strength will continue.
a residual grade 3 tumor. Note the A few centers (including ours) are
excellent gray / white ratio, consi- installing even higher field strengths:
stent with known differences in gray 7.0 Tesla and beyond (WIP). While
matter and white matter blood flow there are a number of technical
and blood volume (Siemens issues at high field, including radio-
MAGNETOM Allegra, Spin Echo EPI).
frequency power deposition, field
inhomogeneity, and increased
system performance requirements,
we believe that these are challenges
that are well worth the effort needed.
As with echo-planar imaging, the
widespread clinical acceptance of
these systems requires a streamlined
user interface and increased robust-
ness, as opposed to the less reliable
performance of research systems.
Which of the above applications (or
perhaps other applications not
mentioned) will provide the most
compelling reason to move to higher
field in the clinical setting remains
to be determined, but the move
* This informationconcerns use of contrast media that has not been
to high field for clinical imaging is
approved by the Food and Drug Administration. undisputable.
23
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MT Tissue Contrast Effect and

its Role in Pediatric MR Imaging
Christine Harris, RT (R)(MR) transmission of neural impulses signal intensity from the free water.
Tamara D. Lee, BSRT(R)(MR)(CT) through the CNS. Myelination is This is the process of magnetization
The Children's Hospital of ongoing throughout the first decade transfer. Contrast is enhanced
Philadelphia of life, and myelin contains protein between tissues that undergo mag-
and lipids, which contribute to T1 netization transfer (water-containing
contrast. During the first two years tissues) and those that do not (fat-
of life, this development should be containing tissues). Magnetization
taken into account when selecting transfer pulses may be used in Spin
techniques that will produce optimal Echo (T1) following administration of
pediatric images. a contrast agent and in Gradient Echo
Introduction sequences (3D TOF MRA), to produce
additional signal suppression of
When imaging the pediatric brain, tissue water.
MR pulse sequence:
many techniques and methods must
be considered. We, the staff at The
Magnetization transfer The clinical applications of magneti-
Children's Hospital of Philadelphia, suppression (MTS) zation transfer can be divided into
plan to share with you our experien- Magnetization transfer (MT) suppres- two categories: contrast augmenta-
ces in this area through a series of sion is a technique similar to fat tion and tissue characterization. In
articles and tips. saturation in terms of hardware a given tissue, the saturation pulses
implementation. However, instead of used in magnetization transfer
It is known that the pediatric patient
an RF pulse centered at the fat reduce the signal intensity. The
presents many challenges during an
frequency, magnetization transfer degree of signal intensity reduction
MR exam. These challenges include:
uses a narrow bandwidth RF pulse depends on the amount of magneti-
1. Safe sedation techniques with a center frequency approximately zation transfer present in this tissue.
2. Monitoring during the MRI exam 1-10 kHz away from the main water Using magnetization transfer sup-
resonance. This off-resonance pulse pression, contrast between tissues
3. Technical parameters
affects some of the tissue water with different amounts of magneti-
In this article, we will discuss tissue zation transfer can be increased.
protons, more specifically the “bound
contrast considerations for imaging
water” protons.
the pediatric brain. Magnetization transfer saturation
Water within a tissue is either mobile pulses can be combined with all
(freely moving) or bound to macro- conventional MR sequences. When
Brain development molecules. While both free and using magnetization transfer for
bound water protons have the same contrast augmentation, the familiar
Why does the pediatric brain present tissue contrasts on these sequences
resonance frequency, they will have
imaging challenges that the mature change. For example, when combi-
different T2 relaxation times. Free
brain does not? The brain matures ning a T1 weighted sequence with an
water protons will have a long T2 and
in an organized and predetermined MT saturation pulse in brain imaging,
a sharp peak. Bound water has a very
pattern that correlates with the fat appears brighter, and the gray
short T2 and a broad resonance peak,
development of functions in the matter of the central sulcus, putamen,
not normally visualized in an image.
newborn and infant. As the pediatric and caudate increases in brightness
The two peaks will be superimposed
brain develops, its water content and conspicuity.
at the same center frequency.
decreases and its myelin content
increases. The infant brain has a Magnetization transfer sequences On Time of Flight (TOF) images,
much higher water content than that apply a narrow bandwidth presatura- blood vessels stand out against
of the older child or adult. The high tion pulse that is centered 1-10 kHz a dark background due to selective
brain water content at birth decreases away from the central water frequency. saturation of stationary tissue. This
rapidly over the first six months of The magnetization transfer RF pulse effect is based on two phenomena.
life. It continues to decrease at is applied off-resonance to saturate One, blood flowing into the imaging
a slower rate until age 2, and then the bound water protons. Exchange plane does not experience the satu-
levels off. Myelination of white between the bound and free water rating effect on the MT pulse, and
matter is an important component of protons transfers the saturation two; the MT effect of blood is lower
brain maturation. It facilitates the to the free water protons, reducing than that of brain parenchyma.
24
 PEDIATRIC IMAGING

Another clinical application is the use

of MT pulses in combination with
contrast enhanced TOF. The repeated
application of RF pulses in TOF MRA
not only gives rise to saturation Figure 1 Figure 2
of stationary tissue, but also leads to Figures 1 and 2 were both acquired with the same parameters, except that
saturation of blood flowing in the in Figure 2 we added an MT pulse. Note the decrease in gray/white matter
imaging plane. As a result, a reduc- contrast in Figure 2.
tion in the vessel-to-background ratio
occurs. By using gadolinium chelates,
this phenomenon can be reduced.
These agents shorten intravascular The benefit is similar to giving Protocol
T1 relaxation times, which diminishes larger doses of contrast, but without
the added expense. This will improve At our institution, MTS is utilized
the sensitivity of blood to saturation
lesion visibility. with pre- and post-contrast imaging,
effects. Gadolinium is largely
and for enhancing lesions such as
insensitive to MT pulses; however,
infection and infarction.
the combination of gadolinium and
MT pulses increases vessel to back- Pitfall Pre-MTS imaging is utilized to assess
ground contrast. pathological enhancement accurately
We have noted that when using the
as well as the sensitivity of certain
Magnetization transfer suppression MT pulse sequence with children
disease processes which may be
can also be used to quantitatively under the age of two, MT resulted in
obscured during standard T1 imaging
characterize tissues. The amount of decreased conspicuity of edema as
(Fig. 3 and 4).
MT in tissues depends on the physical well as gray/white matter contrast.
and chemical characteristics of tissue (Fig. 1 and 2).
components, which may change
in disease states. Such changes can
be quantified using magnetization
transfer. To quantify these changes,
two MR sequences are needed: one
in conjunction with the MT pulse,
and the second one identical but
carried out in the absence of the MT
pulse.

Effects of MT on
MR imaging
MT is utilized routinely with MRA to
suppress the background signal
while maintaining the signal contrast
from the vessel. MT increases the
conspicuity of small and distal blood
vessels.
By suppressing the background signal, Figure 3 Routine Spin Echo Figure 4 Spin Echo with MT Pulse.
the signal ratio between vessel and Note increased visualization of TS
brain tissue will be improved. MT use disease process vs. non-MT image
with post-contrast imaging increases (Fig. 3)
the contrast to noise ratio of enhance-
ment, which is nearly doubled when
compared with non-MT MR Imaging.
25
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

When employing the MTS pulse to

our standard Spin Echo sequence, we
increased our TR. Longer TR with MTS
results in loss of gray/white matter
contrast.
With the help of Siemens, we
have developed a short TR/TE T1 MT
protocol that has improved our
gray/white matter visualization, as
well as maintaining a short scan
time. This change in T1 contrast
improves the visualization of gray
and white matter in children whose
brains are undergoing normal
development (see Fig. 5 and 6).

Figure 5 (TR 800) loss of gray/ Figure 6 (TR 536, TE 12, Flip angle 90
white matter contrast 192 x 256) increase in gray / white
matter contrast

The authors recommend Magnetization transfer analysis of

the following reading materials: brain tumor, infection and infarction,
by MH Pui, in Magnetic Resonance
References: Imaging 2000 Sep; 12(3):395-9
Age-dependent changes in magne- Contrast-enhance magnetization
tization transfer contrast of white transfer MR of the brain: importance
matter in the pediatric brain, Rassek, of pre-contrast images, by JR. Meyer,
Engelbrecht V., in AJNR 1998 Nov- in AJNR 1997 Sep; 18(8)1515-21
Dec; 19(10): 1923-9
T1-weighted three-dimensional
Characteristics and pitfalls of magnetization transfer MR of the
contrast-enhanced, T1-weighted brain: improved lesion contrast
magnetization transfer images of the enhancement, by DA. Finelli, in AJNR
brain, by Shrier S. Higano, in Acad 1998 Jan; 19(1):59-64
Radiol 2000 Mar; 7(3):156-64
Magnetic Resonance of Myelin,
Contrast-enhanced magnetization Myelination and Myelin Disorders
transfer MRI in metastatic lesions 2nd edition, by M.S. van der Knaap,
of the brain, by P, Peretti-Viton, and J Valk
in Neuroradiology 1998 Dec;
40(12):783-7

26
we see a way to do 50% more exams with only 25% more staff

we see a way to get reports to physicians 12 hours faster

we see a way to increase patient satisfaction by improving scheduling accuracy

What do
you see?
we see a way to speed radiology order time by 3 hours

Proven outcomes. It’s what we are helping of integrating medical technology, IT, management
to deliver right now. Across the entire consulting and services. In a way that only Siemens
healthcare continuum. Outcomes that result from can. Visit SiemensMedical.com/proof. See what we
truly efficient workflow. Outcomes that dramatically see. Tangible solutions. Proven outcomes.
improve your bottom line. Outcomes that lead to
a level of care that feels exceptional to the patient.
And the care provider. Proof positive of the value

Siemens Medical Solutions that help

MAGNETOM FLASH

Pediatric MR Workshop

The workshop was attended by: They believed that a good way to
Christine Harris measure EF was to measure extrac-
CHOP, Philadelphia tion from blood into the cortex
(descending aorta as input function)
Tamara Lee and from the cortex into the collec-
CHOP, Philadelphia ting system.
Dr. Robert Zimmerman The second focus in renal imaging
CHOP, Philadelphia was to evaluate the ADC (Apparent
Diffusion Coefficient) of the kidney
Dr. Cornelia Czipull as a marker for renal development.
The lack of radiation exposure, the University of Karlsruhe
possibility of multi-planar imaging Dr. Palasis concentrated on spectros-
and the wide range of tissue contrast Dr. Susan Palasis copy of the brain. She classified
have made magnetic resonance (MR) CHOA, Atlanta the use of spectroscopy under the
imaging an important tool in the Dr. Damien Grattan-Smith following subgroups :
evaluation of pediatric diseases.
CHOA, Atlanta 1. Brain tumors: Diagnosis and
Siemens organized a workshop on characterization of tumors in difficult
Dr. Richard Jones
this topic, which took place in Erlan- locations particularly. Delineation
CHOA, Atlanta of the extent of tumor infiltration
gen. Its aims were two-fold. Firstly,
to get a better understanding of the Dr. Robert Ogg past obvious anatomic abnormality.
use of MAGNETOM systems in this St. Judes, Memphis Monitoring of tumor progression
area, and secondly, to get feedback or response to therapy.
from Siemens’ customers regarding Dr. Thomas Keller
2. Seizures: Localization
future developments which might Kantonsspital, Baden
impact on solutions provided by 3. Ischemia: Prognostication in
Prof. David Gadian
Siemens MR systems. neonatal hypoxic ischemic injury and
University College London
pediatric stroke.
Prof. Dr. Ludger Sieverding
4. Metabolic disorders:
University of Tuebingen Diagnosis and characterization.
Prof. Dr. Rudolf Stollberger
University of Graz
She emphasized “Short TE” MR
Prof. Dr. Franz Ebner spectroscopy as an important tool in
University of Graz the diagnosis and classification
of brain tumors. She mentioned that
Prof. Dr. Thomas Rupprecht
mI:Cr ratio, seen with short TE
University of Erlangen
spectroscopy, had predictive value
regarding tumor grade and histology.
Also for tectal plate tumors, MR could
Highlights of the meeting predict aggressive (Fig. 2) or non-
aggressive behavior (Fig. 3). Overall
she said that MRS was valuable for
Children’s Hospital of the evaluation of brain tumors and
Atlanta had high accuracy in predicting
Dr. Grattan-Smith & Dr. Jones talked tumor grade, adding that both short
about their experience in evaluating and long TE sequences needed to be
renal perfusion and interpolating performed. She summarized the
functional parameters from the future goals for Siemens in terms of
information obtained from renal spectroscopy as :
cortex, medulla perfusion (Fig.1).

28
 PEDIATRIC IMAGING

Long TE SVS

60
Cortex
Cortex(fit)
50 Renal pelvis
Renal pelvis(fit)

40
R1(sec-1)

30

20

10

0
0 100 200 300 400 500 600 700 800
Time(seconds)

Figure 1 Interpolating functional

parameters from renal cortex, me-
dulla perfusion.

Figure 2 3 year old girl with

vomiting. Tectal plate tumor,
spectroscopy shows aggressive
metabolite profile.
Short TE SVS

Long TE SVS

Figure 3 9 year old girl with head-

aches, tectal plate tumor is seen.
Spectroscopy shows non-aggressive
metabolite profile

Short TE SVS

29
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 4
1. To evaluate as much of the
brain as possible (2D CSI- 3D CSI),
(Fig. 4);
2. To evaluate as much
peripherally as possible;
3. To evaluate tissue microhetero-
geneity;
4. To maintain spectral resolution
5. Keep imaging time as short as
possible

Karl-Franzens-University,
Graz and LKH / General
Hospital
Prof. Dr. Stollberger & Prof. Dr. Franz
Ebner stressed protocol optimization.
They sub-grouped the patients as
0-3 months, 3-12 months, 12-24
months and above. Their philosophy
was to optimize the spatial resolution,
contrast resolution, S/N and coil use.
One of his interesting research
topics was MR urography, which they
said could replace the conventional
techniques. Dr. Ebner defined
this technique as “one-stop shop”
imaging, replacing conventional
techniques like IVU, scintigraphy and
sonography (Fig. 5-6).

University of Tuebingen
Prof. Dr. Sieverding provided a
summary of MR use in pediatric
cardiac imaging including morpho-
logy, function (contractility, volume,
flow, perfusion, viability) and meta-
bolism. The sequences used for
congenital heart diseases (Fig. 7) are
black blood sequences, Spin Echo
seqeuences, 2D Gradient Echo and
3D Gradient Echo sequences. He also
expressed his needs in terms of faster
imaging and, in particular, better
monitoring of the patients.

30
 PEDIATRIC IMAGING

2 year old child with optic pathway Children’s Hospital of

tumor. Philadelphia
Christine Harris and Tamara Lee
introduced the Children’s Hospital of
Philadelphia where more than
11,000 MR examinations are per-
formed in any one year. They were
convinced that the new dedicated
pediatrics coils from MRI Devices
(Fig. 8) – supported with 2002
software – would be very useful in
Multivoxel long TE 270ms routine practice. In general they
expressed a need for dedicated
pediatric coils for almost all applica-
tions. They mentioned some recent
remarkable improvements in image
quality with syngo (Fig. 9).
Dr. Zimmerman said that in his clinic
spectroscopy was a routine examina-
tion reaching a total of 400 clinical
examinations and 200 research
patients. He grouped the indications
as frequent and less frequent for the
brain spectroscopy. Frequent indi-
cations were brain tumor diagnosis
Multivoxel short TE 30ms (Fig. 10) and a follow-up with treat-
ment, to clarify whether or not bright
lesions larger than 1 cm were tumors
or metabolic diseases. Less frequent
indications were defined as hypoxic
ischemic brain injury in neonates,
seizures and the differentiation of
abscesses and tumors. He stressed
the need for smaller voxels to be able
to evaluate smaller lesions. He also
expressed his view regarding fetal
imaging, which he said was an area
of potential growth. His require-
ments were for higher resolution
HASTE, thinner section HASTE and
rapid T1 weighted imaging for better
fetal evaluation. He ended his talk by
stressing that MR is the future of
Neuro-anatomy and Neuro-pathology.

31
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 5 IVU vs dynamic MRU:

duplex system left kidney with
ectopic megaureter of upper
moiety

Figure 6 Dynamic renal

MRI imaging vs conventional
imaging

32
 PEDIATRIC IMAGING

Figure 7 Pulmonary
atresia. Multifocal blood
supply

Small Large

Figure 8 Pediatric Neurovascular

CTL Array Coils*
* Certain OEM coils require 510 (k) review and Figure 9 Image examples from
are not commercially available in the U.S CHOP : Pediatric MR imaging with
syngo and optimized sequences

Figure 10 Choline map shows

increased choline in the lesion which
supports the suspicion that the
lesion is a tumor. MR spectroscopy is
frequently used in differential
diagnosis of brain lesions.

33
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

University College London

Prof. Dr. Gadian talked about
structure and function relationships
in children with brain disease. He
stressed three major topics, epilepsy,
ischemic disease and specific cogni-
tive impairments. He gave examples
of hippocampal sclerosis diagnosis
using T2 mapping (Fig. 11) and also
spectroscopic findings (Fig. 12)
related to them. His focus in ischemic
diseases was sickle cell disease (Scd).
His conclusion was that Scd patients
had potential for preventive therapy,
and perfusion fills a key gap linking
cerebrovascular abnormalities to
tissue damage. Combined diffusion /
perfusion MRI would help with
identification of tissues at risk and
contribute to patient management, Figure 11 Hippocampal T2 mapping
including the evaluation of treatment in hippocampal sclerosis.
outcome. In the area of functional
MRI, Dr. Gadian said that this appli-
cation might be used in mapping of
subclinical/interictal events, presur-
gical identification of sensorimotor
cortex, presurgical language/memory
lateralization and identification of
sites of functional reorganization.
Dr. J. Ogg, from St. Jude Children’s
Research Hospital, talked about the
major research projects in his clinic.
He also gave a detailed explanation
of the use of fMRI to investigate
cognitive deficits in survivors of
childhood cancer, which he said was
genuinely feasible (Fig. 13). Figure 12 Hippocampal sclerosis and
spectroscopic findings.
Professor Dr. Thomas Rupprecht
from Erlangen University gave an
excellent talk on the use of low field
Open Systems in the area of pediatric
imaging.
Dr. Thomas Keller, from Kantons-
spital Baden Hospital, talked about
fetal imaging in general and fetal
lung measurements. He also shared
his experience with other MR
systems.
The workshop was a great success,
providing Siemens MR Team the
necessary feedback for future deve-
lopment plans. The friendly atmos-
phere also strengthened the bond Figure 13 fMRI results. Patients Healthy adults
between us and our partners, the
Siemens customers (Fig. 14).
34
 PEDIATRIC IMAGING

Figure 14 The friendly atmosphere

in the workshop strengthened the
bond between us and our partners,
The Siemens customers.

35
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MRI and US in Diagnosis of

Facial Angiodysplasia in Children
dosage and needs iodinated contrast
media injection. It may not be
safe enough for pediatric purposes,
especially for repeated dynamic
examinations. The largest group of
patients with facial soft tissues
angiodysplasias are children.

Noninvasive ultrasonography (US)

with color Doppler mapping has been
used for the diagnosis of angiody-
splasias since the mid 1980’s. Over
the last 10 years US has been impro-
ved by the power Doppler mapping
of blood flow, which is very sensitive
to low rate blood flow [2-3, 5-8,
10,12-14,16]. The US has become
the main method for morphologic
and dynamic examinations of angiodys-
plasia in pediatric radiology thanks to
its safety and wide availability.
V.O.Panov1 M.D., A.G.Nadtotchii2 M.D., Introduction.
A.V.Ivanov3 M.D., L.B.Denisova4 M.D., New possibilities in diagnosis are
1
The Scientific Center for Angiodysplasias are a well-known being created by magnetic resonance
Obstetrics, Gynecology and Perina- and varied group of pathological imaging (MRI) with magnetic reso-
tology of The Russian Academy of disorders of blood vessels. Clinical- nance angiography (MRA). It is well
Medical Sciences, morphological classification of known that MRI produces an excellent
angiodysplasias has been well- contrast of soft tissues, high sensitivity
2
Moscow Center Of Children
elaborated [1,4]. Typically, the for the detection of different fluids
Maxillo-Facial Surgery of The
diagnosis of facial soft tissue angio- (including blood), and multi-planar
Central Scientific-Research
dysplasias is not difficult due to a imaging capabilities. MRI allows non-
Institution of Stomatology,
very prominent clinical picture. invasive demonstration of normal
3
Moscow State Medico- anatomy and pathological processes.
Stomatological University, However, its treatment is not so Currently, MRA without contrast
4
Moscow Regional Scientific- clear: for the correct treatment enhancement is widely being used
Research Clinical Institution strategy in each individual case, it is for brain angiography [9,11,15] and
important to evaluate the morpho- for the examination of cardiac
logical parameters (type of structure, hemodynamic parameters [9,15].
Moscow-Russia localization and volume of the lesion,
lesion extension to other tissues
and organs, main blood supplies) and The main purpose of this study was
the functional characteristics (blood to determine the effectiveness of
distribution, and flow rates). MRI with non-enhanced MRA in the
examination of facial soft tissue
Traditionally, selective and super angiodysplasias, to understand the
selective angiography have been exact indications and improve the
used to determine morphological methodology. Additionally, it was
variants of angiodysplasias, to more used to define the diagnostic role
precisely calculate its volume and to and the relationship of this method
show main blood supply and other with other radiological methods –
involved vessels. But this “gold especially with US and with color
standard” method uses high x-ray Doppler mapping.
36
 PEDIATRIC IMAGING

Materials and methods. ■ T1-weighted Spin Echo (SE) anatomy (Fig. 1). Manipulation of
coronal images: TR/TE=300-600/ the MR-angiography data post-
38 patients (16 males and 22 fema- 14 ms, number of slices = 20-24. processing (maximum intensity
les aged between 2 months and projection – MIP) (Fig. 2) allows one
22 years: mean age 3.2 years), ■ T1-weighted Gradient Echo FLASH
to obtain images of “vessels of inte-
with large and extensive facial angio- sagittal image : TR/TE=100-250/
rest” and to simulate “selective” and
dysplasias, were examined by US 4,6 ms, flip angle
=70-90º, number
“super-selective” angiography.
with color Doppler mapping and by of slices = 9-17.
Special methodology and/or anesthe-
MRI with MRA. Angiodysplasias can 2. Examination of the region of siology are necessary for MRI with
be classified as large if it affects only interest – examination time was no MRA in infant children
one anatomical region of the face longer than 30 minutes, FOV = (younger than 5-6 years).
and as extensive if it affects two 200-220 mm, slice thickness
or more facial anatomical regions. 1-3 mm, matrix 256x256/512x512):
7 patients had the capillary type of
■ T2-weighted TSE coronal or axial Results and Discussion
angiodysplasias and different types
images: TR/TE=3500-4500/120 ms, US with color Doppler mapping was
of arteriovenous fistulas were found
TSE factor = 7, number of slices = 8- more precise, faster and easier
in 20 patients. In 12 cases it was the
16, matrix 512x512. compared to MRI and MRA in regard
primary diagnosis. Disorders were
diagnosed after different types of ■ T1-weighted Gradient Echo FLASH to measurements of blood flow of
treatment in 6 cases and during (TR/TE=125-350/11 ms, flip angle small vessels in angiodysplasias.
treatment in 20 patients. Results
=60-90º, number of slices = 4-10, Blood flow rate determinations with
were verified in 9 cases by angio- matrix 256x256) or TSE (TR/TE= MRI were not reliable enough: mea-
graphy and in 6 cases by histological 150-450/12-14 ms, tse factor = 2-3, suring error for extracranial vessels
examination after surgical treatment. number of slices = 4-10, matrix with diameter 6-8 mm was more
512x512) coronal images. then 15 % compared to the US data.
US with color Doppler mapping The error increased to 25-30% when
examinations were obtained on ■ Regional or “whole-head” 3D Time the vessels’ diameter had decreased
Ultra_ark-9 (ATL, USA), Idea-4 and of Flight MR-arteriography (3D TOF) to 3 mm.
Megas (Esaote, Italy), Sonoline – 3D FLASH with flow compensation
Sienna (Siemens, Germany) with and magnetization transfer, Moreover, the wide range of blood
linear detectors 5.0-7.5 MHz and TR/TE/
=39/10/25, slab thickness = flow rates in the area of angiodys-
emitting surface length from 35 to 32-220 mm; plasias did not allow the design of
64 mm. common standard parameters of
■ Regional or “whole-head” 2D time- such MR-examinations: for correct
All MRI with MRA examinations were of-flight MR-venography (2D TOF) – measurements it is necessary to
obtained on 1.0 T MAGNETOM 2D FLASH with flow compensation experiment with new parameters for
Harmony (Siemens, Germany) [15] in and magnetization transfer, each case.
three steps: TR/TE/
=32/9, 8/35, slab thickness =
60-200 mm. At the same time, MRI has huge
1. Non-specific standard examina- advantages over US in the determi-
tion of the head (skull and brain) – 3. Regional measurement of blood nation of morphologic characters of
time of acquisition was about flow rate was made on relatively angiodysplasias of facial soft tissues.
16 minutes, FOV (Field of View) – large vessels (diameter more then In addition, MRI allows the examina-
200-260 mm, slice thickness 0,3 mm), FOV = 100-200 mm, slice tion of other potential intracranial
3-5 mm, matrix 256x256): thickness = 6-8 mm, matrix disorders and lesions of the mandible
■ T2-weighted single shot Turbo 128_128/256_256): and/or paranasal sinuses (Fig. 3).
Spin Echo (TSE) sagittal image: ■ Special 2D FLASH sequence for
TR/TE=3000-4000/1100 ms, echo- blood flow rate measurement
train length = 240, number of slices = with ECG gating, TR/TE/
=24-179/
1, slice thickness 40-50 mm. 5,5-6,5/30, number of slices = 1.
■ T2-weighted TSE axial images: Use of the combination of saturation
TR/TE=3500-4500/120 ms, TSE factor slabs, different planes and localiza-
= 7, number of slices = 20-24. tions with regard to facial vascular
37
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 1 Saturation slabs are used to perform selective MR

angiography.

1
2

3 c

Figure 3 Typical T2-weighted facial

coronal image of patient D., 19-years old,
with haemangioma of left side of the
face. MRI allows one to easily determine
lesion localization, and volume. Also one
can determine the lesion’s morphological
structure and involvement with other Figure 2 Different views of MIP to be
tissues and organs: 1 – disorders of infra- able to show “vessels of interest”: (a) basic
temporal, pterygo-maxillary and associa- MR-arteriogram; MIP-manipulations allow
ted pharyngeal spacial structures (intra- you to choose (b) larger area of interest or
cranial part), 2 – part of angiodysplasia (c) smaller area of interest.
involving the bone, 3 – haemangioma of
facial soft tissues (extracranial part).
38
 PEDIATRIC IMAGING

Clinical examples
Patient L, 1 year 4 months old:
status post hormone therapy, the
embolization of left external carotid
artery and sclerotherapy of soft
tissue capillary angiodysplasia of the
Figure 4 US in patient L., 1 year and
left side of the face. Isolated active
4 month old, had shown that in the
area of interest there were isolated vessels with high blood flow rate
active vessels (punctate and linear (about 15-20 m/s) and diameter
structures with high echo-signal about 1.5-2.0 mm against back-
marked by arrows). Surrounding ground of diffuse fibrotic changes
tissues had diffuse fibrotic changes. were found by US with color Doppler
mapping (Fig. 4). MRI allowed the
identification of the intracranial part
a b
of the lesion (Fig. 5). MRA (Fig. 6)
shows that the blood supply of
angiodysplasia was realized by
dilated and tortuous vessels belon-
ging to arterial type of blood flow.

Figure 5 T2-weighted MRI images

of the same patient L., 1 year and 4
month old, (a) in axial and (b) coro-
nal planes allow more clear differen-
tiation of the tissue structures. In
these images you can see lesions of
alveolar zone (thin arrows (a) and
(b) and left lateral orbital structures
(thick arrow (b)).

a b Figure 6 In MR-angiography images

of the same 1 year and 4 month
old patient L. (a) in oblique coronal
projection and (b) oblique sagittal
projection, left external carotid
artery is not visualized. (Thin arrows
show the usual localization of the
external carotid artery). Note the
large extent of collateral arterial
blood supply (thick arrows).

39
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

a b

Figure 7 US data of patient K., Figure 8 MR-venograms of the same 12 years old patient K. (a) in axial
12 years old, shows successful and (b) oblique coronal planes. Local constriction of transverse sinus (thin
treatment of left sided facial angio- arrow) with enlarged blood flow through superior sagittal sinus (thick
dysplasia: embolized vessels without arrow at (b)) and collateral veins (dashed thick arrows) at the side of
blood flow (arrows) are well seen embolization.
against background of soft tissues
fibrosis.

Figure 9 US data of patient D., 19

years old, shows large arteriovenous
fistulas (arrows) with high speed
turbulent blood flow.

40
 PEDIATRIC IMAGING

a b Patient K, 12 years old: status post

complex treatment of capillary-
cavernous angiodysplasia of soft
tissue of the left side of the face.
Patient complained of headache for
the last 6 months. US with color
Doppler mapping had shown fibrosis
of the lesion area and vessels without
signs of blood flow (Fig. 7). MRI of
mandibular and facial region suppor-
ted the US data and additionally
diagnosed MRI-characteristics of
increased intracranial pressure,
which was probably the result of
Figure 10 (a) Sagittal MR-venogram of the same patient D., 19 years old, decreased blood flow through left
shows rounded arteriovenous fistulas (dashed thin arrows) and (b) bag transverse venous sinus due to its
shaped ectasic dilatations of the angular vein (thin arrows). MR-arterio- local stenosis. (Fig. 8).
gram in oblique coronal plane demonstrated a lot of dysplastic arteries
inside the lesion (thick arrows) and confirmed that in fistulas there was In our studies, 21 patients (55%) had
mainly venous type of blood flow. Note (b) that left external carotid artery some type of venous sinus stenosis
is not visible and left internal carotid artery is stenotic and only proximal and 19 of them suffered headaches.
part of the vessel is visible (dashed thick arrows). This is a noteworthy feature in
discussions about possible causes of
these headaches.
Accordingly, MRI with MRA data and
data of US with color Doppler map-
a b ping were mainly in close agreement
as to the extra-cranial parts of angio-
dyslplasia disorder. But as we have
observed, MRI with MRA has great
advantages in the examination of
bone and/or intra-cranial lesions,
which were more often displayed in
older children.

Clinical examples
Patient D, 19 years old, with arterio-
venous fistulas of the maxilla and
Figure 11 (a) Axial MR arteriogram of the same 19 year old patient D. soft tissues of left side of the face,
clearly shows additional dysplasia of left ophthalmic artery (thin arrow) was treated by different methods
and posterior communicating arteries (dashed thin arrows). During dyna- over a period of 14 years. Recent
mic probe (squeezing of right common carotid artery) blood flow through worsening of her status was charact-
this ophthalmic artery increased (thin arrow at (b)). So, this dysplastic left erized by increasing sizes of arterio-
ophthalmic artery is involved in the active blood supply of the lesion. venous fistulas of soft tissues of the
left cheek, provoked by a pregnancy
which was aborted because of
medical indications. Large tortuous
arteriovenous fistula about 1.5 cm in
diameter with turbulent high rate
venous blood flow was found by US
41
www.SiemensMedical.com/MAGNETOM-World
 MAGNETOM FLASH

a b 1. 4 cases of different forms of

unclosed Willis ring;
2. 4 cases of significant middle
cerebral arteries asymmetry;
3. 1 case of lateral choroidal artery
atypical root, and
4. 1 case of neck soft tissues artery
atypical root.

Thus, MRI with MRA also has the

following advantages in the diagnosis
Figure 12 (a) T2-weighted coronal vertebra image of patient L., 22 years of facial soft tissues angiodysplasias
old, showed that dysplastic vessels had originated from thoracic vertebral over the other noninvasive method –
circulation. (b) MR-arteriogram demonstrated that these vessels were US with color Doppler mapping:
primarily arterial type of blood supply.
1. MRI allows the examination of
characteristics of facial soft tissues
angiodysplasias more exactly and
objectively;
2. MRI makes it possible to determine
intra-cranial disorders and lesions
of mandible and other facial bones,
paranasal sinuses, etc.
3. MRI with MRA allows the specifi-
cation of arterial or venous type of
with color Doppler mapping (Fig. 9). Research of patient’s history was angiodysplasia blood flow with the
MRI (Fig. 3) had accurately determi- undertaken after MRI examination determination of supply and flow-out
ned the volume of the intra-cranial and revealed that at 2 years old she vessels;
part of angiodysplasia and the lesion’s had been surgically treated because
4. MRI with MRA makes it possible
extension into facial soft tissues and of the exophytic capillary hemangioma
to examine the state of intra-cranial
in cranial bony structures. MR-angio- (most likely an angiodysplasia!) of
vessels and to define any intra-
grams of lesion zone (Fig. 10) con- the soft tissues of the left cheek. This
cranial angiodysplastic changes.
firmed the presence of large arterio- case illustrates a system characte-
venous fistulas with predominantly ristic of this lesion: angiodysplasia
venous type of blood flow. MR- realized in different (and distant)
The US with color Doppler mapping
arteriogram had shown (Fig. 11) that anatomical areas.
essentially exceeds MRI with MRA
intra-cranial arteries (for example,
In our opinion this observation is in the determination of functional
left ophthalmic artery) are actively
rather a special case. This is confir- (hemodynamic) parameters of
involved in blood supply of angio-
med by our results: in 5 patients angiodysplasias. This makes this
dysplasia.
(13% of all examinations), MRI with method irreplaceable in treatment
Patient L, 22 years old: examined by MRA had found 4 cases of intracranial planning and in the evaluation of
MRI because of pathological thoracic arterial anomalies and 1 case of treatment efficacy.
scoliosis with disorders of sensitivity meningial venous malformation.
and locomotor functions of the Accordingly, the combination of
inferior part of the body. Spinal MRI Moreover, in our observations of imaging diagnostic methods is
(Fig. 12) had determined that verte- 8 patients (about 19% of all necessary for the exact, specific and
bral and neurological disorders were examinations), MRI with MRA had adequate diagnosis of facial soft
produced by vertebral angiodysplasia also identified the following arterial tissues angiodysplasias in children.
with mainly arterial blood flow. abnormalities: The US with color Doppler mapping
42
 PEDIATRIC IMAGING

and the MRI with MRA have to be at children: angiography and doppler-
ographafy comparison.// Visualisation in Information about
the top of the list of such methods.
clinic. – Russia-Moscow: Medicine. - the Institution
Moreover, our experience of 1994. -_4. – p.26-29. – in Russian.
Official name – The Scientific
examinations of patients with large [ 7 ] Nadtotchii A.G.,Dyakova S.V.,
and extensive facial angiodysplasias Kulakov O.B., Elkonin A.B. Traditional
Center for Obstetrics, Gynecology
allows one to establish that facial usltrasonography and dopplerography in and Perinatology of The Russian
angiodysplasias in 31% of cases diagnosis of vascular neoplasm of Academy of Medical Sciences.
mandible-facial region in children.// The (Director V.I.Kulakov is a Member of
(13 patients out of 38) were only the Stomatology. – 1994. -_3. –p.73-77. – in
external manifestations of the seg- Russian. the Academy of Medical Sciences).
mental angiodysplasias. So, “whole- Internet site of the Center:
[ 8 ] Nadtotchii A.G., Panov V.O., Ivanov
brain” (even “whole-body” – if it is A.V. Facial angiodysplasia in children: www.pregnancy.ru
possible) MRI with MRA is an local manifestation of system vascular
expedient action in all cases of large lesion?// In Abstracts of VII International Beds – 300
and extensive facial angidysplasias Conference of Mandible-Facial surgeons
and stomatologists. – Sanct-Peterburg- In-patient throughput – 12,700 per
in children when the “object” of Russia. - 2002. – p.107. – in Russian. year (including 2,500 in obstetrics)
examination is small.
[ 9 ] Edelman R.R., Hesselink J.R., Zlatkin and up to 40,000 outpatients per
M.B. Clinical Magnetic Resonance Ima- year – data are for the last year.
ging. - Philadelphia-USA: W.B.Saunders The profile of The Center is revealed
Company. – 1996. – p.2190.
by its name.
Literature [ 10 ] Kramer L.A., Crino J.P., Slopis J., It covers obstetrics, gynecology and
Hankins L., Yeakley J. Capillary heman- perinatology – all types of obstetric
[ 1 ] Dan V.N. Diagnosis and surgery gioma of the neck: prenatal MR findings.//
treatment of congenital angiodysplasias. Am.J.Neuroradiol. – 1997. - Sep; 18(8). care. The Center is the leading
// Thesis for a Medical Doctor’s degree. – –p. 1432-1434. institution in the Russian Federa-
Moscow-Russia. – 1989. - in Russian. tion (and ex-USSR countries) for
[ 11 ] Panov V., Ivanov A., Inaneishvily M.,
[ 2 ] Diyakova S.V., Shafranov S.V., Nadtotchi A. Facial haemangiomas as solving problems relating to
Nadtotchii A.G. et all. Diagnosis and external manifestation of the segmental
treatment of large and extensive heman-
women’s genital functions, gyne-
angiodysplasia: MRI and MRA diagnosis
giom children mandible-facial region.// cological endocrinology (including
advantages.// European Radiology. -
Methodological recommendations. – February 2002, vol.12, suppl.1, p.269 /B- complex treatment during clima-
Moscow–Russia: 0719/ cteric and menopause), non-onco-
MSMSU. - 1996. – 11 p. - in Russian.
[ 12 ] Orvieto _., Zago S., Pollinzi V., logy surgical gynecology, child
[ 3 ] Kulakov O.B., Diyakova S.V., Kizyun
L.Z., Nadtotchii A.G., Ivanov A.V. Tactics Trasforini G. An unusual case of intramu- gynecology (including uro-genital
of treatment of vascular neoplasm of scular hemangioma. // Pathologica. – system development anomalies
labrum and labium of children.// In 1997. - Apr; 89(2). –p.189-92.
and their surgical correction) and
Abstracts of the I Republican Conference [ 13 ] Roebuck D.J., Ahuja A.T. newborn pathology treatment.
“Stomatology and children health”. – Hemangioendothelioma of the parotid
Moscow-Russia. - 1996. - p.79. – in gland in infants: sonography and correla- MR-patient throughput: one session
Russian. tive MR imaging.// _m.J.Neuroradiol. – from 9:00 till 15:00 allows the
[ 4 ] Milovanov A.P. Pathomorphology of 2000. - Jan; 21(1). – p.219-23.
examination of 12 patients.
extremity angiodysplasias. – Moscow-
[ 14 ] Robertson R.L., Robson C.D., Currently the work is organized in
Russia: Medicine. - 1974. – in Russian.
Barnes P.D., Burrows P.E. Head and neck
[ 5 ] Nadtotchii A.G. Ultrasonography vascular anomalies of childhood.//
two sessions but in reality the
examination at the stage of diagnosis Neuroimaging.Clin.N.Am. – 1999. - Feb; maximum number of patients per
and treatment of vascular neoplasm of 9(1). -p.115-32. day is 18 patients, including up to
face and neck of children.// IV Meeting of
Russian Association of Physicians of [ 15 ] Siemens MAGETOM Symphony 3 pregnant patients with their
Ultrasound diagnosis in perinatology and Application Guide Numaris 3.5 VA11F, fetuses.
gynecoclogy. – Nijnii Novgorod-Russia. - 2001
1997. – in Russian. The Center is predominantly
[ 16 ] Yang W.T., Ahuja A., Metreweli C.
[ 6 ] Nadtotchii A.G., Dyakova S.V., Sonographic features of head financed by the government via
Kulakov O.B., Shafranov V.V., Polyaev and neck hemangiomas and vascular the Medical Academy of Medical
Yu.A., Konstatntinov K.V., Nikanorov malformations: review of 23 patients. // Sciences, plus self-financing
A.Yu. Hemodynamic in vascular neo- J.Ultrasound.Med. – 1997. -Jan; 16(1).
activities.
plasm of soft tissues face and neck of –p.39-44.
43
www.SiemensMedical.com/MAGNETOM-World
 MAGNETOM FLASH

Fetal MR Imaging*

Stephen Sinnott M.D,

Bridget Sutton M.D,
Raymond Buckley.R.T (R ) (MR)

The Royal Brisbane, Women’s and

Children’s Hospital is a shared
campus offering diverse facilities.
The Royal Brisbane consists of a
790-bed general, tertiary referral
teaching hospital with a number of
specialities including medicine,
surgery, orthopedics, psychiatry, and
oncology and trauma services.
The Royal Women’s Hospital is a
CASE study
192-bed tertiary, teaching health
facility for obstetric, gynecological Fetal MRI
and neonatal intensive care patients. Patient history.
The Royal Children’s hospital is a The mother is a 35 year old female.
168-bed tertiary pediatric teaching Single 29 week live fetus present.
hospital, with specialities including Normal amniocentesis.
burns, liver transplant, oncology, MRI referral from RWH ultrasound
pediatric surgery, rehabilitation, department.
respiratory medicine and trauma
services.
Image Findings
The RBWH MRI unit comprises 2
Siemens 1.5 Tesla magnets. Ultrasound Findings : Isolated mild
ventriculomegaly of the lateral
A MAGNETOM Vision Plus, and a 2nd trimester, brain
ventricles.
MAGNETOM Sonata which is shared
with the Centre of Magnetic Reso- 3rd and 4th ventricles are normal.
nance, Brisbane, Univervisty of QLD. Cavum septum pellucidum normal.
Cerebellum is normal. No other brain
findings was confirmed. Patient was
or spine abnormality seen.
discharged from hospital after coun-
MRI confirmed the ultrasound fin- seling.
dings of the fetal brain, of bilateral
Short information about ultra-
lateral ventriculomegaly. Gyral
sound imaging of the fetus :
pattern was normal. No other signifi-
cant abnormality. ■ Ultrasound is the primary imaging
modality for pregnant women.
■ Allows real time imaging of the
Results and Discussion fetus.
The finding of bilateral lateral ventri-
* The safety of imaging of the fetuses and infants has
not been established. culomegaly without additional
44
 PEDIATRIC IMAGING

MRI Findings : MRI performed in 2nd trimester, same patient.

■ MRI is used for clarification
purposes in cases where there may
be doubt regarding continuation of
pregnancy.

■ MRI fetal brain imaging

demonstrates corpus callosum, pons,
parenchymal structures, brain
malformation and maturation. Also,
growth retardation, base of the skull,
cervical spine anatomy and placental
abnormalities may be identified.

T2 cor. T2 tra.
MRI Technique in RWBH
■ MRI sequences used are HASTE T2
non-fat sat in 3 orthogonal planes,
sagittal, transverse, and coronal, plus
a transverse FLASH T1 sequence.

■ HASTE sequence parameters;

3-4mm slice thickness, interleaved,
distance factor 0, FOV 300mm,
matrix 256 interpolated, ETL 218,
echo spacing 7.34ms, TR 1100,TE 88,
BW 195, flip angle 150, non fat sat.

■ Breath-hold during sequences

if there is excessive abdomen move-
ment.

■ CP Body Array coil used.

■ Flip angle reduced from 180 to

150 degrees to reduce SAR.
T2 sag. T1 tra. ■ Siemens MAGNETOM Sonata.1.5T,
2002A software.

MRI Patient Preparation

Ultrasound pitfalls : of the brain nearest to the transducer
■ Patient position is oblique if in
may be difficult.
■ Poor fetal visualization due to advanced pregnancy, to reduce
maternal habitus. ■ Posterior Fossa may be difficult to compression effects of inferior vena
image late in gestation. cava of the mother.
■ Poor fetal visualization due to
reduced volume of amniotic fluid. Short information about MRI of ■ No patient preparation or drug
■ Multi-planar imaging difficult due the Fetus administration
to fetal position. ■ MRI can yield additional informa- ■ No MRI contrast given for fetal
tion and/or may be used to confirm imaging.
■ Subtle parenchymal abnormalities
the findings in ultrasound. This could
not always demonstrated.
ultimately change the patient ■ No known adverse effects to the
■ Technical factors to view the side counseling or management. fetus.
45
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MAGNETOM Trio
Musculoskeletal MR Unlimited*

3.0T 1.5T
MAGNETOM Trio
is 3T Unlimited
3T MR systems are attracting
great attention as new hardware and
software become available for
whole-body applications.
In the area of musculoskeletal MR,
the increased 3T Signal to Noise ratio
enables increasing the resolution in
the same acquisition time or reduce
acquisition time.
MAGNETOM Trio has been optimized
at every level so that these advan- 0.8 mm2 isotropic
tages can be fully exploited in all
applications. Maximal homogeneity,
advanced coil technology, 8 RF
channels in standard, iPAT applica-
tions and gradient speed are some of
the many components that contri-
bute to the quality of 3T MR on
MAGNETOM Trio and that make it a
solid investment for the future.

The benefits of MAGNETOM Trio

in musculoskeletal MR:
■ 3T Signal-to-Noise for increased
resolution or decreased acquisition
time 0.6 mm2 isotropic
■ Circularly Polarized extremity
and wrist coils to maximize your SNR. Increased Resolution at 3T with 3D DESS
Unmatched homogeneity for MAGNETOM Trio, CP extremity coil. The increased SNR at 3T enables the
excellent fat saturation resolution to be increased without any apparent loss of SNR.
■ 3D DESS sequences (courtesy of B. Wietek, U. Tübingen, Germany). 3T enables isotropic resolution
of 0.6 mm2 instead of 0.8 mm2 at 1.5T. Sequence 3D DESS.
■ syngo ergonomic user-interface

46
 MUSCULOSKELETAL

Wrist Coil*: Transmit / receive coil

with integrated preamplifiers. No
coil tuning. Used for high-resolution
wrist imaging.

Product Info
Increased Resolution Faster acquisitions in knee Fat saturation on MAGNETOM Trio
in 3T extremity imaging imaging at 3T
2D FLASH with off-center spectral
Wrist: 3D water excitation, 1 mm slice 2D TSE with fat sat, 2 mm slice fat saturation
thickness, 512 matrix, MAGNETOM thickness, 512 matrix in 2:06 min
MAGNETOM Trio, Surface coil.
Trio, CP wrist coil. Wrist imaging is
MAGNETOM Trio, CP extremity coil
particularly challenging as many MAGNETOM Trio offers a homoge-
bones and small tendons and liga- With the increased 3T SNR, protocols neity of 0.30 ppm on a 40 cm DSV.
ments need to be visualized. At 3T, have been optimized so that you This enables the achievement of very
high SNR enables the acquisition of can perform acquisitions with the good fat saturation spectrally or with
small FoV, thin slices (1 or 2 mm) highest resolution (2 mm slice thick- the use of “water excitation”.
and high matrices (512) so that you ness) but also in the fastest way.
can confidently make your diagnosis.

* Cartain OEM coils with the MAGNETOM Trio System require 510 (k)
review and are not commercially available in the US.

47
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Magnetic Resonance Imaging

of the Elbow
Bill J. Leon R.T. (R )(MR) These requirements result in Anatomy and pathology of the elbow
From the Department of Diagnostic demand of high signal to noise. is rather unique. The numerous
Radiology Magnetic Resonance Images are typically noisy or ligaments, tendons, musculo-tendi-
Imaging Center grainy if technical parameters are nous structures and bone marrow to
not chosen properly, such as: be evaluated within this small area
Health South Doctors’ Hospital
a) Selection of moderate to low each run in a different direction.
5000 University Drive,
bandwidth sequences. These sequen- Therefore, we must image the elbow
Coral Gables, Fl 33146
ces selectively filter out certain in a different plane and pulse
bandwidths of radio frequencies such sequence for each of these structures.
as noise, thus increasing the overall
The elbow is a difficult joint to image signal to noise ratio. A trade off to Clinical history from the referring
because of its complexity and various this selection is chemical shift arti- physician or recognizing what patho-
anatomical variants. This article facts, which manifest themselves as logy one is looking for is imperative
reviews the basic cross-sectional misregistration of signal at fat/water so that the scans are obtained with
anatomy of the elbow joint, technical interfaces in the readout direction [1]. the proper planes.
parameters, technical factors and Table 1 should aid in the selection
indications of the elbow that most Radiologists determine pathology
of proper bandwidths [2].
clinicians refer patients for an MRI of soft tissue anatomy such as liga-
scan. Imaging of the elbow must be b) Technologically advanced surface ments, tendons or muscles with
done keeping in mind the normal coils, such as Circular Polarized a variety of pulse sequences. Each
anatomy, specific pathology reques-
ted, and the resolution and visualiza- BW (kHz) BW (Hz/Px) SNR CS in Pixels 1.0T CS in Pixels 1.5T
tion of these anatomical structures 16 130 1.0 1.13 1.70
with a variety of planes and pulse 10 78 1.3 1.88 2.83
sequences. This combination should 8 65 1.4 2.26 3.39
result in obtaining an accurate
diagnosis for the patient. Table 1

Magnetic Resonance Imaging Phase Array Coils or Circular Polarized pulse sequence gives specific infor-
of the elbow joint presents unique Flexible Coils. With these devices mation on the anatomical structure:
challenges: the signal to noise is increased
a) Anatomical structures are much considerably. T1 weighted images, whether they
smaller than other larger joints such are Spin Echo, Turbo Spin Echo (Fast
as the knee or shoulder. Therefore, Spin Echo), or Gradient Echo pulse
it demands high-resolution images, c) Advanced Pulse sequences such sequences, have the characteristic of
defined as: thin cuts (2-4mm), high as Turbo Spin Echo (Fast Spin Echo), relatively good signal to noise. The
matrices (256x256 or higher) and Turbo STIR (Short Tau Inversion images are usually pretty and one
small Fields of View (10-14cms). This Recovery), non-selective 3D gradient may obtain higher resolution images
combination results in very small echo and low bandwidth pulse with this type of pulse sequence. T1
pixels. sequences. All these techniques weighted images are known to have
improve the signal to noise while high sensitivity and low to poor
b) The most comfortable position for specificity of pathology. This means
providing the same or similar con-
the patient is supine with the arms to that if the normal appearance of a
trast to noise and signal intensities of
the side. Imaging off-centered drives tendon is of low signal intensity
the different tissues evaluated.
the MR system components, such as (black) and the tendon reveals
the gradients and the homogeneity intermediate signal (grey) on the T1
of the magnetic field to its limits. weighted image, the following
The elbow, therefore, presents a
c) Small joints require the use of technical challenge for technologists pathology is possible:
dedicated surface coils. The closer since all available resources should 1) Inflammation of the tendon
the coil is to the joint and smaller the be employed to obtain the best (Tendinitis)
coil, the better the signal versus quality scans in the shortest time
noise. possible. 2) Partial tears (some fibers may
48
 MUSCULOSKELETAL

be torn, but not the entirety of Wise and educated selection of Structures in the elbow will be
the tendon) planes and pulse sequences is the discussed according to the require-
true art of knowing how to image a ments of different protocols:
3) Complete tear of the tendon. body part.
One must conclude that although the a) Anatomy,
pathology with T1 weighted images Positioning b) Pathology,
is found, one cannot conclusively The elbow joint may be localized
determine the specific process of the c) Protocols, technique and specific
1/2 inch distal to midpoint of humeral
ailment. techniques for different pathologies
epicondyles.
T2 weighted images, on the contrary, Coil
experience low signal-to-noise and Small Circular Polarized Flexible Coil. Anatomy
are much noisier than T1 weighted Patient supine with the arm by the
images. Pathological processes 1) a) Ulnar Collateral Ligament (UCL).
side, hand supinated
behave differently in these types of Also known as Medial Collateral
images. T2 images are characteristic Ligament. Most commonly injured in
of having low sensitivity and good to throwing athletes [3,4,5,6] such as
high specificity. This means that if a baseball pitchers, catchers, swim-
normal tendon in T1 images is of low mers, divers, tennis, Jai-Lai players.
signal that normally as low signal The UCL complex consists of anterior,
(black) in T2 is seen as well. If a posterior and oblique (i.e., the trans-
tendon is of intermediate signal in verse ligament) bundles. It extends
T1, then one can refer to T2 weigh- from the medial epicondyle of the
ted images and observe the behavior humerus to the medial aspect of the
of that tendon: coronoid process and the medial
Figure 1 Positioning with CP-Flex aspect or margin of the olecranon
1) If it remains of low signal intensity Small Coil, patient Supine, hand
in T2, although it was of intermediate process. [7]
supinated
signal (gray) in T1, the differential b) The Radial Collateral Ligament is
diagnosis includes tendinopathy less commonly injured and its single
(inflammation or strain) or tendon band attaches from the lateral epi-
degeneration (possibly due to condyle of the humerus to the upper
previous injury or chronic inflamma- margin of the annular ligament. [7]
tion).
An axial localizer or scout is necessa-
2) If the same tendon that experien- ry through the humeral epicondyles.
ced intermediate signal (gray) in T1 Then oblique coronal images are
images, experiences high signal obtained in alignment with the
intensity (bright) with T2 weighted epicondyles [3]. Spin Echo T1, T2,
images, this most likely represents Gradient Echo T2* or Turbo Spin-
a tear of the tendon, partial or com- Echo (Fast Spin-Echo) may be obtained
plete can be observed depending of to determine tears.
the signal intensity of the tendon,
2) Osteochondral Defects (OCD) or
whether it involves all or part of the
fractures of the capitellum are the
tendon.
typical source of loose bodies. Iden-
Sensitivity and specificity of pulse tification of the fracture is difficult,
sequences are critical for radiologists. however a combination of pulse
They must make selection of planes sequences may prove invaluable. T1,
and sequence types for each area of T2 Spin Echo and 3D Gradient Echo,
the body, and furthermore for each in particular a DESS sequence (Dual
structure of that specific area. We Echo in Steady State) with recon-
cannot afford to keep a patient in the structions in radial mode with its axis
scanner for too long a period of time. on the actual OCD on the capitellum,
49
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

with an in-plane resolution of less in the sagittal and axial projections

or equal to 1.5 mm thickness, is our are necessary.
method of choice to work up this
diagnosis.
Pathology
An MRI scan is not sufficient to
identify loose bodies. Plain films, 1. Osteochondral defects
spiral tomography or high resolution (transchondral fractures), loose
CT in combination with MR may be bodies, olecranon osteophytes.
the choice of imaging modalities for
2. Medial collateral ligament,
small fragments.(3)
radial collateral ligament complex,
3) Biceps Tendon: The musculoske- complete and partial tears.
letal junction of the biceps tendon is 3. Biceps, triceps. Tendinitis, partial
approximately 3-4 cms proximal to and complete tears.
the elbow joint. The mid substance of
the tendon is most commonly torn 4. Median nerve compression.
and retraction of this tendon is
known to be found as proximal as the
mid shaft of the humerus. Its distal Protocols
insertion at the posterior aspect of
the radial tuberosity is also a site for OCD, MCL, R/O PATHOLOGY BICEPS, TRICEPS TENDON
tears. Weight lifters are prone to 1. 3d gre coronal (T2*) 1. tse t2 coronal fatsat
these injuries. 2. tse t2 coronal fatsat 2. tse pd sagittal
3. tse pd sagittal 3. tse pd transverse
Evaluation of this structure is done in 4. tse pd transverse 4. tse t2 transverse fatsat
the sagittal and transverse (axial)
projections with T1 and T2 Spin-Echo
or Turbo Spin-Echo (Fast Spin-Echo) Technique
sequences.
Plane Sequence TE TR SL Th/Gap Mx Acq FOV Time
The set-up of slices is fairly easy. The 2d gre cor fl2d_22rb44.wkc 22 748 17 2/0.2 256x256 1 130 6’25”
axial slices are set-up utilizing the 3d gre cor fi3d_21rb33.wkc 21 48 26 1.3/0 192x256 1 100 8’01”
sagittal images. One medial and one tse pd c/a/s tse7_45b130.ykc 45 4000 45 3/0 256x512 1 130 5’09”
lateral need to be chosen, demon- tse T2 c/a/s tse7_45b130.ykc 45 4000 45 3/0 256x256 1 130 4’53”
strating the musculoskeletal junction fatsat
(medial) and the distal attachment se T1 cor se_20b65.ykc 20 500 15 3/0.2 256x512 1 140 4’19”
(radial tuberosity) (lateral). Sagittals 3D DESS sag de3d_9b130.xkc 9 27 64 1.5/0 192x256 1 130 7’26”
are set up utilizing axial images, they Turbo stir tirm7_29b130.ykc 29 3915 15 3/0.2 196x256 1 130 3’44”
are done obliquely perpendicular to cor
the alignment of the humeral epicon- se T1 c/s/a fs se_20b65.wkc 20 912 16 2/0.2 192x256 1 120 5’53”
dyles in order to include most of the
mid substance of the tendon.

4) Triceps Tendon. Injuries to its

attachment, at the olecranon
process, is most often seen. However,
direct trauma is the main cause of
pathology. Imaging of the triceps
tendon in full flexion is important in
order to assess partial and complete
tears compared to bursitis in the
olecranon bursa. T1 and T2 Spin-Echo
or Turbo Spin-Echo (Fast Spin-Echo)
50
 MUSCULOSKELETAL

Specific techniques Figure 2 UCL (Ulnar Collateral

for different pathologies Ligament), Common Flexor and
Extensor tendons

common common
common
med flexors extensors
epicondyle extensors
common
lat epicondyle flexors
ucl
ucl

Setup of coronal slices tse T2 cor fs 3D gre t2* cor

ucl tear
ucl tear

se T2 cor turbo stir cor

ucl
avulsion ucl
avulsion

turbo stir cor 3D gre T2* cor

lateral
epicondylitis

medial
epicondylitis

tse T2 fs cor tse T2 fs cor

51
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 3 OCD’s (Osteo-Chondral ocd

Defects), loose bodies

Set-up radial images dess 3D DESS original cor

loose
body

ocd

3D DESS mpr axi 3D DESS mpr sag 3D DESS mpr sag

Biceps, triceps tendons tears

mid biceps

distal biceps
attachment

tse pd sag scout tse pd sag scout tse pd axi proximal tse pd axi distal

mid distal biceps

biceps tear tear

triceps
tear
triceps
tear

tse T2 sag tse T2 axi fs tse T2 sag tse T2 axi fs

52
 MUSCULOSKELETAL

Bone Marrow (Contusions, fractures) Bibliography

[ 1 ] Magnetom applications Guide.
Artifacts and Remedies.
1992 by Siemens AG. page 22.
[ 2 ] Magnetom applications Guide.
Artifacts and Remedies.
1992 by Siemens AG. page 34.
[ 3 ] Murphy BJ. MR Imaging of the Elbow.
Radiology 1992, 184:525-529
FX’
FX [ 4 ] Schwab GH, Bennott JB, Woods
GW, Tullos HS. Bio-Mechanics of Elbow
instability: The role of the medial
collateral ligament. Clin Orthop
1980;146:42052
[ 5 ] Jobe FW, Newber G. Throwing
Injuries of the Elbow,
tse T2 fs cor se T1 cor Clin Sports Med 1986;5:621-635
[ 6 ] Indelicato PA, Jobe FW, Kerlan RK,
et al. Correctable elbow lesions in
professional baseball players:
a review of 25 cases.
In conclusion, technical requirements AMJ Sports Med 1979;7:72-80
for small joints are challenging. To [ 7 ] Stoller DW. Mag Res Imaging in
Orthopaedics Sports medicine 1993
be able to examine small parts such
page 634.
as the elbow, technologists must look
for the appropriate coils and make
sure they order the necessary tools
from the manufacturer. In addition
to state of the art equipment, the
knowledge of anatomy and the
perception of imaging the patient
according to the pathology are of
utmost importance in order to assess
a protocol that fits the patient’s
ailment. It is guaranteed that the
clinician will not refer you another
patient if he/she cannot get a specific
answer from the MR scan, and cer-
tainly these are not times in which
we can afford to scan all pulse
sequences and all planes.
High resolution images with the
proper alignment of the slices is the
ultimate responsibility of the
radiologist and the technologist.

53
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MR Enteroclysis: a New Diagnostic

Approach for Small Bowel Imaging
Nickolas Papanikolaou, M.Sc. be increased to result in clinically
Biomedical Engineer, acceptable image quality. All these
Department of Radiology, requirements can be fulfilled when
University Hospital of Iraklion using high-end MR scanners. High
field strength magnets (1.5 Tesla)
University of Crete Medical School,
can provide intrinsically higher signal
Iraklion, Crete, Greece
to noise ratio comparing to lower
field strength systems. Short repeti-
Nicholas C. Gourtsoyiannis, M.D. tion and echo times which are of
Professor & Chairman, great importance in ultra fast ima-
Department of Radiology, ging can be only achieved by using
University Hospital of Iraklion advanced gradient systems. Dedica-
ted abdominal phased-array RF coils
University of Crete Medical School,
should be utilized to further increase
Iraklion, Crete, Greece Figure 1 Coronal TrueFISP section
the limited signal to noise ratio of
the ultrafast pulse sequences. demonstrating small bowel at its
entire length. The use of an iso-
MRI examination protocols of the osmotic water solution as an intralu-
Introduction small bowel usually comprise T1- and minal contrast agent resulted in
T2-weighted sequences in axial and homogeneous opacification of the
With the advent of high performance coronal planes. Both T1- and T2- bowel lumen. Note the increased
gradient systems, image quality of weighted sequences should be fast conspicuity of the normal bowel wall
already existing ultrafast pulse enough to allow comfortable breath- due to the high resolution capabi-
sequences i.e. HASTE, true FISP and lities and total absence of motion.
hold acquisition times and reduce
FLASH improved substantially and the motion related artifacts. For T1-
clinical applications including small weighted images, most authors are
bowel imaging became feasible. using gradient echo sequences in
Within this context, MR Enteroclysis 2D and 3D acquisition modes with or
was developed, as a comprehensive without fat saturation prepulses,
examination of the small bowel, while for T2-weighted images, TSE
providing luminal, transmural and and HASTE sequences are commonly
exoenteric diagnostic information of employed [1-7]. More recently, the
small bowel diseases. Clinical app- TrueFISP sequence has been success-
lications of MR Enteroclysis include fully applied in small bowel (SB)
diagnostic evaluation and follow up imaging [1], providing high resolu-
of patients with inflammatory or tion images of the bowel wall (Fig. 1)
neoplastic diseases and small bowel and additional information from
obstruction. the mesenteries. Fat suppressed TSE
or STIR sequences have been also
applied to assess the activity in
Pulse Sequences Crohn’s disease [4].
Figure 2 Coronal 3D FLASH image
Ultrafast pulse sequences should be A three-dimensional (3D) version of with fat saturation acquired 75
employed to reduce motion related SGE sequences was recently introdu- seconds after intravenous injection
artifacts arising from physiological ced (3D FLASH) [5]. As opposed to of gadolinium. Increased gadolinium
motion (respiration and peristalsis) 2D FLASH, 3D FLASH provides increa- uptake is evident on descending
in the abdominal area. The spatial sed through-plane and in-plane colon corresponding to inflammatory
resolution of these sequences should spatial resolution by the acquisition processes due to Crohn’s disease.
be high enough to permit demon- of thin partitions (2 mm) and high Normal bowel wall exhibits moderate
signal intensity when active
stration of small lesions i.e. ulcers, matrices (512) (Fig. 2), respectively.
inflammation is present.
commonly present in small bowel Additionally they offer higher signal
diseases. Inherent poor signal to to noise ratio comparing to the 2D
noise ratio of these sequences has to sequences. The acquisition time for
54
 GASTROINTESTINAL IMAGING

covering the whole small bowel is stration of the mesenteries due to

Figure 3 Coronal HASTE image 22-25 seconds and it can be further k-space filtering effects. Tissues with
acquired after antiperistaltic drug reduced by employing slice interpo- short T2 relaxation constant, such
administration, demontrates equally
lation techniques (VIBE sequence) as lymph nodes and fibrous tissue,
well as the TrueFISP sequence the
which recently became attractive in are missing the high order spatial
anatomy of the small bowel by the
high contrast resulted from the low abdominal imaging. When combined frequencies due to the special way
signal intensity intestinal wall and with positive intraluminal contrast that the k-space is filled in HASTE
high signal intensity intraluminal agents they may be used as source sequence resulting in a blurring
contrast agent. images for virtual endoscopic views effect in these tissues (Fig. 6).
generation. The major disadvantage
TrueFISP sequence was introduced
a of the 3D FLASH sequence is the
for MR examination of the small
increased sensitivity to motion
bowel after duodenal intubation [1].
artifacts that may cause blurring of
The contrast in TrueFISP images is
the intestinal wall; administration of
somewhat more complex and invoke
antiperistaltic drugs can overcome
both T1 and T2 contributions in the
this drawback.
form of the T2/T1 ratio. The higher
this ratio is the brighter the tissue will
The single shot variant of TSE
be, thus bowel wall exhibit interme-
sequence with half fourier technique,
diate to low signal intensity (T2/T1 ~
the so called HASTE sequence, gene-
0.2 at 1.5T) while fluids presented
rates heavily T2 weighted images
with high signal intensity (T2/T1~ 0.9
maintaining signals from solid tissues
at 1.5T). Motion related artifacts are
b although with lower resolution. The
minimal on TrueFISP images due to
acquisition time is less than 1 second
short acquisition time [8,9] (Fig. 7).
per slice resulting in minimal respira-
TrueFISP sequence is capable of
tory related artifacts. Normal intesti-
demonstrating the mesenteries due
nal wall exhibits low signal intensity
to high contrast resolution between
(Fig. 3), while inflammatory or
the bright peritoneal fat and the dark
neoplastic lesions are presented with
vessels and lymph nodes (Fig. 6) [1].
high signal intensity. The long echo
train used in HASTE sequence makes One important difference between
it insensitive to susceptibility artifacts TrueFISP and HASTE sequences is the
which may appear in gradient echo insensitivity of the former to intralu-
sequences due to intraluminal air minal flow voids, due to the balanced
presence. Additionally, it is not and symmetric gradient design in the
Figure 4 HASTE (a) and TrueFISP sensitive to chemical shift artifacts TrueFISP sequence (Fig. 5). Conse-
(b) images acquired from a patient thus it can be used for accurate quently, the use of antiperistaltic
with Crohn’s disease located on quantification of intestinal wall drugs can be avoided giving a major
the sigmoid colon. Wall thickening thickness (Fig. 4). Adequate reduction advantage to TrueFISP over the other
measurements can be performed
of the endoluminal signal intensity, sequences previously used requiring
accurately in HASTE images due to
provided by the use of a negative pharmaceutical reduction of bowel
insensitivity to chemical shift arti-
facts. TrueFISP image demonstrate contrast agent, results in depiction of motion [2,3,7]. The major difference
the involved sigmoid colon with bowel wall abnormalities with high between TrueFISP and the other
higher conspicuity while the chemical conspicuity. In case of positive endo- steady state sequences is that repha-
shift artifact is seen as a black thin luminal contrast agents, HASTE sing gradients are applied in all three
line at the boundaries of the intesti- sequence is sensitive to intraluminal directions, thus making the sequence
nal wall and the mesenteric fat. flow voids related to intraluminal velocity compensated in all three
Thickened wall on TrueFISP images motion (Fig. 5). This problem may be directions [8,9]. Therefore steady
exhibits moderate signal intensity reduced when acquiring HASTE state coherence can be maintained
thus it is easy to differentiate it from images after spasmolytic drug admi- even in the presence of non-accelera-
the underlying chemical shift
nistration. Another limitation of ted (1st order) motion. Additionally,
artifact.
HASTE sequence is the poor demon- the TrueFISP sequence can be used
55
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

for studying vascular abnormalities a b

related to small bowel diseases due
to its velocity compensation capability.
Fast flow in the major mesenteric
vessels renders high signal intensity.
On the contrary the distal small
mesenteric branches appear with low
signal intensity, probably due to
saturation effects. When utilizing
water solutions as intraluminal
contrast agents, the high T2/T1 ratio
results in high endoluminal signal
intensity that remains relatively
constant throughout the entire small
bowel lumen, when administered Figure 5 Coronal HASTE (a) and
via a nasojejunal catheter [1]. TrueFISP (b) images acquired with-
out any antiperistaltic drug admini-
Single shot TSE (SSTSE) sequence, stration on a patient with normal
was initially introduced [10] to small bowel. Intraluminal motion,
visualize the pancreatobiliary tree, demonstrated as flow voids, can be
providing heavily T2 weighted images. seen on HASTE images resulting in
poor luminal homogeneity. On the
Within the context of MR enteroclysis
contrary, TrueFISP images are rather
it is extremely helpful for monitoring insensitive to this kind of motion due
the infusion process and assessing to the flow compensated gradient
the degree of distention of bowel scheme in all three directions
lumen [1]; in addition it provides intrinsic to that sequence.
functional information [2]. With the
advent of gradient systems, the a b
acquisition of high resolution SSTSE
projectional images become feasible
(Fig. 8).

MR Comprehensive
Examination Protocol of
the Small Intestine
A state of the art MRI examination of
the small intestine should comprise:
adequate bowel distention, homo-
geneous lumen opacification, increa- Figure 6 Coronal HASTE (a) and
sed conspicuity of the bowel wall, TrueFISP (b) images in a patient with
demonstration of the mesenteries, Crohn’s disease located at the distal
information about bowel motility, ileum. Wall thickening and mesent-
ability to obtain dynamic post con- eric changes i.e. increased vascularity
trast images, high contrast resolution (“comb” sign) and mesenteric lymph
and sufficient spatial resolution to nodes presence, are signifacantly
evaluate subtle mucosal lesions, more conspicious on TrueFISP images
while HASTE sequence suffers from
images free from artifacts – especially
short T2 k-space filtering effects.
motion artifacts – and rapid acqui-
sition times. All these virtues can be
integrated in a comprehensive MRE
56
 GASTROINTESTINAL IMAGING

examination protocol including small thin lines of high signal intensity,

bowel intubation, administration of longitudinally or transversely (fissure
a biphasic contrast agent, i.e. an iso- ulcers) oriented within the thickened
osmotic water solution (PEG), heavily bowel wall (Fig. 9). Cobble-stoning
b T2 weighted single shot Turbo Spin pattern can also be appreciated on
Echo (SSTSE) images for MR fluoro- MR Enteroclysis images, as patchy
scopy and for monitoring the infu- areas of high signal intensity, sharply
sion process, T2 weighted imaging demarcated, along affected small
employing HASTE and TrueFISP bowel segments (Fig. 10). TrueFISP
sequences and dynamic T1 weighted images are superior to HASTE in
imaging using a post-gadolinium demonstrating linear ulcers or cobble-
3D FLASH sequence with fat suppres- stoning and intramural tracts, while
sion. This protocol can provide ana- 3D FLASH images are less sensitive.
tomic demonstration of the normal Wall thickening is clearly shown by all
Figure 7 Coronal TrueFISP (a) intestinal wall (TrueFISP, HASTE, 3D MR Enteroclysis sequences (Fig. 11)
and post gadolinium 3D FLASH (b) FLASH), identification of wall thicke- provided that the small intestinal
images demonstrating normal ning or tumorous lesions (TrueFISP, lumen is adequately distended;
jejunal loops in a patient with poor
HASTE, 3D FLASH), lesion characte- otherwise MR Enteroclysis may result
breath-holding performance. Note
rization or evaluation of disease in false positive or negative results.
the superior image quality of the
TrueFISP which as a sequentially activity (3D FLASH, TrueFISP), assess- The thickened wall in the absence of
technique is freezing motion while ment of exoenteric/mesenteric extensive edema has low to moderate
the 3D FLASH sequence suffers from disease extension (TrueFISP, 3D signal intensity on TrueFISP and
blurring related to respiratory FLASH) and information concerning HASTE images. The thickness of bowel
motion. intestinal motility (SSTSE). wall and the length of the involved
small bowel segment can be accura-
tely measured on MR Enetroclysis
Clinical Applications images. Luminal narrowing and
associated prestenotic small bowel
Crohn’s Disease dilatation are easily recognized
within all sequences. MR Enteroclysis
MR Enteroclysis can disclose a variety
was in full agreement with conven-
of lesions commonly found in
tional enteroclysis in detecting,
patients with Crohn’s disease. These
localizing, estimating the length of
lesions can be classified according
all involved small bowel segments
to their location as superficial, mural
and in assessing thickening of bowel
and extramural. Subtle mucosal
wall, luminal narrowing or high
abnormalities such as nodularity or
grade stenosis in one series [11]
superficial ulcerations may be depic-
(Fig. 12).
ted by MR Enteroclysis, although to a
lesser extent comparing to conven-
MR Enteroclysis has a clear advanta-
tional enteroclysis, due to the lower
Figure 8 Projectional SSTSE coronal ge over conventional enteroclysis in
spatial resolution of MR Enteroclysis.
view resembling that of conventional the demonstration of exoenteric
Dedicated ultrafast, high resolution
enteroclysis. Increased acqusition manifestations or complications of
sequences and stronger gradients
matrix (512) and short scan time Crohn’s disease [11]. The extent of
will be needed to increase the
(3.7 seconds) in combination with fibrofatty proliferation and its fatty or
increased signal to noise ratio arising detection rate of these subtle, early,
fibrotic composition can be assessed
from the iso-osmotic water solution but not specific, manifestations of
on TrueFISP images, while it can be
used as intraluminal contrast agent the disease.
only suspected on conventional
result in excellent image quality.
Using TrueFISP images, MR Entero- enteroclysis. Fibrofatty proliferation
Intestinal folds can be depicted
consistently with high conspicuity. clysis can demonstrate the characte- may present space-occupying lesion
ristic discrete ulceration of Crohn’s characteristics, separating and/or
disease; deep linear ulcers appear as displacing small bowel loops (Fig. 13).
57
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

The involved mesentery may contain

small lymph nodes, mostly less than
8 mm in diameter, easily detected
by their low signal intensity against
the bright mesenteric fat, on True-
FISP images. Such lymph nodes are
not clearly demonstrated on HASTE
images, due to k-space filtering
effects or on 3D FLASH images, due
to saturation of mesenteric fat signal.
Gadolinium uptake on 3D FLASH
images allows identification of small
inflammatory nodes (Fig. 14) which
might serve as a marker for recording
disease activity. Sinus tracts and Figure 9 Coronal TrueFISP spot view Figure 10 Coronal TrueFISP image
fistulas are demonstrated by the high of the ileum in a patient with active in a patient with long standing
signal intensity of their fluid content Crohn’s disease (CDAI = 266). Fissure Crohn’s disease. The patient were
ulcer and modarate wall thickening examined due to disease recurrence
on TrueFISP and HASTE images, but
can be depicted on the antimesenter- presenting with abdominal pain,
they may be overlooked on the 3D
ic wall of the involved loop. diarrhia and fever. Cobblestoning
FLASH images, due to limited contrast appearance of the mucosa is shown
resolution with surrounding tissues. while small superficial ulcers in
Abscesses can be recognized by their another affected loop can be depic-
fluid content and post-contrast wall ted as well.
enhancement.

There are strong indications that

disease activity can be assessed with
MR Enteroclysis technique [4,12] and
this may represent one of the most
important indications of the exami-
nation in the near future. The so
called “comb sign” corresponding to
increased mesenteric vascularity, can
be ideally seen on TrueFISP images
(Fig. 6), close to the mesenteric
border of a small bowel segment in
the form of short, parallel, low signal
intensity linear structures perpendi-
cular to small bowel loop long axis
[11]. The “comb sign” can be demon-
strated on 3D FLASH images as high Figure 11 Limited wall thickening Figure 12 Patient with Crohn’s
signal intensity linear structures due demonstrated in all three MR Enter- disease presenting with ileous. A
to vascular enhancement. Small oclysis sequences. TrueFISP (left) and fibrotic stenotic lesion can be depic-
bowel wall contrast uptake is consi- HASTE (center) images are depicting ted both in the post-contrast 3d
dered the most important indicator minor wall thickening as low signal FLASH (left) and TrueFISP (right)
of disease activity [4,12] and it intensity against the bright lumen images which was confirmed with
can be appreciated on T1 weighted while on post-gadolinium 3D FLASH surgery. Prestenotic dilatation is
3D FLASH images. Wall thickening, image (right) the degree of contrast demonstrated equally well on both
uptake can be appreciated. images.
significant enhancement of the
mucosa and relatively hypointense
submucosal edema have been repor-
ted as common findings on post
58
 GASTROINTESTINAL IMAGING

gadolinium FLASH images in active enhancement patterns post gadoli-

Crohn’s disease [4] (Fig. 14). The nium administration [13]. High
severity of disease process can be contrast between the tumor and
ranked using measurements of wall surrounding high signal intensity fat
thickening, the length of the involved enables MRI to demonstrate the
segment and gadolinium uptake in local extention of the lesions [13].
comparison to renal cortex enhance-
Small bowel leiomyoma, leiomyosar-
ment. It may be argued that measure-
coma, adenocarcinoma, carcinoid
ments of bowel wall might be
tumor and lymphoma present post-
influenced by the degree of luminal
contrast enhancement that is better
distention in normal bowel loops or
appreciated on fat-suppressed T1-
in inflamed but distensible involved
weighted 3D FLASH images. Intense
segments, where extensive fibrosis is
enhancement can be seen with
lacking. Consequently, determina-
Figure 13 Cross-sectional and carcinoid tumor, leiomyoma and
tion of a reproducible threshold for
projectional evaluation of a patient leiomyosarcoma.
bowel wall thickening measurements
with Crohn’s disease. On the left side, corresponding to active disease may Lipomatous tumors and tumor
a TrueFISP thin section is demonstra-
require optimal luminal distention hemorrhage can be detected on non-
ting wall thickening of the terminal
that could be achieved either by enhanced, non-fat suppressed 3D
ileum while on the right side fibrofat-
ty proliferation and separation of the intubation or by any appropriate oral FLASH images which should be
adjecent bowel loops can be better contrast agents that might be develo- acquired in addition to the MR Enter-
appreciated on the SSTSE image. ped in the future. Active disease in oclysis comprehensive imaging
small bowel segments may also be protocol. Small bowel loops distor-
manifested by high signal intensity of tion or neoplastic invasion is depicted
intestinal wall on T2 weighted ima- by all MR Enteroclysis sequences,
ges [4] due to the long T2 relaxation while associated lymphadenopathy,
time of edema. Fat suppressed T2 is well demonstrated on TrueFISP
weighted images may be more and 3D FLASH images.
sensitive in demonstrating submuco-
sal edema due to scaling effects
that are responsible for gray-scale
Small Bowel Obstruction
rearrangement during the image
reconstruction process. MR Enteroclysis can provide anatomic
and functional information identical
to that provided by conventional
Neoplastic Bowel Disease enteroclysis in cases of small bowel
obstruction [9]. In addition, extralu-
MR Enteroclysis incorporates the minal causes may be better illustrated
advantages of cross-sectional MRI using MR Enteroclysis. MR fluoros-
with those of conventional entero- copy, utilizing a dynamic projectional
Figure 14 Patient with active Croh- clysis, which is highly sensitive in the SSTSE sequences, is extremely help-
n’s disease. Post gadolinium 3D detection of small bowel tumors. ful in diagnosing low grade stenosis
FLASH image demonstrates contrast High signal intensity of the intralu- and in determining the level of
uptake by small and medium size minal fluid and mesenteric fat on obstruction. TrueFISP and post
mesenteric lymph nodes while the TrueFISP images, allows for the gadolinium enhanced 3D FLASH
characteristic ‘target’ sign can be demonstration of tumors exhibiting images can disclose the level and the
found on a nearby involved ileal intermediate signal intensity. Small cause of obstruction. In a recent
loop. Note that the mucosa exhibits bowel neoplasms are mildly hypoin- study of 27 patients with post surgi-
similar signal intensity to the vessels
tense to isointense in comparison cal adhesions, cine MR imaging using
due to increased gadolinium uptake.
with the intestinal wall on precon- the TrueFISP technique resulted in a
trast non-fat suppressed T1 weighted sensitivity of 87.5% and a specificity
FLASH images and present various of 92.5% [14].
59
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Others Combination of CP Body Array

negative oral contrast media in combina-
tion with enteroclysis.
The role of MRI in small bowel ische- Flex, CP Body Array Extender and Eur Radiol 2000;10(9);1377-82.
mia has not been established, yet. CP Spine Array with IPA [ 7 ] Holzknecht N, Helmberger T, v. Ritter
Limited reported experience indica- C, Gauger J, Faber S, Reiser M.
■ Ideal for MR Colonography,
tes that bowel wall changes, vascular Breathhold MRI of the small bowel in
MR Enteroclysis and combination Crohn’s disease after enteroclysis with
engorgement and mesenteric edema of upper abdomen and pelvic oral magnetic particles.
can be appreciated on MRI [15]. examinations. Radiologe 1998;38: 29-36.
Superior mesenteric artery blood [ 8 ] Haacke M, Tkach J. Fast MR Imaging:
flow changes in chronic mesenteric ■ No patient repositioning Techniques and Clinical Applications.
ischemia can also be studied with AJR 1990;155:951-964.
■ Uniform signal intensity allows
phase-contrast cine-MRI [16]. In for optimal soft tissue contrast [ 9 ] Oppelt A, Graumann R, Barfuss H,
addition, there are indications that Fischer H, Hertl W, Schajor W.
gastrointestinal bleeding can be ■ CP Body Array and CP Body Array A new fast MRI sequence.
Extender, each with 4 coil design Electromed 1986;3:15-18.
diagnosed by dynamic post contrast
enhanced 3D MR Angiography, with 4 integrated preamplifiers [ 10 ] Laubenberger J, Buchert M,
Schneider B, Blum U, Hennig J, Langer M.
using a blood pool agent on animal Breath-hold projection magnetic resonance-
studies [17]. cholangio-pancreaticography (MRCP):
References a new method for the examination of the
bile and pancreatic ducts.
Conclusions [ 1 ] Gourtsoyiannis N, Papanikolaou N, Magn Reson Med 1995;33(1):18-23.
Grammatikakis J, Maris T, Prassopoulos
[ 11 ] Prassopoulos P, Papanikolaou N,
MR imaging has a potential to change P. Magnetic Resonance Imaging of the
Grammatikakis J, Roussomoustakaki M,
small bowel using a True-FISP sequence
how we evaluate the small intestine, Maris T, Gourtsoyiannis N. MR Enteroclysis
after enteroclysis with water solution.
because of its superb soft tissue imaging findings in Crohn’s disease.
Invest Radiol 2000;35(12):707-711.
Radiographics 2001; 21:S161-72.
contrast and functional information [ 2 ] Umschaden HW, Szolar D, Gasser J,
it can provide, its direct multiplanar [ 12 ] Schunk K, Kern A, Oberholzer K,
Umschaden M, Haselbach H. Small-
Kalden P, Mayer I, Orth T, Wanitschke R.
capabilities and the lack of radiation Bowel Disease: Comparison of MR
Hydro-MRI in Crohn’s Disease.
exposure. Adequate bowel disten- Enteroclysis Images with Conventional
Appraisal of disease activity.
tion, homogeneous lumen opacifica- Enteroclysis and Surgical Findings.
Invest Radiol 2000;35:431-437.
Radiology 2000;215:717-7125.
tion, fast sequences with breath-hold [ 13 ] Semelka RC, John G, Kelekis N,
[ 3 ] Schunk K, Metzmann U, Kersjes W,
acquisition times, both T1- and Burdeny DA, Ascher SM. Small bowel
Schadmann-Fischer S, Kreitner KF,
T2-weighted imaging and contrast neoplastic disease: demonstration by
Duchmann R, Protzer U, Wanitschke R,
enhancement are cornerstones for MRI. JMRI 1996;6:855-860.
Thelen M. Serial observation in Crohn´s
an optimal MRI examination of the disease: Can hydro-MRI replace follow- [ 14 ] Lienemann A, Sprenger D, Steitz
through examinations? HO, Korell M, Reiser M. Detection and
small bowel. A comprehensive MR
Fortschr Röntgenstr 1997;166: 389- Mapping of intraabdominal adhesions by
Enteroclysis imaging protocol should 396. using functional cine MR imaging:
comprise SSTSE, TrueFISP, HASTE and preliminary results.
[ 4 ] Maccioni F, Viscido A, Broglia L,
fat suppressed 3D FLASH sequences. Radiology 2000;217:421-425.
Marrollo M, Masciangelo R, Caprilli R,
SSTSE is utilized for monitoring the Rossi P. Evaluation of Crohn’s disease [ 15 ] Ha HK, Lee EH, Lim CH, Shin YM,
infusion process and performing activity with magnetic resonance Jeong YK, Yoon KH, Lee MG, Min Y, Auh
MR fluoroscopy while TrueFISP and imaging. Abdom Imaging 2000; YH. Application of MRI for small intestinal
25:219-228. diseases. JMRI 1998;8:375-383.
HASTE are mainly used for anatomic
[ 5 ] Gourtsoyiannis N, Papanikolaou N, [ 16 ] Li KCP, Whitney WS, McDonnell CH,
demonstration and detection of the
Grammatikakis J, Maris T, Prassopoulos et al. Chronic mesenteric ischemia:
pathology. 3D FLASH sequences after P. MR Enteroclysis protocol optimiza- evaluation with phase-contrast cine MR
intravenous gadolinium injection may tion: Comparison between 3d FLASH imaging. Radiology 1994;190:175-179.
aid tissue characterization. Inflamma- with fat saturation after intravenous [ 17 ] Hilfiker PR, Weishaupt D, Kacl GM,
tory or neoplastic diseases, including gadolinium injection and true FISP Hetzer FH, Griff MD, Ruehm SG, Debatin
sequences. JF. Comparison of three dimensional
intestinal wall abnormalities, exoen-
Eur Radiol 2001;11(6):908-13. magnetic resonance imaging in conjunc-
teric disease manifestations and
[ 6 ] Reiber A, Aschoff A, Nussle K, Wruk tion with a blood pool contrast agent and
complications, disease activity and to D, Tomczak R, Reinshagen M, Adler G, nuclear scintigraphy for the detection of
a lesser extent, mucosal abnormalities Brambs HJ. MRI in the diagnosis of small experimentally induced gastrointestinal
can be appreciated on MRE. bowel disease: use of positive and bleeding. Gut. 1999 Oct;45(4):581-7.
60
 GASTROINTESTINAL IMAGING

MAGNETOM Trio
Body MR Unlimited*
MAGNETOM Trio
is 3T Unlimited
3T MR systems are attracting
great attention as new hardware and
software become available for

Product Info
whole-body applications.
New coil designs, combined with
iPAT technology and excellent Figure 1 Very fast MR spectroscopy Spine imaging at 3T
shimming procedures, open the door of the prostate 12 coil design with 12 integrated
for fast, excellent image quality Works in Progress, 1 cm3, 39 s preamplifiers (6 CP pairs). Smoothly
body MR at 3T. acquisition time! integrated into the patient table. No
MAGNETOM Trio, WIP endorectal coil tuning. Used for high resolution
MAGNETOM Trio has been optimized coil (MedRad Inc.) imaging of the whole spine.
at every level so that these advan- The increased SNR at 3T enables
tages can be fully exploited in all very fast acquisitions. The increased
applications. Maximal homogeneity, chemical shift at 3T shows as a nice
advanced coil technology, 8 RF separation of the metabolite peaks
channels in standard, iPAT applica- in the spectrum. (courtesy of
tions and gradient speed are some Pr Herschapp, Barentsz, Fütterer,
of the many components that Klomp, Scheenen, Nijemgen, the
contribute to the quality of 3T MR on Netherlands).
MAGNETOM Trio and this makes it
a solid investment for the future.
2D FLASH with off-center spectral
The benefits of MAGNETOM Trio fat saturation
in Body MR: MAGNETOM Trio, 12-channel spine
■ Best homogeneity of 0.30 ppm array C-spine: FLASH, TR/TE 500/
11 ms, 3 mm slice thickness.
on 40 cm FoV, including in the
z-direction for best coronal abdomi-
nal and spine images
■ Advanced RF system with
8 independent channels in standard
supporting the 8-channel body array,
12-channel spine array, 8-channel Without iPAT, TA: 27 s With iPAT x2, TA: 15 s
cardiac array, …. Large FoV fast acquisitions in
■ iPAT is standard for fast abdominal imaging
acquisitions 2D FLASH fat sat, 40 cm FoV,
T- and L- spine: TrueFISP, 512 matrix,
with and without iPAT
3mm slice thickness
MAGNETOM Trio, 8-channel torso array
Excellent homogeneity, including
in the z-direction, guarantees
an excellent fat saturation even in
coronal abdominal imaging. In
addition, the flexible standard iPAT
feature on MAGNETOM Trio enables
acquisition times to be accelerated.
Body Array Coil: 8 coil design with
8 integrated preamplifiers. No coil
tuning necessary. Coverage in
z-direction 30 cm. Optimized for high
* Cartain OEM coils with the MAGNETOM Trio
resolution imaging of thorax, System require 510 (k) review and are not
abdomen and pelvis. commercially available in the US.

61
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

All You Want to Know About “HASTE”

David Purdy, Ph.D.

US R&D Collaborations,
Malvern, PA
180º pulses
90º pulse

The syngo MR HASTE sequence allows

the user to make a smooth transition
between the traditional HASTE signal echoes
sequence and the single shot RARE
technique. This article illustrates how
the user controls this transition. Figure 1 Pulse and echo timing for HASTE. For clarity, only the first 15
HASTE ( Half-Fourier Acquired Single- echoes are shown. A different phase encoding gradient amplitude is used for
shot Turbo Spin-Echo) is a “single- each echo. This is applied before each echo, and reversed after each echo.
shot” technique, that is, the slice is
excited by a single 90° pulse, followed
by a large number of 180° pulses that
form multiple echoes [1]. Each echo
has a different phase encoding
gradient strength, so all of the infor-
mation for a slice is collected in a
single echo train (Fig. 1).
Unfortunately, the MR signal decays
a little between each echo (T2 decay), Although each raw data line has We normally consider that an image
so the raw data from the later echoes a different echo time (TE), the brigh- with 256x256 resolution requires
does not have the desired intensity. test lines will dominate the image 256 phase encoding steps. However,
This is very similar to the effect of the contrast, and the brightest line if all of the spins in the slice are
raw data filters that you can apply to occurs when the phase encoding perfectly in phase, we only need 129
your protocols. The result is image gradient is zero. It is reasonable to steps (the “zero” amplitude, and 128
blur. define the effective TE as the time increasing steps). In practice, the
To minimize the blur, it is best to between the 90° pulse and the echo spins are not perfectly in phase, and
collect all of the echoes as quickly as corresponding to the “zero” phase some phase correction is needed.
possible using the shortest possible encoding step. This is provided by acquiring a few
echo spacing. Since low amplitude extra lines of data on the other side
gradients can be ramped up By changing the starting point of of the “zero” line. This allows us to
and down more rapidly than high the phase encoding steps, we can reconstruct a low resolution image,
amplitude gradients, the syngo MR change the effective TE of the HASTE and thus obtain the image phases. In
sequence is optimized to reduce the sequence. The purpose of the original practice, we need about seven extra
echo spacing when lower gradients HASTE sequence was to obtain a very lines of data, so the relative phase
are used for thicker slices or lower fast image with the shortest possible encoding amplitudes for the low
resolution (which includes larger TE. Therefore, the sequence began resolution image are –7, –6, –5, –4,
readout FoVs at the same base matrix by using the initial echoes for the –3, –2, –1, 0, +1, +2, +3, +4, +5, +6,
size). The echo spacing is also lowest phase encoding gradient and +7. The Margosian algorithm [2]
reduced as the performance of the amplitudes, and acquired the higher can then be used for reconstruction
gradients increases (Turbo to Ultra to amplitude gradient steps with later of the high resolution image. The user
Quantum). The Sequence tab card echoes. The “half-Fourier” technique interface shows that the “Phase partial
shows this echo spacing. is an efficient way to do this. Fourier 4/8” reconstruction is used.
62
 TECHNOLOGY CORNER

For the shortest TE of the HASTE

sequence, the relative gradient
amplitudes for the echoes run from
–7 through zero to +128. Thus, the
eighth echo has no phase encoding, 7 lines
and the effective TE is eight times the the “zero” Line
echo spacing.
Example: For the Turbo gradients in
“normal” mode, a 340 mm FOV, a 128 lines
bandwidth of 391 Hz/pixel, a 40 mm
slice thickness, a 256 base matrix,
100% phase resolution, and “normal” TE
RF, the echo spacing is 6.24 ms, so
the effective TE is 50 ms (Fig. 2). The
complete echo train consists of (7 +
129), or 136 echoes, so the last echo Figure 2 Simplified timing diagram for the original HASTE sequence.
occurs 849 ms after the 90° RF pulse. Each block represents multiple 180° RF pulses and the resulting echoes.
Because a little extra time is needed The “zero” line is the echo that is not phase encoded, also called the
for the first half of the first RF pulse, central line of k-space. Phase oversampling is turned off. TE is eight times the
the second half of the last echo, and echo spacing, and the acquisition window is 136 times the echo spacing.
a little housekeeping, the whole
image acquisition takes 856 ms (the
minimum TR). If you increase TR, the
system just adds a little wait time
after the image is acquired.

Longer TE
Suppose you want a longer TE? In
theory, you could greatly increase
the echo spacing to make the eighth
echo occur later, but this would
dramatically lengthen the duration of 63 lines 128 lines
the echo train, and there would be
little signal in the late echoes. A
better solution is to collect more than TE
seven negative phase encoding lines.
Figure 3 shows an example with
phase encoding steps –64 to –1,
followed by the ‘zero’ line, followed
by steps +1 to +128.
In this example, the “zero” phase Figure 3 Shows an example with phase-encoding steps -63 to -1,
encoding line occurs in echo 64, so followed by the “zero” line, followed by steps +1 to +128.
the effective TE is 64 x 6.24 = 399 ms.
For this you only need to change TE
in the user interface. As you click
the “up arrow” to increase TE, you
can see TE jump in units of the echo
spacing. With each click, another
echo and phase encoding line is
added to the left side of the left box
in Figure 3.
63
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

In theory, we could use the Margosian

algorithm to reconstruct just lines
–7 to +128, which would limit the
acquisition window (and T2 decay) to
849 ms. In practice, the “phase
partial Fourier 6/8” algorithm is used
to reconstruct all 192 data lines to
127 lines 128 lines
improve the SNR; the acquisition
window is increased to 192x6.24 =
1198 ms. TE

Single-Shot Turbo Spin

Echo (RARE)
Suppose you want an even longer TE?
By setting TE to the maximum value Figure 4 Setting TE to the maximum gives a single-shot turbo spin
echo sequence, here with 256 echoes and 256 phase encoding steps.
in the user interface, we can acquire
TE is 128 times the echo spacing, and the acquisition window is 256 times
a full 127 negative phase encoding
the echo spacing.
steps before the “zero” line (Fig. 4).
The effective TE is then 128x6.24 =
799 ms, and the acquisition window
is a little more than 256x6.24 =
1597 ms. Since this is a full matrix of
data, the user interface shows that
Phase partial Fourier reconstruction
is “off”, and the SNR is improved with
respect to HASTE . There is significant
T2 decay of the signal during this
long acquisition.
This full-matrix sequence can be
called “Single-shot Turbo Spin Echo”
or RARE (Rapid Acquisition with 95 lines 96 lines
RElaxation) [3].
Even longer TEs are possible by TE
adding additional echoes between
the 90° RF pulse and the “zero” line.
This occurs as a byproduct of phase
oversampling (see below).
All of the examples above assume a
square FOV and 256x256 square Figure 5 Single-shot turbo spin echo with maximum TE and 192 echoes
pixels. The echo spacing and TE and 192 phase encoding steps. TE is 96 times the echo spacing, and the
values will vary significantly with the acquisition window is 192 times the echo spacing.
protocol parameters.

64
 TECHNOLOGY CORNER

Echo Spacing the echo spacing, as shown in Figure The total number of phase encoding
2. Phase oversampling requires extra lines is rounded up to 152. Because
In general, we want to keep the time phase encoding lines, and therefore phase oversampling inserts extra
between echoes short. As noted extra HASTE echoes. If 100% phase steps between the normal phase
above, the sequence can run faster oversampling is requested, the encoding steps, the minimum echo
with lower gradients. This means minimum TE will be 16 times the time is not seven times the echo
that the “echo spacing” will decrease echo spacing. spacing, but ten times it (56.8 ms).
with lower resolution and thicker
slices. Larger readout fields of view The maximum TE (Fig. 4) is the echo Because these matrix parameters
will also reduce the echo spacing, spacing (ES) times half of the number affect TE, it is best to set the
because this reduces resolution. of Fourier lines that are acquired. The bandwidth first, then the matrix
Making the FoV rectangular by number of Fourier lines will depend parameters, and then TE.
changing the “FoV phase” percentage on the base matrix size (B), the phase
resolution (R), the phase FoV (F), The minimum TE is shortened
does not affect resolution, and will
and the phase oversampling (PO). by using the normal gradient mode,
not change the echo spacing.
The last three are expressed as fast RF mode, a high bandwidth,
For the example above, the “Whisper
percentages, so the formula looks a larger FoVs, reduced phase resolu-
Gradients” add 0.3 ms to the echo
bit complicated: tion, thicker slices, and no phase
spacing. The Fast RF option reduces
oversampling. The other matrix
the echo spacing by 0.2 ms, while
parameters have no effect on the
the Optimized RF adds 0.3 ms.
minimum TE.
The higher the performance of the
gradient amplifier, the shorter the One way to lengthen the maximum
echo spacing. All of these changes TE is to increase the echo spacing
are made automatically, and directly Example: Start with the previous by reducing the bandwidth on the
affect the minimum and maximum example (Turbo gradients in “normal” Sequence tab card (for comparison,
echo times. mode, a 340 mm FOV, a bandwidth the MAGNETOM Vision
of 391 Hz/pixel, a 40 mm slice thick- tse240_1100b156 sequence had a
When you change parameters that ness, “normal” RF, 256 base matrix, bandwidth of 156 Hz/pixel). You can
affect the echo spacing, the system 100% phase resolution, no phase also slightly increase the echo
attempts to maintain your original oversampling, echo spacing 6.24 ms, spacing with the “Whisper” gradient
selection of TE, but this might not be minimum TE 50 ms, maximum TE setting or the “Optimized” RF option.
possible. In its attempt to maintain 799 ms). Change the phase
TE, the system will usually change resolution to 63% (“161x256” pixel A more efficient way to lengthen the
the number of echoes before the resolution), the phase FoV to 75% maximum TE is to increase the
“zero” phase encoding line, automa- (340x255 mm), and the phase number of acquired lines. Use “100%
tically shifting between HASTE, and oversampling to 25%. The reduced FoV phase” (square FoV) to avoid
single-shot TSE as needed. This can gradients shorten the echo spacing reducing the number of lines. A
cause more change in the appearance to 5.68 ms, so the maximum TE is: phase resolution of 100% helps, but
of the image than you might expect the square pixels may be too small
for a “simple” change in echo spacing. for good SNR. A good alternative is to
pick the appropriate phase resolution
for good SNR, but increase the maxi-
Effect of Matrix Parameters mum TE by adding phase oversamp-
on TE ling. Phase oversampling should be
used with care, since it increases the
Comparing Figure 4 with Figure 5 already long acquisition window,
shows that reducing the number and will increase the blurring caused
echoes (phase encoding steps, by T2 decay. These tricks to increase
Fourier lines) reduces the maximum the number of acquired lines also
value of TE. increase SAR.

If phase oversampling is turned off, Another possibility is to use more

the shortest TE is always eight times phase resolution than desired, and
65
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

then regain the SNR by applying a comparable to HASTE, say 4 seconds,

fairly strong raw data filter. the acquisition time is 12 seconds.
The HASTE sequence acquires the
whole image for one slice with a
Magnetization Preparation single 90° RF pulse, so the tissue has
the full (equilibrium) magnetization.
Selecting the FATSAT option applies Depending on TE, the HASTE sequence
a single FATSAT pulse before the 90° requires between 0.86 and 1.6
pulse. This can only be effective if seconds. The syngo MR HASTE
the TE is short (the HASTE sequence, sequence also has a much more
Fig. 2). flexible choice of TE values.
This sequence uses a large number Some “tse” protocols use the TSE
of RF pulses, so each slice should sequence and some use the HASTE
experience the full magnetization sequence. Identifying which pulse HASTE lung imaging, PAT x3,
transfer effect without any special sequence is associated with a parti- GRAPPA, 256x256
preparation. Selecting the magneti- cular protocol is achieved by moving
zation transfer option applies a single the cursor to the sequence code
MT pulse before the 90° pulse, so located to the right of the Scan Time
its effect will be negligible compared display above the protocol. After
to all of the 180° pulses. a few seconds, a tool tip will appear
showing the sequence name.
There is no preparation scan for this
sequence. The effective TR is infinite
unless you select multiple acquisi-
tions, or request closely spaced slices.
Comparison of HASTE to
If you make a single acquisition of EPI Sequences
several widely-spaced slices, TR can Single-shot Turbo Spin Echo is similar
be set as short as possible, provided to EPI, since they both use a single
that the SAR is within bounds. If you 90° RF pulse followed by multiple
need multiple acquisitions of exactly echoes with different phase enco-
one slice, or if you request one or dings. However, the term EPI is MAGNETOM Harmony,
more acquisitions of closely-spaced usually reserved for sequences that HASTE, 0.9 s/ slice
slices, TR should be set long (for form multiple gradient echoes, while
example 4000 ms). For multiple TSE uses multiple 180° RF pulses to
acquisitions of two widely-spaced form spin (and also gradient) echoes.
slices, TR can be reduced to half that. TSE is slower and has much higher
SAR, but the image quality is better,
and fat-water separation is not a
Comparison of HASTE to problem.
Standard TSE Sequence
The standard TSE sequence allows
turbo factors of up to about 129, so
[ 1 ] B. Kiefer, J. Graessner and
at least two 90° excitations are R. Hausmann, J. Magn. Reson. Imaging
needed to acquire a full 256 matrix. 4(P) (1994) 86.
With two excitations, TR becomes
[ 2 ] P. Margosian, F. Schmitt and
a significant factor in the image D. Purdy. Health Care Instrum. 1 (1986)
contrast. For this reason the standard 195
TSE sequence runs one prescan with HASTE Thick Slab, right kidney
[ 3 ] Hennig J, Nauert A, Friedburg H., with double collecting system,
this TR to establish a steady-state “RARE-imaging: a fast imaging method
level of magnetization, for a total of 2.45 sec acquisition time
for clinical MR.”
three excitations. For a TR somewhat Magn. Reson. Med. 3 (1986) 823
66
 TECHNOLOGY CORNER

HASTE liver
imaging,
MAGNETOM Trio,
8-channel Body
Array Coil
TR/TE 2000/90 ms
TA: 0.39 s
FOV 300x400,
192x512 matrix,
SL 6 mm

HASTE fetal imaging HASTE with respiratory trigger

Courtesy of Dr. Op de Beeck
Antwerp University Hospital

HASTE for MR Enteroclysis

HASTE 512 matrix for liver imaging,

11 sec for 20 slices,
4 mm slice thickness

67
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Medical Devices and Accessories Deve-

loped for Use in the MR Environment
Frank G. Shellock, Ph.D. In consideration of the many devices Non-magnetic Oxygen &
Adjunct Clinical Professor of and accessories that are commercially Gas Cylinders
Radiology, University of Southern available for safe use during MRI
California procedures, it is surprising that According to Chaljub et al., accidents
incidents and accidents related to related to ferromagnetic oxygen
Founder, Institute for Magnetic
ferromagnetic projectiles, excessive tanks and other gas cylinders that
Resonance Safety, Education, and
heating of devices and other problems, become projectiles may be increa-
Research
continue to occur. These have resulted sing. Therefore, MR facilities should
in at least one fatality, several devise an appropriate policy for
injuries, substantial damage to MR delivery of oxygen or other gases to
The increasing capabilities of magne- systems and down-time (i.e. loss of patients undergoing MR procedures.
tic resonance (MR) studies to impact revenue) for MRI centers. The use of non-magnetic (usually
medical diagnosis and prognosis have aluminum) oxygen and other gas
Therefore, the intent of this article
dramatically increased the number cylinders is one means of maintai-
is to review the various devices and
of MR procedures performed world- ning a risk-free MR environment with
accessories that are specifically
wide. Many more patients, especially regard to this equipment (Fig. 1).
designed for use in the MR environ-
those in high-risk or special popula-
ment or for interventional MRI proce- It should be noted that non-magnetic
tion groups, are undergoing MR
dures, with the hope that this infor- tanks must be prominently labeled
examinations for an ever-widening
mation will help prompt MR health- to avoid confusion with magnetic
spectrum of medical indications.
care professionals to recognize the cylinders. Furthermore, all healthcare
many products that exist and which workers that work in and around the
Additionally, as Jolesz et al. have
are essential to ensure patient MR environment must be informed
stated, continuous progress has been
safety. In addition, these devices and regarding the fact that only non-
made to expand the use of MRI
accessories may help to create a magnetic oxygen and other gas
beyond diagnosis and into interven-
more efficient or more profitable MR cylinders are allowed into the MR
tion. This has resulted in the develop-
center. system room.
ment and performance of innovative
procedures that include percutaneous
Non-magnetic oxygen regulators,
biopsy (including breast, bone, brain
flow meters, cylinder carts, cylinder
and abdominal), endoscopic surgery
Figure 1 stands, cylinder holders for wheel-
of the abdomen, spine and sinuses,
Non-mag- chairs and suction devices, are also
open brain surgery, and MR-guided
netic oxy- commercially available to provide
monitoring of thermal therapies,
gen tanks safe respiratory support of patients in
i.e. laser-induced, RF-induced, and of various the MR environment.
cryomediated procedures. sizes
(Magmedix,
Various manufacturers and sellers, Gardner,
prompted by recommendations and MA). Patient Comfort Devices
requests from MR healthcare profes-
sionals, have recognized the need Certain patients who undergo MRI
for developing specialized medical procedures experience emotional
devices, equipment, accessories and distress that can range from mild
instruments necessary for use in the anxiety to a full-blown panic attack.
MR environment and for interventio- Patient distress contributes to adver-
nal MRI procedures. Accordingly, se outcomes for the MRI procedure,
there are now numerous patient including unintentional exacerbation
support devices and accessories that of patient anxiety, a compromise in
have been developed and which the quality – and thus the diagnostic
have undergone thorough evaluation power – of the imaging study, and
to assess and verify appropriate use decreased efficiency of the imaging
in the MR environment or during facility due to delayed, cancelled
interventional MRI procedures. or prematurely terminated studies.
68
 MRI SAFETY

Fortunately, there are a variety of recommendations concerning the define the activities, use of equip-
techniques that can help minimize monitoring of patients during MR ment, and other pertinent issues
these problems for patients. For procedures. This information indicates pertaining to a medical or other
example, special systems can be used that all patients undergoing MR emergency is important for patient
during MRI procedures to manage procedures should, at the very least, safety in the MR setting.
the anxious patient, such as MR- be monitored visually and/or verbally
For example, a specific plan needs to
compatible headphones to provide (e.g. via an intercom system), and
be developed for handling a patient
music to the patient (which also that patients who are sedated,
where there is the need to perform
reduces gradient magnetic field- anesthetized or are unable to com-
cardiopulmonary resuscitation in the
induced noise) and MR-compatible municate, should be physiologically
event of a cardiac or respiratory
video systems to provide a visual monitored and supported by the
arrest. This includes the means to
distraction to the patient (Table 1). appropriate means. Of note is that
immediately remove the patient from
There is even a virtual reality environ- guidelines issued by the Joint Com-
the MR system to a place outside the
ment system that provides combined mission on Accreditation of Healthca-
MR environment to properly conduct
audio and visual distraction to the re Organizations (JCAHO) indicate
CPR, allowing the use of necessary
patient (Fig. 2). A similar device is that patients who receive sedatives
equipment such as a cardiac defibril-
designed for use in fMRI procedures. or anesthetics require monitoring
lator. For this reason, it may be
during the administration and
necessary to have a stand-by non-
recovery from these medications.
magnetic stretcher or gurney avail-
Additionally, policies and procedures able for the rapid transfer of the
must be implemented which continue patient, especially for MR systems
appropriate physiologic monitoring that do not have tables that separate
of the patient by trained personnel from the MR system or that quickly
after the MRI procedure is performed. disengage.
This is especially needed for a patient
Notably, the healthcare professionals
recovering from the effects of
who are members of the Code Blue
a sedative or general anesthesia.
team, (i.e. responsible for establis-
Conventional monitoring equipment hing and maintaining the patient’s
and accessories were not designed airway, administering drugs, recor-
to operate in the harsh magnetic ding events and conducting other
resonance (MR) environment where emergency-related duties) must be
Figure 2 Specialized equipment static, gradient and radio frequency identified, trained in MR safety and
used to provide virtual reality (RF) electromagnetic fields can continuously practiced in the perfor-
environment and for fMRI studies mance of these critical activities
adversely effect or alter the operation
(Resonance Technology, Inc., relative to the MR environment.
Northridge, CA). of these devices. However, various
physiologic monitors and other For cases when it may not be possible
patient support devices have been to remove the patient from the MR
Monitoring Equipment developed or specially modified to system room during an emergency,
perform properly during MRI proce- particularly where the patient is
In general, monitoring during an MRI
dures (Table 1). Besides patient experiencing a respiratory or cardiac
examination is indicated whenever a
monitoring, various support devices arrest, it is advisable to have various
patient requires observations of vital
and accessories may be needed for non-magnetic devices and accesso-
physiologic parameters due to an
use in the high-risk patient to ensure ries readily available, including an
underlying health problem or whene-
safety. Many of these have likewise oxygen cylinder, laryngoscope,
ver a patient is unable to respond or
been modified or designed to be suction system, stethoscope, blood
alert the MRI technologist or other
safely used in the MR environment or pressure manometer and other
healthcare worker regarding pain,
during interventional MRI procedures similar emergency equipment appro-
respiratory problem, cardiac distress,
(Table1). priate for the MR environment
or other difficulty that might arise
during the examination. In addition, (Table 1).
a patient should be monitored if
there is a greater potential for a Emergency-Related
change in physiologic status during Equipment MR Contrast Agent
the MR procedure. Injection Systems
Emergencies can, and do, happen in
In 1992, the Safety Committee of the MR environment. Therefore, the The controlled power injection of
the Society for Magnetic Resonance development and regular practice of MR contrast agents is gaining in
Imaging published guidelines and an emergency plan to address and popularity for a variety of clinical
69
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

applications, including examinations

of abdominal organs, vascular anatomy
and dynamic MRI studies of the
breast. Power injectors must be able
to operate in the MR environment
without affecting magnet homoge-
neity, degrading signal-to-noise, or Figure 4 Examples of non-magnetic
causing artifacts. Two of devices that devices and accessories developed
are available for power delivery of or modified for use in the MR
MR contrast agents: the Optistar MR environment.
Contrast Delivery System (Mallinckrodt,
St. Louis, MO) and the Spectris MR
Injection System (Medrad, Inc., MR facilities that handle both
Indianola, PA) (Table 1). out-patients and in-patients should
additionally consider obtaining a
non-magnetic patient slider board,
MRI Compatible Ventilators physiologic monitoring equipment
(e.g. fiber-optic pulse oximeter), non-
Devices used for ventilation of magnetic oxygen tank (including
patients typically contain mechanical non-magnetic regulator, cart or
switches, microprocessors and Figure 3 The Omni-Vent Series stand), portable suction, Mayo stand,
ferromagnetic components that may D Ventilator used for respiratory and other devices and accessories
be adversely affected by the electro- support of patients in the MR (Table 1).
magnetic fields used by MR systems. environment (Magmedix, Garner, MA).
Ventilators that are activated by high- Of note is that MR centers should
pressure oxygen and controlled by environment by obtaining a selection have a sufficient number of non-
use of fluidics (i.e. no requirements of non-magnetic or other suitable magnetic oxygen tanks and fire
for electricity) may still have ferro- accessories or equipment. For exam- extinguishers in the immediate and
magnetic parts that can malfunction ple, useful items for an out-patient general area to prevent responding
as a result of interference from MR facility include non-magnetic equip- emergency staff members from
systems. ment such as one or more wheel- introducing ferromagnetic objects
chairs, stretcher or gurney, step into the MR environment. In fact,
MR-compatible ventilators have stool, IV pole, laundry cart, stethos- some hospital-based MR centers have
been modified or specially designed cope, blood pressure manometer, non-magnetic oxygen tanks and fire
for use during MRI procedures perfor- storage or utility care, fire extinguishers used throughout their
med in adult as well as neonatal extinguisher and custodial cart buildings to prevent projectile
patients. These devices tend to be (Figs. 4 and 5). accidents.
constructed from non-ferromagnetic
materials and have undergone pre-
clinical evaluations to ensure that Biopsy Needles, Biopsy
they operate properly in the MR
Guns, and Tissue Markers
environment, without producing
artifacts on MR images. There are at Interventional MRI has been used
least two sources of respirators for to guide tissue biopsy and apply
patients that require respiratory markers with encouraging results.
support in the MR environment Obviously, the performance of these
(Table 1). These devices have been specialized procedures requires tools
tested in association with MR that are compatible with MR systems.
systems operating at 1.5-Tesla or less Many conventional biopsy needles,
(Fig. 3). biopsy guns, and tissue markers have
been evaluated with respect to
compatibility with MR procedures,
Basic Patient Management not only to determine ferromagnetic
qualities but also to characterize
Accessories and Equipment Figure 5 Non-magnetic custodial
cart (the wheels, casters, and imaging artifacts. The results have
All new and existing MR facilities bucket handle are all non-magnetic). indicated that most of these are not
should be prepared to handle A non-magnetic mop handle and useful for MRI-guided biopsy proce-
patients and everyday situations mop head clamp should be used dures due to the presence of excessive
(including maintenance) in the MR with this equipment. ferromagnetism and associated
70
 MRI SAFETY

imaging artifacts that limit or obscure COMPANY PRODUCTS

the area of interest. Fortunately, AESCULAP, INC. MRI Surgical instruments
several biopsy needles and biopsy 3773 Executive Center Pkwy
guns have been constructed out of Center Valley, PA 18034
non-ferromagnetic materials specifi- (800) 282-9000
cally for use in interventional MRI www.aesculap.com
procedures. These are now commer- DRAEGER MEDICAL , INC. Anesthesia equipment
cially available from various vendors 3135 Quarry Road Ventilator
(Table 1). Telford, PA 18969
(800) 437-2437
The placement of a marking clip or www.draeger.com
wire enables the accurate localization E-Z-EM, INC. Biopsy needles
of the surgical excision site and is a 717 Main St. Biopsy guns
Westbury, NY 11590 Biopsy site markers
useful surrogate target, even if the
(800) 544-4624
entire lesion is removed and there is www.ezem.com
a subsequent need for wire locali- IN-VIVO RESEARCH Monitoring equipment
zation prior to surgery. Marking clips 12601 Research Pkwy.
and wires have been specially Orlando, FL 32826
designed for use in interventional (800) 331-3220
MRI procedures (Table 1). www.invivoresearch.com
MAGMEDIX Non-magnetic accessories
158R Main Street Respiratory equipment
Surgical Instruments Gardner, MA 01440 MR facility start up kits
(866) 646-3349, (978) 630-5580 Monitoring equipment
Interventional MRI procedures have www.Magmedix.com Patient comfort/positioning devices
evolved into clinically viable techni- MRI tools and instruments
Patient transport equipment
ques for a variety of minimally invasive Cryogen accessories
surgical and therapeutic applications. MRI carts and maintenance devices
Besides the typical MRI safety concerns, Signs and site control devices
there are possible hazards in the MALLINCKRODT, INC. OptiStar MR Contrast Delivery System
interventional MRI environment 675 McDonnell Blvd.
related to the instrumentation and St. Louis, MO 63134
accessory equipment that must be (314) 654-3981, (314) 654-2000
www.mallinckrodt.com
addressed to ensure the safety of MR
MEDRAD Monitoring equipment
healthcare practitioners and patients.
One Medrad Dr. Music system
Surgical instruments are an obvious Indianola, PA 15051 Spectris MR Injection System
necessity for interventional MRI (800) 633-7231, (412) 767-2400
procedures. However, many of these www.Medrad.com
instruments are made from metallic MRI DEVICES CORPORATION Biopsy needles
materials that can create substantial 1515 Paramount Drive Biopsy positioning devices
problems in association with inter- Waukesha, WI 53186 Biopsy localization systems
ventional MRI procedures. (800) 524-1476
www.mridevices.com
The interventional MRI safety issues RESONANCE TECHNOLOGY, INC. MRI audio/video systems
that exist for a surgical instrument 18121 Parthenia St. fMRI products
include unwanted movement caused Northridge, CA 91325 Custom built devices
(818) 882-1997
by magnetic field interactions (e.g.
www.fmri.com, www.mrivideo.com
the missile effect, translational
attraction, torque), heating generated
Table 1 Examples of companies
by RF power deposition, and artifacts that provide devices and accessories
associated with the use of the instru- Figure 6
MR-compatible for use in the MR environment or for
ment, if it is in the imaging area of interventional MRI procedures (for a
surgical
interest during its intended use. comprehensive listing of companies,
instruments
To address these various problems, (Aesculap, please refer to Shellock FG. Reference
surgical instruments have been Center Valley, Manual for Magnetic Resonance
developed that do not present a PA). Safety: 2002 Edition. Amirsys, Inc.,
hazard or additional risk to the MR Salt Lake City, Utah, 2002)
healthcare practitioner or patient in
Important note from Siemens: We wish to offer our sincere
the interventional MRI environment apologies to Frank G. Shellock for mis-spelling his name in
(Table 1, Fig. 6). the safety video for which he acted as consultant.

71
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Accessories and Supplies from Siemens

Injectors*
MEDRAD
MR Injector Spectris Solaris
A high-quality injector for the precisely-
timed injection of MR contrast media.
It administers a tight CM bolus, thereby
maximizing dynamic and functional MR
examinations. By allowing a reproduction
In addition to its own products, of examination results, it enables constant
Siemens is also able to offer products and repeatable injection parameters to be
from leading manufacturers, tested set.
for compatibility with our MR sy- MEDTRON Injektor MRT
stems. These fulfill the requirements
for the highest quality of diagnostic
imaging as well as comply with
standards laid down by law.
Here are just a few of the highlights
of the product range offered by
Siemens. ULRICH MR Contrast media injector

Laser Cameras & Printers*

AGFA Drystar 2000
A digital dry imager which produces high-
quality monochrome films for diagnostic
purposes. Since the films are non light-
sensitive, handling is comparable with an
More detailed information can be obtained
office printer: space-saving and easy to
from our virtual 3D hospital rooms at
operate.
http://www.med.siemens.com/
AGFA Drystar 3000 DICOM
medandmore
The Drystar 3000 is a completely dry
working documentation system for cost-
efficient and decentralized applications.
The small footprint and low power con-
sumption alleviate the positioning of the
printer. A selection of two film formats is
possible. It boasts a geometrical resolution
capacity of 320 ppi. An online densito-
meter guarantees stable image quality.
There is an integrated controller module.
Documentation is via DICOM PMS through
a software option.
72
 MRI SAFETY

AGFA Scopix LR 5200 P Special Furniture*

This laser imager with integrated film
processor has a resolution capacity twice AGA MR Stretcher, non-magnetic
that of previously-known laser imagers, A sturdy CrNi steel construction for the
and is therefore used in areas in which an safe and comfortable transporting of
especially high-detailed display is impor- the patient, including a totally adjustable
tant. head part.

MAQUET IV Stand, non-magnetic

Monitoring Systems* A stable stand, equipped with electrically
conductive and lockable castors, also
INVIVO Patient Monitoring System
suitable for use in the MR room, thanks to
Consisting of a 3150 Omni Trak patient its non-magnetic effect.
monitoring system and a 3155 remote
screen with wireless data transmission,
several configurations are available. MEYRA Wheelchair – non-magnetic
This foldable wheelchair facilitates
patient transport into the MR room. An
INVIVO Pulsoximeter MRI 4500 adjustable I.V. pole is a significant
Due to its MR compatibility, this system contribution to ease-of-transportation.
facilitates precise monitoring as well as
interference-free MR scanning.

Respirators for use in the MR Room* Technical Equipment*

BLEASE Frontline Genius Anesthetic HEIMANN Handheld Metal Detector
System For non-contact examination of persons
This simple-to-operate and flexible Front- for any type of metal object prior to
line Genius system can be used for the entering the examination room.
anesthesia of adults and children in the
MR room on systems of up to 1.5 Tesla.

TOTAL Fire Extinguisher

Non-magnetic fire extinguisher filled
with carbon dioxide in accordance with
fire class B.

* Some of these non-Siemens devices described in the article may be pre-product

prototypes that may not have completed US FDA, European CE Mark or other reviews for
safet or effectiveness that are necessary prior to commercial distribution of these
devices. Some devices may not be available in all countries

73
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Monitoring of Neoadjuvant
Chemotherapy with Dynamic Breast MR
Bruce A. Porter M.D. FACR However, it is clear that neoadjuvant evaluation using a 3-dimensional
First Hill Diagnostic, Seattle, chemotherapy can often control dynamic method. It will then focus
Washington, USA LABC locally to a sufficient degree on the ability of MR to monitor
that many patients become operable, neoadjuvant therapy of breast malig-
and some are even converted to nancies.
become candidates for breast conser-
vation surgery [4,6].
Technique
A longstanding and significant
All the images in this report were
problem in monitoring neoadjuvant
produced on a 1.0 Tesla MAGNETOM
Introduction: chemotherapy has been the inability
Harmony MR system with standard
of conventional methods (breast
software and gradients (20 mT/m).
Recent advances in understanding exam, mammography, and ultra-
Evaluation of all breast cancers at our
the pathophysiology and genetics of sound) to reliably and accurately
facility begins with a large (450 mm)
breast cancer have led to more determine breast cancer size
Field of View coronal short TI inver-
specific and effective therapies. (T classification) and then to reliably
sion recovery (STIR) image set [15]
Patients with locally advanced breast measure tumor changes in response
of the chest, angled parallel to the
cancer (LABC) appear to benefit from to treatment [1,2,5,6,8]. Physical
sternum as determined from a
and be appropriate candidates for exam and mammography have
midline sagittal pilot image (See
these new therapies [1-4]. These known limitations for monitoring
Protocol Table) (Fig. 1) [6]. This is a
patients frequently have extensive therapy; post-treatment fibrosis can
highly sensitive screening tool for
tumors, which may involve the skin, readily mimic cancer on both exams,
distant metastases, particularly to the
chest wall, or regional lymph nodes, which may either under or overesti-
or have the typical clinical findings of mate the size and viability of residual
the T4 or inflammatory carcinomas. cancer. A number of authors [1,2,8,9]
Although these often aggressive have reported on the successful use
tumors tend to be highly sensitive to of contrast-enhanced breast MR to
chemotherapy [1], LABC patients monitor neoadjuvant chemotherapy.
have a generally poor long-term MR allows accurate (6) and nonin-
prognosis, with predicted five-year vasive initial staging of the patient’s
survival rates of 30% or less. Conven- tumor (which is particularly vital in
tional surgical options for locally this group, since conventional
advanced breast cancer have been surgical-pathological staging is not
limited; many of these patients have available). Evaluation of architectural/ Figure 1a Coronal STIR chest reve-
been, understandably, considered morphological features of breast als multiple hyperintense minute
inoperable [5]. As a result, over the lesions is key to diagnosis [10,11]. bone metastases which confluently
past 15 to 20 years a variety of Breast MR can also detect treatment- involve a right posterior rib (arrow).
preoperative chemotherapeutic related effects not only on tumor size
treatments have been proposed and and morphology, but also on tumor-
used for the treatment of LABC to associated angiogenesis and neovas-
improve management, and this cularity, by documenting alterations
approach has been termed “neoad- in blood flow [3]. These changes are
juvant chemotherapy”. The intent reflected by enhancement curves
of neoadjuvant chemotherapy is to generated during dynamic image
shrink or, ideally, to sterilize the acquisition [9,11,12-14] and can be
tumor before surgery and thus seen earlier than alterations in tumor
improve operability and long-term size or morphology [3]. Absence
Figure 1b Coronal STIR image more
survival [1,6,7]. Although some of enhancement, while a favorable anteriorly portrays a proximal left
reports have indicated a survival finding, does not indicate cure or humeral metastasis as a rounded
advantage with neoadjuvant chemo- eradication of tumor. This paper very bright focus; additional lesions
therapy, the question of an improve- presents a pictorial overview of our (not shown) were found in the spine,
ment in survival remains unresolved. current methods for breast cancer clavicles and scapula.
74
 WOMAN’S HEALTH

bone [16,17]. STIR also allows detec- examination. The examination is

tion of regional lymph node metas- done with fat saturation; however,
tases involving the axillary, internal Figure 2a 44 year old woman with to further improve the contrast of
mammary, supra- and infraclavicular rapidly advancing inflammatory the subsequent maximum intensity
and cervical nodes (Fig. 2a, b), as carcinoma of the left breast, palpable projection images (MIPs) the fat
well as soft tissues of the chest and axillary and supraclavicular lympha- saturation source images are subtrac-
liver [17]. Axial STIR images of the denopathy. Coronal STIR images ted (post-contrast minus pre-con-
chest are often used when lesions reveal inflammatory changes of the trast), particularly at 1 or 2 minutes
are identified on the initial coronal breast with skin thickening and post-injection (Fig. 3e) and then at
images; both initial STIR image sets hyperintensity, edema of the pecto- 4 minutes for review and production
ralis muscle, and extensive left
are acquired with the patient supine of representative high-contrast MIPs.
axillary adenopathy with perinodal
in the body coil. If bone or visceral edema. Note the enlarged and The MIP images are filmed in the
metastases are identified, the patient hyperintense azygoesophageal node axial (Fig. 3f), coronal, and oblique-
has documented Stage IV metastatic (arrow). sagittal (MLO-like) projections.
disease, and neoadjuvant therapy The contrast is administered via an
may not be appropriate. STIR images antecubital vein using a 20-22 gauge
also portray lymphedema associated
with inflammatory (T4) carcinomas
(Fig. 2) However, the most valuable
contribution of the initial chest study
for this sensitive exam is to detect
unsuspected Stage IV metastatic
disease or to improve the clinical
confidence that the patient indeed
has locally advanced, but not meta-
static, cancer. The next portion of the
exam is combined dynamic and high- Figure 2b Coronal STIR image more Figure 3a A 71 year old woman
anteriorly detects bilateral supracla- with an infiltrating ductal carcinoma
resolution 3D bilateral contrast-
vicular adenopathy extending into and a question of multifocal/multi-
enhanced study of the breasts, which
the upper anterior mediastinum centric tumor and possible nipple
is done in the prone position. Axial (arrows). The extent of the lymphe- infiltration on mammogram. Precon-
STIR breast coil images (Fig. 2c) are dema is well seen on this very water- trast axial T1-weighted FLASH images
initially acquired for assessment of sensitive sequence. show heterogeneously dense breast
internal mammary nodal involve- parenchyma. As is often seen with
ment, tumor-associated edema, or bilateral imaging, there is some mild
chest wall infiltration. This very fluid- inhomogeneity of fat suppression.
sensitive sequence also is useful
for identification of breast cysts and
fibroadenomas, both of which are
generally of very high signal on STIR.
Dynamic contrast-enhanced MR of
the breasts is performed with a
dedicated bilateral circularly polari-
zed breast imaging coil (Siemens Figure 2c Axial STIR breast coil
Medical Solutions), with an 80 slice image also shows fluid extending
pre-contrast T1- weighted 3D FLASH along the pectoralis muscle as well
(See Protocol Table) (Fig. 3a). curves as malignant left axillary nodes with Figure 3b Axial fat-saturated T1-
irregular ill-defined margins and weighted FLASH image at 2 minutes
(Fig 3d) are generated from these
perinodal edema, an indicator of after contrast reveals a heterogene-
serial dynamically acquired source extranodal tumor extension (N2 ous, lobulated, irregular, spiculated
images. Prior to the exam the adenopathy). The right parasternal enhancing mass in the subareolar
patients are carefully coached regar- high signal (arrow) was an ultra- space just lateral to the nipple,
ding the extreme importance of sound confirmed 5 mm malignant measuring 2.4 cm at its maximal
remaining completely still during the internal mammary lymph node. point.
75
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

section, highresolution “VIEWS” entire 80-slice image set on one

images (Volume Interpolated Exam, projection image. A contrast enhan-
Water-Stimulation) are complemen- cement curve (Fig. 4b) was genera-
tary to the dynamic exam and provi- ted from a region of interest placed
de great morphologic detail (Fig. 3g, at the periphery of the markedly
h). They are particularly helpful in enhancing mass. This illustrates the
neoadjuvant chemotherapy patients typical rapid uptake of contrast
following treatment, since they material with subsequent washout
are acquired with a delay of between pattern, which is a curve very highly
Figure 3c The most intensely
5 and 10 minutes after contrast predictive of malignancy. Other
enhanced voxels are identified by
review of images at high-contrast injection. curve types seen with malignant
settings, and the ROI is placed there lesions have been described; a
At this time treatment-suppressed
to generate the enhancement curves plateau or progressive pattern may
but still viable tumor may become
in Figure 3d. also be observed.
visible, which may not be seen at the
normal maximal enhancement time
of untreated cancers, 1 to 2 minutes
following injection of contrast.
Therefore, careful review of these
delayed high-resolution images can
be of particular importance in the
postchemotherapeutic setting.

Figure 3d Time-enhancement curve Clinical Cases Figure 3e This “2-minute subtrac-

from 0 (precontrast) to 5 minutes tion image” is the result of subtrac-
Neoadjuvant Case 1: A 53 year old
demonstrates abrupt early enhance- ting Figure 3a from Figure 3b. Sub-
ment (wash-in) with a peak of 159 % woman presented with a large, firm,
traction improves the contrast and
at 1 minute and a subsequent wash- but poorly defined right breast mass
conspicuity of the lesion, suppresses
out of contrast. The larger marks on and palpable axillary lymph nodes. background tissues, and corrects for
the x-axis represent 1 minute inter- MR examination for tumor size, non-uniformity of fat saturation.
vals. This is a typically malignant as well as for staging, was requested.
curve obtained from a region of The extent of the tumor is well seen
interest (ROI) placed at the point of on an axial MIP image from the
maximal tumor enhancement. dynamic series at 1 minute (Fig. 4a).
This demonstrates a bulky tumor
intravenous catheter with a bolus
involving the majority of the lateral
injection of a standard dose
right breast. A large asymmetrical
(0.1 mmol/Kg) of gadolinium-based
draining vein to the internal mamma-
contrast material. A 20 ml saline
ry venous plexus was also present.
flush follows the gadolinium at a
This is a common observation in
rate of approximately 2 ml/sec, and
large, locally advanced breast can- Figure 3f The axial 3-dimensional
five serial post-contrast 60-second
cers, and is readily appreciated with MIP image demonstrates a solitary
T1 FLASH acquisitions (Fig. 3b) are
the bilateral 3D technique. There is lesion in the left breast with a large
begun midway through the adminis- asymmetrical draining vein, and a
no tumor visualized in the left breast.
tration of the saline flush. Areas of normal right breast. This image from
The latter is a clinically relevant
maximal enhancement are identified the 2-minute postcontrast set shows
finding of great importance, since MR
(Fig. 3c) and contrast-enhancement. approximately equal enhancement
has a very high negative predictive
of the internal mammary artery and
Following the dynamic exam, a high- value. Considerable reassurance can vein (small arrows). Additional MIP
resolution sagittal 3-dimensional be offered to the patient with this images are filmed in the coronal and
water-saturation image set (Fig. 3g) simultaneous bilateral exam. An bilateral oblique positions (not
is acquired, either unilateral or advantage of the MIP technique is shown), and clearly document the
bilateral (Protocol Table). These thin- that a single MIP can summarize the absence of additional cancers.
76
 WOMAN’S HEALTH

A coronal STIR image of the chest,

done before the breast exam, reveals
right axillary lymphadenopathy
(Fig. 4c) and, more importantly, an
abnormal lymph node is identified on
STIR at the junction of the posterior
cervical chain and the supraclavicular
fossa. This had not been detected on
clinical examination, and had poten-
Figure 3g 1.2 mm thick VIEWS Figure 4c Coronal STIR chest image
tially profound impact on the staging
acquisition with an interpolated reveals right axillary adenopathy .
512x512 matrix and a 180 mm field of this patient’s cancer. Ultrasound The node is oval, enlarged, and there
of view results in very high resolution examination and fine needle aspira- is replacement of the normal dark
and spatial detail. The fine spicula- tion (Fig. 4d) confirmed an abnormal- hilar fat by STIR-intense tumor.
tion of the mass, as well as its internal appearing node with a positive A STIR-hyperintense lymph node is
heterogeneity and relationship to cytology indicating Stage IIIC metas- also identified in the posterior
the skin, is very well defined. tatic breast carcinoma, and the patient supraclavicular fossa / posterior
underwent neoadjuvant chemo- cervical chain (arrow).
therapy. A follow-up MR examination
was requested following three
months of neoadjuvant chemotherapy
Sag>Cor -5
(Fig. 4e). As demonstrated, there
is nearly complete resolution of the
pathologic enhancement, and the
abnormal venous drainage also
returned to normal. However, punc-
tate areas of mild contrast accumula-
Figure 3h A composite “thin” MIP tion remain, and therefore multiple Figure 4d Ultrasound-guided fine
comprised of 6-8 individual slices is 14-gauge core biopsies were perfor- needle aspiration of the lymph node
used to better demonstrate the med of this region, demonstrating in Figure 4C yielded cytology
relationship of the mass to the scattered malignant cells and chronic consistent with metastatic breast
nipple-areolar complex. The multiple inflammation. The enhancement carcinoma.
focal areas of nonspecific enhance- curve after treatment can be compared
ment elsewhere are a reflection of directly to the pretreatment curve in
the time delay from contrast Fig. 4f. There has been marked
administration for this sequence
flattening of the contrast curve,
(5-10 minutes).

Figure 4e Axial MIP image after

3 months of neoadjuvant chemothe-
rapy. Punctate areas of mild contrast
accumulation are present, and may
represent either underlying benign
Figure 4b Peak enhancement is foci of enhancement or small islands
Figure 4a (Neoadjuvant Case 1): reached at 2 minutes (represented of residual viable tumor at this time.
An axial MIP from the dynamic series by the vertical line) and the curve
(at 1 minute) demonstrates an 8 cm shows rapid initial enhancement
tumor as well as a large asymmetrical with a mild washout pattern thereaf-
draining vein. Note the absence of ter. Peak enhancement is 156 % at
abnormal enhancement in the left 2 minutes. This is typically a malig-
breast. nant-like enhancement curve.
77
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

which is still only slowly rising at the

end of the dynamic acquisition
(5 minutes), and no peak is seen. On Figure 4f Pre- versus post-treatment
the more delayed VIEWS images the enhancement curves. The vertical axis
mild mottled enhancement present has been set at 200 units to match
in the area of previous tumor on the pretreatment (upper) curve, and
these much-delayed post-contrast the ROI was placed as close as possible
images is also consistent with sub- to the site of the pretreatment ROI.
stantially treated, but not eradicated, Post-treatment (lower curve)
enhancement is now only 71 % at Figure 5b Following 6 months of
cancer. A follow-up coronal STIR
2 minutes (compared to 156 %). neoadjuvant chemotherapy the
image of the chest (Fig. 4g) reveals mass has diminished markedly and
The flattening of the curve is an
virtual resolution of the axillary and important indicator of response to now measures 2.5 x 1.6 x 1.6 cm.
supraclavicular adenopathy, which therapy.
is no longer palpable. The increased
STIR signal intensity in the proximal
right humerus is a reflection of
marrow hormonal stimulation due to
granulocyte colony stimulating factor
(GCSF) treatment. The large field
of view used on coronal STIR imaging
allows visualization of most of the
liver in most cases.
Figure 5c Axial MIP images at
Figure 4g Coronal STIR image 9 months documents re-enlargement
Neoadjuvant Case 2: This 47 year (compare to Figure 4c). Note the of the mass following a change in
old woman noted increasing tender- increased STIR signal in the proximal chemotherapy. The mass now
ness and swelling of her left breast right humerus (arrow) due to measures 3.2 x 2.6 x 2.4 cm. and
marrow hyperplasia secondary to displayed a malignant curve.
and axilla, but had a history of a
granulocyte-colony stimulating
known ruptured left saline implant.
factor (GCSF) treatment.
The firmness and enlargement of the
breast had been attributed by her
Sag>Cor -17
and her physician to scarring from
the implant rupture. The asymmetry
of vascularity seen on the 3D MIP
image (Fig. 5a) is striking, and a
reflection of the extensive angiogenic
ability of this tumor and its neovas-
cularity. The patient received six Figure 5d Sagittal VIEWS image
months of neoadjuvant chemotherapy, reveals a thickened, nodular rim
and a follow-up MR examination Figure 5a (Neoadjuvant Case 2) enhancement with a central fluidic
shows a marked response to therapy Axial MIP image of a markedly area of necrosis. The mass is
(Fig. 5b). There is persistent rim enhancing heterogeneous and spiculated, with morphologic features
enhancement and moderate lobula- exceedingly vascular mass involves consistent with residual neoplasm.
tion and spiculation; however, the the majority of the left breast and Notice the partially collapsed saline
asymmetrical vascularity has virtually has a 9 cm diameter, but it spares implant posterior to the mass
resolved. The contrast enhancement the skin and chest wall. Peak enhan- but anterior to the pectoralis muscle.
curve at this time demonstrates a cement occured at 1 minute (259 %)
with a malignant washout pattern
peak enhancement at 2 minutes of
thereafter. Note the curvilinear
98 %, with a mild washout pattern
enhancement of the malignant left
thereafter, which is consistent with a axillary lymph nodes (arrow).
substantial response. The changed
shape of the curve is the most
78
 WOMAN’S HEALTH

important indicator of response. The Acknowledgements [ 7 ] Esserman L, Kaplan E, Partridge S,

malignant lymph nodes had resolved. Tripathy D, et al. MRI phenotype is
I would like to acknowledge the associated with response to doxorubicin
The decision was made to continue and cyclophosphamide neoadjuvant
significant contributions of Helmuth
chemotherapy; however, the patient chemotherapy in Stage III breast cancer.
Schultze-Haakh, PhD and Nancy Annals of Surgical Oncology 8(6):549-
developed therapy related cardiotoxi- Gillen from Siemens Medical Solu- 559.
city, and had a change of treatment tions for their longstanding support
protocol. Three months later a [ 8 ] Weatherall PT, Evans GF, Metzger GJ,
and creative contributions to this Saborrian MH, et al. MRI vs histologic
follow-up MR documents interval work, as well as Brandy Wolff and measurement of breast cancer following
enlargement of the mass (Fig. 5c). Steve Meyers, First Hill Diagnostic chemotherapy: comparison with x-ray
The sagittal high-resolution VIEWS Imaging, and my colleague Justin P. mammography and palpation.
image (Fig. 5d) confirms the morpho- Journal of Magnetic Resonance Imaging
Smith, M.D. Invaluable assistance for
logical features of malignancy, with 13:868- 875 (2001).
manuscript preparation was provided
a thickened, nodular rim of markedly by Mildred Downey Broxon. [ 9 ] Kuhl CK, Schild HH. Dynamic image
enhancing material surrounding an interpretation of MRI of the breast.
area of central necrosis. At this point Journal of Magnetic Resonance Imaging
12:965-974 (2000).
the decision was made to operate.
References [ 10 ] Ikeda DM, Hylton NM, Kinkel K,
Hochman MG, et al. Development,
[ 1 ] Trecate G, Ceglia E, Stabile F, standardization, and testing of a lexicon
Conclusions Tesoro- Tess JD, et al. Locally advanced for reporting contrast-enhanced breast
breast cancer treated with primary magnetic resonance imaging studies.
MR technology has advanced to the chemotherapy: comparison between Journal of Magnetic Resonance Imaging
point that it is possible to obtain a magnetic resonance imaging and 13:889- 895 (2001).
combined high temporal resolution pathologic evaluation of residual disease.
Tumori 85:220-228, 1999. [ 11 ] Schnall MD, Rosten S, Englander S,
dynamic exam and a high spatial et al. A combined architectural and
resolution morphologic examination [ 2 ] Gilles R, Guinebretiere J-M, Toussaint kinetic interpretation model for breast
of both breasts using standard MR C, Spielman M, et al. Locally advanced MR images.
equipment and a dedicated breast breast cancer: contrast-enhanced Academic Radiology 2001;8:591-597.
imaging coil. The approach described subtraction MR imaging of response to
preoperative chemotherapy. [ 12 ] Kaiser W, Zeitler E. MR imaging
in this paper combines the strengths Radiology 1994; 191:633-638. of the breast: fast imaging sequences
of both examinations. The indications with and without Gd-DTPA.
for breast MR are continuing to evolve. [ 3 ] Tsuboi N, Ogawa Y, Inomata T, Radiology 1989;170:681-686.
One unique application of this Yoshida D, et al. Changes in the findings
[ 13 ] Porter BA, Taylor V, Smith JP,
of dynamic MRI by preoperative CAF
method is for initial staging of patients Tsao V. Contrast-enhanced magnetic
chemotherapy for patients with breast
with locally advanced breast cancer resonance mammography.
cancer of stage II and III: pathologic
Academic Radiology 1994; 1:S36-S50.
and subsequent monitoring response correlation.
to therapy. Being able to document Oncology Reports 6:727-732, 1999. [ 14 ] Porter BA, Smith JP, Borrow JB:
changing morphological features and MR detection of occult breast cancer in
[ 4 ] Drew PJ, Kerin MJ, Hahapatra T, et al.
patients with malignant axillary
alterations of enhancement patterns Evaluation of response to neoadjuvant
adenopathy.
provides a broad perspective on the chemoradiotherapy for locally advanced
Radiology 197(P):130, 1995.
staging and biology of breast cancer breast cancer with dynamic contrasten-
hanced MRI of the breast. [ 15 ] Bydder GM, Young IR. MR imaging:
in vivo, while providing a clinically European Journal of Surgical Oncology clinical use of inversion recovery
relevant basis for decision-making on 2001;27:617-620. sequence. Journal of Computer Assisted
management of these challenging Tomography 1985;9(4):659-675.
[ 5 ] Mumtaz H, Hall-Craggs MA,
patients. As treatment protocols for
Davidson T, et al. Staging of symptomatic [ 16 ] Porter BA. Marrow-infiltrating
breast cancer continue to evolve and primary breast cancer with MR imaging. disorders. In Moss K, Gamsu G,
become more specific and effective, AJR 1997;169:417-424. Genant H,eds. Computed Tomography
the availability of such a technique of the Body.
[ 6 ] Abraham DC, Jones RC, Jones SE, Philadelphia: WB Saunders 1991.
for monitoring day-to-day response
Cheek JH, et al. Evaluation of
to therapy will become all the more neoadjuvant chemotherapeutic response [ 17 ] Porter BA. Magnetic resonance
important. of locally advanced breast cancer by imaging for advanced staging of breast
magnetic resonance imaging. cancer.
Cancer 1996;78:91-100. CMRS Vision, December 1998: 1,5-13.
79
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Thin-MIP Evaluation in
3D Mammographic Imaging
Greta Vandemaele, Ph.D. acquisition or from head to feet in
MR Applications, Belgium axial exams (ima+/-). When a lesion is
encountered, we apply the “projec-
tion views” key. 5 MIP projections
appear on the screen, radially-orien-
ted. The orientations correspond to
the RX mammographic views: cranio-
caudal (axial), oblique and medio-
lateral (sagittal) views. We place the
center point on the lesion and specify
In MR breast imaging, gadolinium the extension of the MIP in “thick-
enhancement of lesions is followed ness” to cover the entire lesion.
with a high spatial resolution 3D- Orientation control should be applied
sequence (typically fl3d_512_in to get correct orientation of the
phase), covering the entire breast. breast.
A high temporal resolution is needed
Small lesions, trajectories of small
to detect the peak enhancement rate
intra-ductal carcinoma, can be seen
of the lesions. Subtraction of post
with this evaluation (Fig. 3b, c).
minus pregado measurement shows
Galactophoric ducts can be detected
the enhancing lesion.
with thin MIP on 512_T2_tirm or on
A 3D MIP of these subtraction images T1_fatsat imaging (Fig. 4a). Depending
depicts the vascular structure of the on the constitution of the fluid in
breast, the extension of the patho- the ducts, they appear hyperintense
logy and shows the presence of multi- (fluid, inflammation) or hypointense
focal lesions (Fig. 1). Very often, (containing lipids) on T2_tirm or
however, these MIP images suffer hyperintense on T1_fatsat imaging.
from artifacts. Slight patient move- They will not be visible on the
ment makes subtraction of the fat subtraction images, where only the
incomplete which may mask lesions obstructive papilloma (Fig. 4b)
on the MIP image (Fig. 2a). Dense or intra-ductal carcinoma will be
mammary glands may cover up small detected.
lesions in the overall MIP (Fig. 2c,d). Figure 1 MIP on a subtraction series
Good results were obtained in other of T1_fl3D_512
That is why we always combine clinical applications: detection of
normal 3D MIP of the breast with small aneurysms in 3D TOF, evalua-
thin-MIP evaluation in the 3D plat- tion of small stenosis in peripheral
form. angio and thin MIP on 3D CISS images
of the intra-acoustic ducts. Whenever
the overlay of surrounding structures
How is a thin MIP may hamper the 3D MIP evaluation,
thin MIP might solve the problem
evaluation performed?
and nicely depict pathology.
The subtraction series is loaded
Courtesy of Dr. M. A. Labaisse,
into the 3D MIP. The segment of the
ACCITAM Tournai, Belgium and
originally measured orientation
Dr. Ch. Van Ongeval- KU Leuven,
(coronal or axial) is made active.
Belgium.
“Thin MIP” is then pressed under
“type” whereby the MIP-image changes
to an MPR-image (here the originally
measured slices). We screen
all images for lesions, going from
anterior to posterior in coronal
80
 WOMAN’S HEALTH

Figure 2a MIP on a subtraction with Figure 3a The axial images with Figure 4a Thin MIP on a
incomplete fat subtraction and dense thin MIP orientations gallactophorous duct in T2_tirm,
breast tissue. filled with fluid.

Figure 2b The box of MIP Figure 3b Sagittal thin MIP Figure 4b Thin MIP on the
evaluation on the right breast. projection (medio-lateral view) with subtraction T1_fl3D series, showing
a width of 5mm. a small papilloma, obstructing the
duct.

Figure 2c Sagittal MIP of the right Figure 3c Axial thin MIP

breast. (cranio-caudal view) with a width
of 5mm.
81
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

CP Breast Array Coil is compatible with iPAT parallel imaging

applications for high resolution dynamic MRI of the breast.

iPAT Breast Imaging Examples

Courtesy of Prof. Dr. med. H. Otto

Evangelische Kliniken Gelsenkirchen
GmbH

Product Info
Klinik für Radiologie, Nuklearmedizin
und Radioonkologie

Second carcinoma on the right side

CP Breast Array Coil of the breast. Subtraction result after
dynamic high-resolution imaging
■ 4 coil design with 4 integrated with Flash 3D. True 512 matrix
preamplifiers within 54 sec acquisition time.
■ Mediolateral compression
capability
■ Circular polarized coil design offers
up to 40% higher signal-to-noise
■ Array technology allows the
coverage of large fields of view and
high-quality breast imaging
■ No coil tuning
STIR 512 matrix image showing
■ Size: 530 mm x 500 mm fibroadenoma. TA : 2:24

■ Weight: 7.3 kg (16.094 lbs)

STIR 512 matrix image showing DCIS

TA : 2:24

82
The MAGNETOM Family
Leading the Innovations in MR

www.SiemensMedical.com

When the choice is yours and you have The MAGNETOM Open Class
gained a certain perspective on MR systems, Open to everyone
your decision will be based on what‘s best • MAGNETOM Concerto
for your patients and your business: • MAGNETOM Rhapsody

The MAGNETOM Ultra Class

The MAGNETOM® Maestro Class 3T & beyond
A new degree of perfection • MAGNETOM Allegra –
• MAGNETOM Harmony 1T the brain scanner
• MAGNETOM Symphony 1.5 T • MAGNETOM Trio –
• MAGNETOM Sonata 1.5 T the whole body scanner
MAGNETOM FLASH

Case Report:
Stroke Diagnosis with MR
Priv.Doz. Dr. med. Franz Fellner
Institut für Radiologie
Landesnervenklinik
Wagner-Jauregg, Linz, Austria

81 year old patient suffered from

stroke symptoms during coronary
angiography procedure. Right hemi-
paresis and aphasia were the major
findings in the physical examination. Figure 1a Diffusion weighted Figure 1b ADC map
The patient was immediately trans- image. B 1000
ferred to our clinic and examined.
Diffusion weighted images showed
a lesion in the basal ganglia and
perfusion weighted images showed
decreased perfusion in a large area
fed by left middle cerebral artery.
This was a clear perfusion diffusion
mismatch indicating an ischemic
penumbra (Fig. 1,2).
The neurologist decided for an
immediate thrombolytic therapy with
these findings.
The next day, the patient could talk
and move which was a dramatic
quick response to the therapy. Follow-
Figure 2a Perfusion weighted Figure 2b Perfusion weighted
up MR examination showed adequate image before therapy. (MTT, Mean image before therapy . (TTP, Time to
perfusion in the previously diagnosed Transit Time map) Peak Map)
hypoperfused area (Fig. 3).

Figure 3a Perfusion weighted Figure 3b Perfusion weighted

image after intravenous thromboly- image after intravenous thromboly-
tic therapy. (MTT, Mean Transit Time tic therapy. (TTP, Time to Peak Map)
Map)
84
 NEURO IMAGING

Application Package:
Neuro Perfusion Evaluation

Product Info
■ Color display of relative Mean
Transit Time (relMTT)
■ Flexible selection of Arterial
Input Function (AIF) for reliable
quantification
■ Single shot and segmented EPI
sequences for fast acquisition
■ Diffusion weighted imaging with
b max of 10,000 s/mm2
■ Single shot EPI for perfusion
imaging
■ Multidirectional Diffusion
Weighted (MDDW) imaging for
diffusion tensor imaging

85
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Dream Machines and Getaway Speed…

Dream Machines and

Getaway Speed –
This is What Siemens CMR and
Harley Davidson Have in Common

For this year’s annual meeting in

February 2003, the Society of Cardio-
vascular Magnetic Resonance in
Medicine (SCMR) chose the birthplace
of the legendary Harley Davidson
motorcycle, Orlando, Florida.
And again, this year the meeting
saw a record attendance of over 800
SCMR representatives compared to Mecca that features the latest in However, the highlight of the evening
~600 last year and ~300 the year Harley motorcycles, accessories and was the announcement of self-gated
before. – for this one special night only – the CMR, a revolutionary new technique
The exponentially growing interest latest in Siemens CMR. proudly unveiled by one of its
and awareness of the power that inventors, Dr. Orlando Simonetti.
Cardiovascular MR has as a diagnostic After a welcome drink, Dr. Stefan
imaging tool, is reflected emphatically Assmann, CMR Product Manager,
by these numbers. presented the new cardiovascular
features, which will be part of the
Self-gated CMR –
For Siemens, this year’s SCMR next syngo MR software version with Siemens, Innovation is
meeting broke many records, too: 2004A. Huge progress – focusing on Continuous
Siemens customers again presented workflow and ease of use – has again
the largest share of abstracts, with Siemens have brought CMR into
been made with the latest software
more than 40% of the total. A record, clinical routine with Black-Blood
version. Dr. Assmann highlighted the
but no surprise, as this reflects the turbo spin echo, TrueFISP cine, and
features which resulted from plan-
fact that Siemens partners lead the Delayed Enhancement. Now we are
ning during our Annual Ambassadors
field in CMR. continuing our leadership of the field
meeting in New York last June.
in innovation with the announce-
The huge potential of CMR was
ment of Self-gated CMR, a new
demonstrated throughout the SCMR We can all look forward to working
imaging technique, which eliminates
meeting in many interesting talks with great new features, such as
the need for ECG during cardiac MR
and posters. Dynamic Signal, the perfusion evalu-
exams.
ation tool, or with Phase Sensitive
And Siemens had some exciting
Inversion Recovery, or “AutoViability”, For optimal cardiac image quality and
new developments to share with its
which eliminates the need for precise highest resolution, MR imaging must
partners during the meeting. As
adjustment of inversion time in be synchronized with the heartbeat.
special occasions require special
delayed enhancement imaging. Self-gated MR is the innovative
places, we decided to come together
Among many other new features, answer to this simple but complicated
with our MAGNETOM World CMR
radial techniques for high resolution prerequisite.
Ambassadors Friday night at The
real time imaging, and new iPAT
Harley Davidson First Historic Factory
applications, will also form part of The ECG signal is typically used to
in Orlando.
the new software, once again pro- synchronize MR imaging with the
More than 240 people joined us at ving Siemens’ product leadership in heartbeat. ECG triggering has several
this 35,000 square foot motorcycle CMR. practical limitations:
86
 CARDIO VASCULAR

1. Proper placement of ECG leads Self-gated CMR, simply stated,

takes a significant amount of the analyzes the acquired MR data itself,
patient set-up and total scan time and is able to track the motion of
the heart. It can also differentiate
2. Certain patient groups with poor
between cardiac and respiratory
physiological ECG signal can be
motion, and can use either motion
difficult to image.
to gate the images, or even use both
3. ECG signal is distorted by the static in combination (Fig.2).
magnetic field and can also be distor-
The technique was developed by
ted by switching of magnetic field
Andrew Larson of Northwestern
gradients and RF pulses during
University, together with Siemens
scanning, making triggering difficult.
scientists and Dr. Rick White, of the
Cleveland Clinic Foundation. Initial
clinical studies are underway at these
The New Approach of Self- sites, as well as at the NIH, where
gated CMR Andrew Larson is currently working.
The self-gating technique extracts First patient studies and more detai-
cardiac motion information from MRI led information on the technique will
data (Fig.1) and eliminates the need be shown in the next issue.
for wires and electrodes to be atta-
After the talk, Andrew Larson was
ched to the patient. No additional
awarded the first MAGENTOM World
navigator echoes are acquired, and
CMR Research Student Of The Year
the high spatial and temporal resolu-
Award for his significant contribu-
tion of segmented cine is achieved!
tions to self-gated CMR.
However, it was not only Andrew
who had a big smile on his face:
all the participants were happy to
experience the fun of test driving a
great machine.
Of course it was not possible to bring
enough MAGNETOM scanners for
everybody to the event. Therefore a
Figure 1 Comparison of conventio-
nal ECG trigger signal (black line) substitute was provided – a real
with self-gated signal (blue) shows Harley – guaranteeing almost the
excellent agreement of both methods same amount of fun.
Every participant was given the
opportunity to test drive a Harley,
and nearly everybody did and
See you next year at the SCMR in
enjoyed the experience.
Barcelona, Spain 13-15 February,
The next day at the SCMR meeting, 2004.
the Siemens event and self-gated
Some customers comments
CMR were THE topics of the day on
Figure 2 Four-chamber view of the the show floor.
human heart. No difference in image “Best user event in years”
quality between the ECG gated (left) Nomen est Omen: SCMR – Siemens ...and on self-gated CMR
and self-gated (right) technique Cardiovascular MR
can be observed. Combined cardiac
“Biggest thing in 5 years”,
and respiratory gating was applied. SCMR, a great meeting in any sense – “Biggest scientific news of
(Courtesy: A. Larson, NIH, thanks to the partnership with our the meeting”
O.Simonetti, Siemens Medical) customers !
87
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MAGNETOM Trio
MR Angiography Unlimited

MAGNETOM Trio
is 3T Unlimited
3T MR systems are attracting great
attention as new hardware and
software become available for whole-
body applications.
In the area of MR Angiography, 3T
benefits Time of Flight (ToF) techni-
ques, as T1 of blood and stationary
tissue become longer, thereby
increasing the signal of the vessels
and decreasing background signal.
The increased SNR at 3T offers the
potential to increase resolution with
the same dose of contrast, for better
diagnostic information.
MAGNETOM Trio has been optimized
at every level so that these advan-
tages can be fully exploited in all
applications. Maximal homogeneity,
advanced coil technology, 8 RF
channels in standard, iPAT applica-
The benefits of MAGNETOM Trio Inline Technology in the syngo user-
tions and gradient speed are some of interface
in MR angiography
the many components that
contribute to the quality of 3T MR on ■ Advanced RF system with Automatic subtraction
MAGNETOM Trio. 8 independent channels is standard
Automatic MIP in all orientations
supporting the 8-channel torso array,
8-channel neurovascular array and
8-channel head array coils
■ iPAT is standard for fast
acquisitions
■ Fastest gradients for a large FoV
(200 T/m/s slew rate)
■ syngo ergonomic user-interface

88
 CARDIO VASCULAR

Time of Flight MRA of the hand with

water excitation
Without the use of contrast agent
MAGNETOM Trio, CP wrist coil
Longer T1 at 3T provides excellent
inherent contrast for time-of-flight
techniques. Excellent background
suppression is enhanced by using the
water excitation technique.

Product Info
3D contrast-enhanced carotid MRA
3D FLASH, standard contrast dose
MAGNETOM Trio, iPAT-compatible
8-channel neurovascular array
Very high-resolution imaging:
80 partitions, 0.9 slice thickness,
512 matrix in only 35 seconds with
the Trio gradients.

Peripheral MR 2D Phase contrast image

Angiopgraphy of the sagital sinus
MAGNETOM Trio, integrated SAR- 2D FLASH, phase contrast,
optimized body coil 4.5 sec / slice
3D FLASH acquisition in 1:30 min MAGNETOM Trio, CP head coil
Acquired with 3 steps automatically
with the panoramic table
The design of the integrated body
coil of MAGNETOM Trio shows
excellent signal-to-noise, enabling
the visualization of even small
vessels of the lower leg.

89
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MRI Flow Quantification Techniques

Gary McNeal and How does MRI flow What is the Phase Image
Kevin Johnson quantification work ? and why is it important ?
Advanced Application Specialists
MRI flow quantification techniques In flow quantification techniques we
Cardiovascular MRI R&D Team
actually measure the velocity (cm/sec) are interested in both the magnitude
Siemens Medical Solutions USA
and then calculate the associated and phase of the difference between
flow (ml/sec) by multiplying velocity signal S1 (flow-compensated) and
times the cross-sectional area. How signal S2 (flow-encoded). When an
do we measure velocity? In contrast image is reconstructed it may be
to stationary protons, any protons displayed as either a magnitude
moving within a magnetic gradient image in which the pixel intensity
Why use MRI flow quantifi-
generate a phase shift in the trans- represents the length of the vector or
cation ? verse magnetization. For protons as a phase image in which the pixel
MRI is rapidly gaining acceptance as with constant velocity, the phase intensity represents the angle of the
an accurate, reproducible, and shift is linearly proportional to the vector.
noninvasive method for optimal velocity. This fact can be exploited
assessment of structural and functio- for velocity measurement by apply- ■ The phase image (Fig. 2c) repre-
nal parameters in patients with heart ing a very specific flow-encoded sents a phase reconstruction of the
disease.1 Diagnosis of cardiac disease magnetic gradient in the desired difference signal (S2-S1). It looks
requires accurate assessment of direction. grainy because it represents the
function as well as morphology of phase of the signal rather than the
As seen in Figure 1, a flow-compen-
the heart. The acceptance of Cardiac magnitude of the signal. Blood is
sated magnetic gradient creates a
MRI as a clinical diagnostic modality depicted as white if flowing in the
reference phase (the phase of signal
depends on its ability to demonstrate positive direction (ascending aorta),
S1 is zero), then a flow-encoded
several important diagnostic features black if flowing in the negative
magnetic gradient creates a different
including cardiac morphology, direction (descending aorta), or mid-
phase due to the constant velocity
regional and global ventricular grey if stationary. This image repre-
of the protons within the gradient
function, cardiac perfusion, coronary sents not only the speed of flow, but
(the phase of signal S2 is γ).
arterial anatomy, and flow.2 It is the also its direction. The pixel intensity
The measured velocity is linearly
ability of MRI techniques to quantify is directly proportional to the velocity
proportional to the measured phase
flow that will be discussed in this and its color indicates its direction.
difference (γ).
article. Flow measurements using Both speed and direction information
MRI can be used for examinations of are extracted during post-processing
blood vessels, cardiac valves, or to yield numerical and graphical
cerebral aqueducts. The advantages flow results. Thus, the phase image is
of MRI flow quantification over the most informative of the three
Doppler echo include: different types of displayed images.

■ MRI contains both anatomical and My ■ The rephased image (Fig. 2a)
functional information. S2 represents a magnitude reconstruc-
tion of the flow-compensated signal
■ MRI allows access to all anatomical
only (S2). This image is useful for
regions in all orientations.
drawing the regions-of-interest (ROI)
■ MRI is sensitive to a broad range of for quantitative evaluation of the
flow velocities. S1 Mx flow results. It looks like a typical
gradient-echo image with flow-
compensation.
Figure 1
■ The magnitude image (Fig. 2b)
represents a magnitude reconstruc-
tion of the difference signal (S2-S1).
This image may also be useful for
drawing the ROI’s. In this image,
90
 CARDIO VASCULAR

are marked with text “LPH” in the

Figure 2 upper right corner as a reminder.
(a) Rephased Image (b) Magnitude Image (c) Phase Image
■ For velocity encoding along the
stationary tissue appears black and the phase difference (γ) has reached x direction the pixel intensity will be
flowing blood appears bright regard- its maximum negative angle (– 180 white if moving toward the left or
less of the direction of flow. Thus, degrees) and therefore the pixel black if moving toward the right.
this image represents only the speed intensity has reached its maximum ■ For velocity encoding along the
of flow and contains no information negative value (– 4096 = maximal Y direction the pixel intensity will be
about its direction. black). Or, when the measured white if moving toward the posterior
velocity is exactly zero, then the or black if moving toward the
phase difference (γ) is also zero and anterior.
What is the VENC and why the pixel intensity is zero (0 = mid-
grey halfway between white and ■ For velocity encoding along the
is it important ?
black. Figure 3 shows how the phase z direction the pixel intensity will be
The velocity at which the phase difference is mapped to the pixel white if moving toward the head or
difference (γ) reaches 180 degrees is intensity. black if moving toward the feet.
known as the Velocity Encoding
Factor (VENC). For example, if the
VENC is set to 100 cm/sec then a Why and how is cardiac
+ 4096
velocity of 100 cm/sec will produce a + 180 gating used ?
phase difference (γ) of 180 degrees
+ 90
whereas a velocity of 50 cm/sec will To measure the changes in velocity
produce a phase difference (γ) of and flow caused by the beating
only 90 degrees. Before running the heart, data acquisition must be gated
0 deg 0
scan the user must choose an to cardiac motion, thereby resulting
appropriate VENC based upon his or in a series of images evenly spaced
her expectation of the peak velocity. throughout the cardiac cycle. Such
– 90
If the VENC is too high or too low the images are typically played in a “cine
pulse sequence can not accurately – 180 loop” to visualize the flow in real-
- 4096
determine the velocity. Ideally, time. Figure 4 shows a series of cine
the VENC should be set just slightly images acquired in the axial plane
greater than the peak flow. Figure 3 with velocity-encoding applied in the
through-plane direction (head-feet)
Remember that the positive direc- to visualize pulsatile flow through
How does the pixel tions are defined toward the patient’s the ascending aorta. See how the
intensity indicate speed left (L), and toward the patient’s signal changes from white to mid-
posterior (P), and toward the patient’s grey as the blood pulses through the
and direction ?
head (H). In fact, all syngo images ascending aorta.
Pixel intensities range from – 4096 to
+ 4096, independent of the VENC
selected. When the measured velocity
in the positive gradient direction
has reached the chosen VENC, then
the phase difference (γ) has reached
its maximum positive angle (+ 180
degrees) and therefore the pixel
intensity has reached its maximum
positive value (+ 4096 = maximal
white). Or, when the measured velo-
city in the negative gradient direction
has reached the chosen VENC, then Figure 4
91
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Chosing a VENC significantly greater

than the actual peak velocity (>150 %)
will result in sub-optimal SNR and
sub-optimal measurement accuracy.
The forward flow is not displayed as
maximum white and the reverse flow
is not displayed as maximum black
(Fig. 7a).
Chosing a VENC significantly less
than than the actual peak velocity
(< 90%) will result in severe velocity
aliasing that may not be adequately
compensated with the VENC Correc-
tion in post-processing (Fig. 7b).
In some cases of highly turbulent
flow, jets have been observed
in which the peak velocity makes a
transition from being too high

Figure 5
Acceptable results may be obtained
if the VENC is only slightly less than
Figure 5 explains how a cine flow
the peak velocity (within 10%). In
quantification sequence works.
this case, a small amount of velocity
A trigger pulse derived typically from
aliasing will be present, but the VENC
the ECG starts the process by acqui-
Correction in post-processing may
ring a segment of data containing
be used to compensate for aliasing
both signals S1 and S2. This process
(Fig. 6b).
is repeated for as many heartbeats as Figure 7a VENC too high
needed to collect all the data
(192 matrix x 20 images x 2 signals).
Fourier Transforms are performed
separately on the 2 different signals
S1 and S2 to produce two different
sets of phase images. Then the flow-
encoded images are subtracted from
the flow-compensated images for
subsequent cine display and quanti-
tative analysis.
Figure 6a Optimal VENC Figure 7b VENC too low
(aliased) to near zero within one
image pixel. In these cases the VENC
How to optimize the VENC ? Correction cannot properly report
a velocity in the pixels that have
Optimal results may be obtained if
a mixture of aliased and non-aliased
the VENC is only slightly greater than
signals. Therefore in these cases,
the peak velocity (within 10 %). This
it is best to avoid aliasing altogether
will ensure the best possible signal-
rather than rely on the VENC
to-noise ratio (SNR) and the greatest
Correction.
degree of measurement accuracy
(Fig. 6a). Figure 6b Acceptable VENC
92
 CARDIO VASCULAR

Rather than simply guessing at the

optimal VENC, it may be prudent to
run several quick test scans at several
different VENC’s. This can be accom- Figure 8a Left-right shading Figure 9a Figure 9b
plished by temporarily reducing the Coronal localizer LVOT localizer
matrix and the number of averages
while increasing the number of lines
per segment for the quick test scans
(repeat at several different VENC’s).
Determine the best VENC and reset
the parameters back to their
original values before performing the
diagnostic scan.

Figure 8b No shading
How to optimize Figure 9c Axial Ascending Aorta
measurement accuracy? How to align the velocity-
As discussed earlier, the pixel inten- encoding gradient? the velocity-encoding gradient must
sities in the phase images represent be applied in-plane (readout direction,
Accurate flow quantification requires head-feet). Localizers in the axial
the velocities being measured.
that the velocity-encoding gradient is view are used to prescribe the slice
Moving protons are either white or
aligned primarily along the direction through both the ascending and
black, whereas stationary protons
of the flow (use in-plane rotation descending aorta.
should be homogeneously mid grey
of FOV if necessary). For example,
anywhere in the image. If there
a 20 degree misalignment between
is any significant shading across the
the velocity-encoding direction and
image the velocity measurements
the actual flow direction can cause
may be inaccurate. The shading
up to 6 % error in the velocity measu-
in Figure 8a was caused by failure to
rement. The user must select the
follow one or more of these recom-
velocity-encoding gradient either
mendations:
through the slice (through-plane) or
1. Ensure the equipment remains within the slice (in-plane), depending
within its operational specifications upon the slice orientation and the
by routinely performing preventive flow direction.
maintenance, especially the Figure 10a Axial localizer
In Figure 9 the ascending aorta is
eddy-current and shim calibrations.
assessed with a flow quantification
2. The measured region-of-interest slice run in an axial oblique plane.
must be as near isocenter as possible. Since the flow in the ascending aorta
Ensure the slice is within +/- 50 mm is pedominantly in the head-feet
of isocenter along the head-feet direction the velocity-encoding
direction. If the table or patient must gradient must be applied through-
be moved more than +/- 150 mm to plane (slice thickness direction).
meet this requirement, it is recom- Localizers in the coronal and left
mended to relocalize afterwards. ventricular outflow views are used to
position the slice exactly perpendi-
3. Normal or Whisper Gradient Pulses Figure 10b
cular to the aorta. The aortic contour Sagittal Ascending Aorta
are preferred in the measurement
is shown in Figure 9c and will be
protocols. Although Fast Gradient
described later.
Pulses can be used, they could be
more likely to contribute to shading In Figure 10 the aorta is assessed
effects, especially if recommenda- with a flow quantification slice run in
tions 1 and 2 above are not followed. a sagittal oblique plane. In this case
93
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

How to assess pulmonary- How to perform

systemic shunts ? the Post-Processing ?
To assess pulmonary-systemic shunts Figure 11a ■ After running a flow quantification
it is necessary to compare two separate Pulmonary Outflow localizer pulse sequence, load the resulting
flow measurements – one through Rephased Images and Phase Images
the ascending aorta and another into ARGUS, select FLOW ANALYSIS.
through the pulmonary artery. Refer
back to Figure 9 for positioning ■ Crop all images by about 50% –
through the ascending aorta and refer Window to best see flow in the Phase
to Figure 11 for positioning through Images.
the pulmonary artery. The Net For- ■ Enter the R-R interval as the
ward Volume through the pulmonary Trigger Time from the last image in
artery is known as QP, whereas the the series.
Net Forward Volume through the
ascending aorta is known as QS. The Figure 11b Axial Pulmonary Artery ■ Enter the patient’s height and
ratio QP / Qs represents the direction weight (used to normalize the results
and amount of blood being shunted. to BSA).
Typical starting choices for VENC’s
■ Select Active Contour 1 and draw a
are about 120-250 cm/sec for the
contour around the vessel of interest
ascending aorta and about 80-140
on a Rephased Image or a Phase
cm/sec for the pulmonary artery, but
Image (whichever best shows the full
these may vary from one patient to
lumen – contour in Fig. 11)
another and from one clinical scenario
to another. ■ Propogate Active Contour 1 by
■ QP / QS = 1 no shunt. clicking on the bold-double-headed
Figure 12 Atrial Septal Defect (ASD) arrow.
■ QP / QS > 1 shunt is from systemic
system into pulmonary system. Figure 13
■ QP / QS < 1 shunt is from pulmo-
nary system into systemic system.
Figure 12 demonstrates an atrial
septal defect (ASD) by using a dyna-
mic first pass contrast enhanced scan
in the four chamber horizontal long
axis view of the heart. An ARGUS
flow analysis was performed separa-
tely on the pulmonary artery and
the ascending aorta using the steps
listed below (Fig. 13). Analysis of the
pulmonary artery yielded 131 ml Net
Forward Volume (Qp) and analysis
of the ascending aorta yielded 82 ml
Net Forward Volume (Qs), thereby
resulting in a QP / QS ratio of 1.6
(see Fig. 14 & 15). This indicates that
blood was shunting from the left
atrium into the right atrium.

94
 CARDIO VASCULAR

■ Adjust Active Contour 1 on Figure 14

all images as needed to completely Pulmonary Artery
include the vessel lumen and exclude
all stationary tissue – this is critical
for accurate results so make your
best guess if the edge definition of
the lumen is uncertain – refer to
earlier and later images in the series
as a reference.
■ After verifying that all contours
are correct click on Accept Generated
Contours.
■ In the Results Taskcard click on
the 1 to see the results for the vessel
of interest.
■ Click on Velocity and Flow to get
the curves – click on Temporal to get
a table.
Although not generally necessary,
it is possible to perform a “reference Ascending Aorta
correction” of the measured velocities
within the region-of-interest relative
to a zero baseline represented by
stationary tissue with no flow. If the
measured velocity within stationary
tissue happens to be non-zero, it
represents an offset error that should
be corrected in the region-of-interest.
Reference correction is generally
unnecessary if the slice and region-
of-interest are near isocenter and
there are no nearby field inhomoge-
neity artifacts from stents, implants,
prostheses, or air-tissue interfaces.
However if desired, a reference
region may be drawn in an area of
stationary tissue near the region-of-
interest. It must contain homogene-
ous signal with no flow artifacts or
field inhomogeneity artifacts. To
draw the reference region click on
the Ref button in the Contour toolbox
(Fig. 13), click on the Circle button
and draw a circle on a Phase image,
and click on Simple Copy to propogate
the reference region through all
images. To apply the reference
correction to the measured velocities,
click on Flow Options and Use Base-
line Correction.
95
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

How to assess flow jets

through cardiac valves?
To assess stenotic or regurgitant
jets through cardiac valves one can
visualize the jets with in-plane velo-
city-encoding. This is not a “quantita-
tive” approach, but rather an optional
“qualitative” approach. As described
earlier, it is always critical to align
the velocity-encoding gradient to the
direction of the jet (use in-plane
rotation of the FOV if necessary). In
this example of a stenotic pulmonary
valve we begin with some images of
the pulmonary valve to visualize the
jet (Fig. 16). TrueFISP cine images
(Fig. 16a) were acquired to confirm
the location of the jet, followed
by velocity-encoded images with in-
plane (head-feet) VENC of 500
Figure 15 Pulmonary Artery cm/sec (Fig. 16b,c). We continued
with some images of the pulmonary
valve in a modified right ventricular
outflow view (RVOT) that were
planned directly through the jet from
the previous images (Fig. 16d). Again
we acquired velocity-encoded images
with in-plane (head-feet) VENC of
500 cm/sec (Fig. 16e,f). At cardiac
catheterization the peak velocity was
estimated to be 403 cm/sec.

How to assess CSF flow in

the cerebral aqueduct?
To assess CSF flow in the cerebral
aqueduct it is necessary to acquire an
axial slice through the aqueduct with
very high spatial resolution (120-140
mm FOV, 256x256 matrix, 3 mm
slice thickness, multiple averages).
Refer to Figure 17 for positioning the
Ascending Aorta axial slice perpendicular to the
cerebral aqueduct from a midline
sagittal localizer. Flow through the
cerebral aqueduct is normally biphasic,
with both cranial and caudal flow
occuring during each heartbeat.
Typically there is cranial component
of flow occuring at the time of the
96
 CARDIO VASCULAR

a b c
ECG trigger (time=0), quickly there-
after it reaches a peak in the cranial
direction, then it reverses direction
toward caudal, and finally late in the
cardiac cycle it reverses direction
again toward cranial. The net cranial
flow and the net caudal flow are
almost equal under normal conditions
(a difference of perhaps only a few
microliters per heartbeat), but this
may vary under abnormal conditions.
A typical starting choice for VENC is
about 10-15 cm/sec, but this may
also vary from one patient to another
and from one clinical scenario to
another – stenosis generally requires
a higher VENC due to the resulting
flow jet.
In the following example of a normal
cerebral aqueduct an ARGUS flow
analysis was performed on the data
d e f as described in Figure 13, except the
Figure 16 contour of the aqueduct lumen was
(a) TrueFISP cine image through pulmonary valve shows the jet. propagated as a simple circle with
(b) Rephased image with in-plane VENC 500 cm/sec shows the valve. the command Simple Copy. The
aqueduct contour is shown in Figure
(c) Phase image with in-plane VENC 500 cm/sec shows the jet. 17. A flow analysis of the cerebral
(d) Modified RVOT was planned directly through the jet. aqueduct yielded a Net Flow of 0.013
ml in one heartbeat of this normal
(e) Modified RVOT TrueFISP cine image through pulmonary valve shows the
patient (the end-point of the curve in
valve & jet.
Figure 21).
(f) Modified RVOT phase image with in-plane VENC 500 cm/sec shows the jet.

Figure 17a Figure 17b

Midline sagittal localizer Axial Cerebral Aqueduct

97
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 18 shows the curve for Average

Velocity versus Time (cm/sec). This
curve represents the average velocity
within the specified contour of the
cerebral aqueduct. Velocities in the
positive direction are displayed above
the horizontal axis, whereas velocities
in the negative direction are displayed
below the horizontal axis. The velocity
of CSF flow in a normal cerebral
aqueduct is non-zero at the beginning
of the cycle, returns to the same
value at the end, and has both positive
and negative velocity components
(cranial and caudal flow).
Figure 19 shows the curve for Peak
Velocity versus Time (cm/sec). This
curve represents the peak velocity
within the specified contour of the
cerebral aqueduct. In turbulent
conditions the peak velocity may be
Figure 18
considerably greater than the average
velocity (as in the ascending aorta),
but in laminar conditions the two are
generally similar (as in the cerebral
aqueduct). The peak velocity curve
may provide a good indication of
how well the chosen VENC matches
the actual peak velocity of the mea-
surement. If the VENC was chosen
significantly too low, the Peak Velocity
curve will be aliased – that is, it will
appear to take a dip right at the peak
of the curve. If this were the case
and there was only minor aliasing,
the VENC ADJUST feature would
allow the user to shift the VENC in
the positive or negative direction as
needed to compensate for the aliasing.
However, in this example the chosen
VENC was 15 cm/sec and the peak
velocity was only 2 cm/sec – that is,
a VENC of 5 cm/sec would have been
Figure 19 more appropriate.

98
 CARDIO VASCULAR

Figure 20 shows the curve for Flow

versus Time (ml/sec). This curve
represents the average flow within
the specified contour of the cerebral
aqueduct. This curve is derived by
multiplying the Average Velocity
curve by the cross-sectional area of
the lumen as determined from its
contour. Note in the example that
the flow reached only 0.04 ml/sec in
the positive direction (cranial) and
only 0.10 ml/sec in the negative
direction (caudal) – these are typical
values for a normal patient. If you
add up (integrate) all the area under
the positive portions of the curve you
will get the net volume of CSF (ml)
that flowed in the cranial direction
over a single heartbeat. Similarly,
integrating the negative portion of
the curve gives you the net volume
(ml) of CSF that flowed in the caudal Figure 20
direction. Just a technical note: this
flow curve is expressed in units of
ml/sec, but flow is sometimes discus-
sed in units of ml/min and would
require that these numbers should be
multiplied by 60.
Figure 21 shows the curve for Net
Volume versus Time (ml). This curve
is derived by integrating the pre-
viously described Flow versus Time
curve. Unlike all the other previous
curves, this one typically does not
end up at the same point that it
started. The endpoint of this Net
Volume curve represents the total
volume of CSF that passed through
the aqueduct lumen over a single
heartbeat. In this example the net
flow was 0.013 ml per heartbeat in
the caudal direction. Furthermore,
from the specified R-R interval of 900
ms we can calculate a caudal flow of Figure 21
about 0.87 ml/min (= 0.013 ml/beat
*67 beats/min).

99
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 22 represents a summary

of the results and may be obtained
by clicking on the Temporal button.
This shows that the VENC is 15 cm/sec
and the body surface area is 1.85
square meters (estimated from
patient’s height and weight). The
peak velocity is 4.35 cm/sec in the
caudal direction (the peak of the
curve in Fig. 19). The average velocity
is 0.59 cm/sec in the caudal direction
(the average of the curve in Fig. 18).
The Average Flow is 0.02 ml/sec in
the caudal direction (the average of
the curve in Fig. 20). From these
results the Average Flow Per Minute
can be calculated as 0.0012 liter/min
(= 0.02 ml/sec * 60 sec/min / 1000
ml/liter). Note that 0.0012 liter/min
is so small that it is listed as zero in
the table. For just one heartbeat the
Figure 22 Forward Volume is +0.01 ml (in the
cranial direction), the Reverse Volume
is +0.02 ml (in the caudal direction),
and thus the resulting Net Forward
Volume is -0.01 ml (in the caudal
direction).

Acknowledgements
We would like to thank our colleagues
Dr. John Lesser, Dr. M. Tadavarthy,
and Jana Lindberg, RT, at Abbott
Northwestern Hospital who provided
some of our data and advised us
regarding the clinical interpretation
of some of the finer clinical aspects
of this technique.

References
Didier D, Ratib O, Lerch R, Friedli B.
Detection and quantification of valvular
heart disease with dynamic cardiac MR
imaging. Critical Reviews in Diagnostic
Imaging. 1999;40:1299-1301.

Sakuma H, Takeda K, Higgins C.

Fast magnetic resonance imaging of the
heart. European Journal of Radiology.
1999;29:101-113.
100
 CARDIO VASCULAR

MAGNETOM Trio
Cardiac MR Unlimited*
3T magnets offer double signal- The active ECG electrodes:
to-noise (SNR) compared to 1.5T. Robust fiber optic signal transmission.
However, at 3T, artifacts, for example, High reliability at 3T.
due to the greater chemical shift
Cardiac Array Coil: Receive coil
can be very prominent. For these
with integrated preamplifiers. No coil
reasons, MAGNETOM Trio has been

Product Info
tuning. Used for high-resolution
optimized at every level so that the
cardiac imaging.
increase in SNR can be fully exploited
in cardiac MR. Maximal homogeneity,
advanced coil technology and Coronary MR at 3T
gradient speed are some of the many
Acquired with 1D PACE for motion
components that contribute to the correction and active ECG electrodes.
quality of cardiac MR at 3T.
MAGNETOM Trio, iPAT-compatible
8-channel cardiac array coil.
The benefits of MAGNETOM Trio A: 3D FLASH with fatsat, pixel size
in cardiac MR 0.9 x 0.9 x 1.2 mm
■ Dedicated 8-channel cardiac array A B B. 2D TSE dark blood, pixel size
coil, iPAT compatible 1 x1.5 x 1.2 mm
■ Active ECG electrodes
Function –
■ Excellent homogeneity on a In-flow and out-flow tract at 3T
40x40x40 cm FoV to ensure best fat
Acquired in 12 s, 276x384 FoV
saturation and TrueFISP imaging
MAGNETOM Trio, iPAT-compatible
■ iPAT standard for fast acquisitions 8-channel cardiac array
■ Fastest gradients on large FoV Due to the high-homogeneity
(200 T/m/s slew rate) of the MAGNETOM Trio magnet,
TrueFISP exhibits excellent signal
■ syngo ergonomic user-interface
and contrast-to-noise at 3T.

Morphology –
2D TSE dark blood of the heart
MAGNETOM Trio, iPAT-compatible
8-channel cardiac array

Function with 2D cine TrueFISP of

the heart

Enhanced workflow with syngo MAGNETOM Trio, iPAT compatible

user-interface 8-channel cardiac array

Visualization of all views. The high SNR of the TrueFISP and

3T magnetic field strength of
Automatic loading and display of cine
MAGNETOM Trio results in the very
dataset.
good SNR of the heart at 3T in
Ergonomic ECG display integrated Without iPAT With iPAT factor 2 extremely short acquisition times.
into the interface. (TA = 15 s) (TA = 8 s)
* Cartain OEM coils with the MAGNETOM Trio System require
Temporal resolution:
510 ( k ) review and are not commercially available in the US. 25 ms, 256x256
101
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Basic Cardiac Positioning and Terminology

Raleigh MRI Center, longer scanning, and conversely,

Raleigh, North Carolina, USA a single breath-hold may be all that
is needed on the shorter scans.
Depending on the radiologist’s pre-
Margaret King, RT (R)(MR),
ference, images may be acquired on
Raleigh MRI Center,
inspiration or expiration as long as it
3811 Merton Dr., Raleigh,
is consistent throughout the exam.
NC, USA

Introduction
Localizer Images
Cardiac imaging can be intimidating.
The heart is not a straightforward
organ. However, cardiac imaging is
not quite as difficult if you under-
stand the basics and the terminology.
HLA – Horizontal Long Axis-shows
all 4 chambers
(similar to oblique coronal)
VLA – Vertical long Axis-shows
2 chambers, left atrium and ventricle
(oblique sagittal)
Transverse scout Sagittal scout Coronal scout
Short Axis – perpendicular to the
ventricular septum

Patient Preparation and

Positioning
The patient is positioned head-first,
supine, with leads attached. The
body array coil is attached over the
chest, centered approximately at
the level of the nipples. Both body
array elements should be activated,
together with spine elements 2 and
3, unless one of the spine elements
sufficiently lends enough signal to
cover the heart in conjunction with
the body array elements. The patient
Utilizing the transverse image with the best depiction of the left ventricle (LV),
should be comfortable with the large
position a slice parallel to the septum through the LV to generate a vertical long axis
leg cushion placed under their knees, (VLA).
and be offered detailed breathing
instructions prior to entering the
bore. It is productive to practice the
breathing to ensure accurate, speedy
inhalation and exhalation. Most
imaging can be done on the second
inspiration/expiration. Three breaths
may be necessary for some of the
102
 CARDIO VASCULAR

Using the VLA, envision an imaginary line bisecting the mitral valve and exiting
the apex of the LV. Position three short axis images perpendicular to the imaginary line
to generate three short axis (SA) images.

Using the VLA and the short axis image which best demonstrates the apex of the right
ventricle, position three slices parallel to the long axis of the LV on the VLA as well as
perpendicular to the septum exiting the apex of the right ventricle on the short axis to
generate a four chamber view. The mid slice should be the best four chamber image,
with the anterior slice yielding an image of the Left Ventricular Outflow Tract (LVOT) .

103
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

The anterior slice should yield a Left Ventricular Outflow Tract (LVOT) image.
If you are trying to obtain a four chamber of the heart using single slice positioning,
and your image demonstrates the LVOT where you can appreciate the aorta coming
off of the left ventricle, you should then be able to move your slice more posterior
to achieve a true four chamber.

Anatomy

E
C
D I
H
A J
F
B G

Horizontal Long Axis Vertical Long Axis Short Axis

A. Right Atrium F. Mitral (Bicuspid) Valve

B. Left Atrium G. Left Ventricle
C. Right Ventricle H. Left Atrium
D. Left Ventricle I. Left Ventricle
E. Tricuspid Valve J. Right Ventricle

104
 CARDIO VASCULAR

Sequence Details TrueFISP, Single Slice or Most cardiac work-ups begin with
Multi-Slice (Morphology) the basic imaging described above.
Cardiac imaging utilizes many se- Commonly, a four chamber view is
quences. Most of the images shown trufi_singleshot_15sl, #slices 1-15, obtained and imaged with T1, T2 or
above are a single, phase image from slice thickness 5mm, TR 459, IR, and Cine. From the four chamber
a cine. Depending on the indications TE 1.56, TA ~9.9s, matrix size 256, image, a fine tuned VLA or two
for the cardiac MR, a variety of 60% FOV 340, Rectangular FOV 82%, chamber image is made with T1, T2
sequences may be used. Morphology AC 1, BW 980, FA 62. and Cine. For various pathologies,
sequences include but are not limited the cardiac exam will be tailored
to T1, T2, HASTE, IR, GRE and True- from that point on. Functional
FISP imaging. Cine imaging may TSE T2, Single Slice analysis will require short axis cine
include TrueFISP cine as well as (Morphology) through the left ventricle. Viability
FLASH cine. A list of the parameters and perfusion can also be performed.
for frequently used sequences are tse15_db_t2, #slices 1, slice thick-
The basic terminology and metho-
listed below. ness 5mm, TR 700, TE 70, TA ~8.4s,
dology for obtaining a four chamber,
ETL 15, matrix size 256,
two chamber and LVOT will demon-
78% FOV 340, Rectangular FOV 82%,
strate the basic heart anatomy and
TSE T1, Single Slice AC 1, BW 235, FA 180.
cine will demonstrate basic contractile
(Morphology) function.
Tse9_db_t1, #slices 1, slice thickness TrueFISP Cine, All cardiac exams will begin with
5mm, TR 600, TE 24, TA ~11s, Multi-Phase (Function) basic imaging as described above.
TD 50ms, ETL 9, matrix size 256, The radiologist will choose the type
60% FOV 340, Rectangular FOV 82%, tf2d15_norm_HR, #slices 1 multi- of imaging sequences. Once a four
AC 1, BW 305, FA 180. phase, slice thickness 5mm, TR 47.4, chamber view is achieved, the battle
TE 1.58, TA ~11s, ETL 9, is half-won, as those basic images
matrix size 256, 79% FOV 340, will be used for positioning and
Rectangular FOV 82%, AC 1, imaging for the remaining portion
BW 930, FA 60, segments 15. of the cardiac exam.

Discussion Scanner
The imaging sequences used to MAGNETOM Sonata
obtain the four chamber of the heart
are a matter of choice and may vary
from facility to facility. Frequently,
Coils used
cine images are used to work up to
the four chamber, since scan times CP Spine Array Elements 2&3 and
are substantially shorter than in the CP Body Array Elements 1&2
past. The HASTE sequence in the
localizer or morphology protocol tree
will yield 7-15 slices in a breath hold, Software Version
and are also used for multislice
syngo MR 2002B
imaging in any given orientation.

105
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Upper Extremity CE MRA with

CARE-BOLUS Using syngo MR 2002B
Steve Rigsby RTR MR Objective:
Senior MR Application Specialist
■ To perform contrast enhanced MRA of upper extremity from the arch
Siemens Medical Solutions, Inc. to distal portion of a single extremity
USA

Materials used:
■ Siemens MAGNETOM Sonata with syngo 2002B software and panoramic
table option
■ Receive coils used: CP Body Array, CP Spine Array, and the CP large Flex coil.
■ MR compatible power injector **
■ Intravenous catheter **

MR Imaging Protocol:
1. II Scout_lower arm_0mm
3 plane scout with lateral offsets of the sagittal images to include
both forearms
2. I Scout_chest_up arm_350mm
3 plane scout with lateral offsets of the sagittal images to include both
humerii
3. I fl3d_chest_up arm _350mm
3D FLASH coronal sequence
TR: 3.5 matrix: 352x512
TE: 1.2 FOV: 280x400
slice thickness: 1.8 fat sat selected
no. of slices: 52 large FoV filter
4. II fl3d_lower_arm_0mm
3D FLASH sagittal sequence
TR: 4.4 matrix: 416x512
TE: 1.5 FOV: 320x400
slice thickness: 1.4 centric reordered k space filling
no. of slices: 60 large FOV filter
5. Pause for contrast
Trigger for inline pre/post subtraction
6. Carebolus-cor
New inline subtracted gad bolus tracking sequence in the coronal plane
Copy reference “adjust volume” from sequence 3
7. I fl3d_chest_up arm_350
Copy reference "everything” from sequence 3
8. II fl3d_lower_arm_0mm
Copy reference “everything” from sequence 4
106
 CARDIO VASCULAR

Procedure: Figure 1
Patient positioning.
* The patient is placed in the supine
position on the MR table, in a head
first orientation. The patient’s chest is
positioned at the level of spine coil
elements two and three, with the
body array coil positioned parallel to
these coils and off set to the extremity
of interest. Next the large flex coil
is wrapped around the forearm of
interest in a spiral fashion and secu-
red in place with the gray Velcro sequence is opened and this positio- Always choose “Manual”, otherwise
straps. This coil will cover from the ned on the localizer with correspon- the post sequences will perform
elbow to the palm of the hand. The ding table position (0 mm). This tuning functions before actually
“tail” of the coil and the coil interface sequence is set up in a sagittal orien- running the scans, thus losing arterial
box are positioned to point into the tation to remove the possibility of phase and receiving only venous
magnet. The forearm and hand are aliasing from the hip/body anatomy. phase images. Commence the care-
positioned in a sagittal orientation bolus scan. “Online display” will open
(to stop the hips and body from An injection pause is now the next in the exam task card. This sequence
aliasing into the image). The elbow step in the measurement queue. This also has inline properties for auto-
and forearm is supported with pause serves an important purpose. matic subtraction (Maestro Class).
sponges and all coils secured with After the contrast box has been After starting the scan no images will
table straps (Fig. 1). selected on the “pop-up” menu, this appear in the “online display” for
will be the marker to the system that 3-4 seconds as steady state must be
An intravenous line is inserted into sequences of like names to the above reached first to rid inflow artifacts
the unaffected arm. This is now fl3d scans should be “inline” sub- (bright blood with no contrast).
connected to the power injector with tracted and orthogonal MIP images
extension tubing. Once the first image is seen in the
should be created. online display, the contrast should be
Center the laser light to the center of injected. Wait until the contrast
the large flex coil (forearm), then The continue button should be reaches the arch and can be seen in
move the patient into the center of selected, marking everything from the subclavian artery as well, then
the magnet. The patient is registered this point post contrast. select the “stop and continue” icon in
and all sequences moved from the the online display window. This will
above protocol into measurement Next the Carebolus-cor Gadolinium stop the carebolus sequence and
queue at one time. This will enable bolus tracking sequence will open. run the I fl3d_chest_up arm_350
auto copy of parameters and tuning This is positioned over the arch of the and the II fl3d_lower_arm_0mm
adjustments to take place. aorta. At this point a popup window sequences. Thus they will scan and
will ask you to verify if further scan follow the contrast flow down the
The first two scouts will run and the
adjustments should be performed arm as the table moves.
table will automatically move the
“automatically” or “manually”.
required 350 mm as programmed in Each of these post contrast sequences
the sequences. When these are are pre-defined to automatically sub-
Since these adjustments were done
completed the table will be in the tract and create MIPs in the coronal
on the pre-contrast, and also since
chest_upper arm location (350 mm) and sagittal plane. The resulting
the post contrast have “copy adjust
and the I fl3d_chest_up arm_350 images are seen in Fig. 2 and Fig 3.
volume” selected, you do not
pre-contrast scan is positioned on the
need another adjustment. The post-
localizer of corresponding table
contrast sequences have “copy
position (350 mm). This sequence is
references” installed in the parame-
run using a breath-hold technique.
ters to automatically position every-
After this scan is completed, the thing including tuning values from
II fl3d_lower_arm_0mm pre-contrast the pre-scans.
107
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Notes
CARE Bolus package
* The information presented is for
illustration only and is not intended
to be relied upon by the reader
for instruction as to the practice of

Product Info
medicine. Any health care practitioner ■ CARE Bolus for excellent ceMRA
reading this information is reminded with optimum contrast useage
that they must use their own lear-
ning, training and expertise in dealing ■ Fastest switching from 2D to 3D
with their individual patients. This measurements for good results
material does not substitute for that
duty and is not intended by Siemens ■ Centric, elliptical phase reordering
Medical Solutions, Inc. to be used for excellent contrast
for any purpose in that regard.
Figure 2 CP Body Array Coil
** Some of these non-Siemens
devices described in the article may
be pre-product prototypes that
may not have completed US FDA,
European CE Mark or other reviews
for safety or effectiveness that are
necessary prior to commercial
distribution of these devices. Some
devices may not be available in
all countries where Siemens has
systems.

Siemens makes no claims as to the

patient/staff safety, MR compatibility,
or clinical capability of any of the
Figure 3 CP Large Flex Coil non-Siemens devices included in the
article. Before introduction of any
device into the MR suite, the device
should be inspected by qualified
hospital personnel, and the non-
magnetic properties of the device
and its clinical operation in the mag-
netic field verified before it is used in
a procedure. Use of these devices for
animal or human procedures must
comply with any applicable Govern-
mental or local hospital safety and
animal/human studies committee’s
requirements.

108
 CARDIO VASCULAR

FAQs Cardiac Imaging

Michaela Schmidt
Cardiovascular MRI
Advanced Application Specialist
Erlangen, Germany

1. How can I get the best

image quality with dark
blood sequences?
The dark blood (db) pulse is used to
null the blood signal and improves
the image quality for morphological
imaging significantly. It consists
of a non-selective inversion directly
followed by a slice selective Figure 1
re-inversion pulse, played out directly
after the trigger event.
TR – TRmin = waiting period
■ For good image quality, it is
necessary to shift the measurement
to the time in the cardiac cycle when TR min = data acquisition period
the heart has moved back to the
same position it held when the dark In case of poor image quality shift
blood pulse was applied. The measu- the TR in steps of 50 ms in either direction.
rement can be shifted with the
parameter TR (Fig. 1).
Figure 2a TR is too long, there is
■ For patients with long RR-Intervals already signal from the blood
a longer TR is required – but not
higher than 800 ms. For patients
with short RR-Interval a shorter TR is
required.

Figure 2b TR is too short, the slice

which has seen the re-inversion
pulse hasn’t moved back to its origi-
nal position. No signal from the
myocardium.

Figure 2c Optimal TR.

TIP:
When you cannot optimize both the
myocardial signal and the black
blood, the image with better myocar-
dial signal is preferred (TR too long).

109
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

aVR
aVR
(-30 deg.)
(-150 deg.)

I
(0 deg.)

-aVR
(30 deg.)
III
(120 deg.) II
aVR
(60 deg.)
(90 deg.)

2. How can I get a good The projection of the electrical vector of the myocardial activation onto
ECG trace? the body surface depends on the orientation of the heart. The best result is
achieved when the electrodes are positioned along the heart
■ Prepare the skin electrical axis (usually the same as the long axis of the left ventricle)
Clean wet or oily skin with a dry
Figure 4 The heart axis of tall
paper towel and remove hairs. Never
and/or young patients is more likely
use alcohol to clean the skin as this to be vertical.
would remove the electrolytes.
■ Use appropriate electrodes
Do not use old or dry electrodes, or
MR-incompatible electrodes. If you
have to reposition the leads, always
use new electrodes.
Figure 5 The heart axis of older
■ Position electrodes with care
and/or big patients is more likely to
Avoid positioning the electrodes be horizontal.
on the breast muscle, or remote from
the heart.
■ Check the ECG trace
Figure 6 There are two ways of
If necessary, reposition the electro- positioning standard leads.
des until you get a robust signal
with a high and clear QRS complex, Figure 6a shows frontal positioning
and a small flow artifact on the chest which allows better
signal and higher patient comfort
(at location of T- wave).
but sensitive to patient positioning.
Figure 6b is the positioning on Figure 6a
the back which is a bit further from
the heart compared to the frontal
positioning and thus giving less
signal but is not as sensitive to the
respiratory motion as the frontal
positioning. Figure 6b

Figure 7 During positioning of

the active leads you have to keep in
mind that the amplifier can vibrate
during scanning so the ECG leads
should be positioned within the
cushion. On women with large
breasts, the ECG may also be positio-
ned above the breast or directly on
the sternum.
110
 CARDIO VASCULAR

3. How do I perform flow Figure 8 Note the change in signal

quantification measure- intensity in the stationary chest
wall tissue from left to right in the
ments at the Isocenter? off-center image (Fig. 8a), and the
The accuracy of quantitative flow significant reduction of this effect
measurements is improved signi- when scanning at the isocenter
(Fig. 8b). Figure 8a Figure 8b
ficantly by scanning at the isocenter
(Fig. 8).

STEP BY STEP:
A. Perform examination
as usual and position your
slice for flow quantifi-
cation.

B. On the Routine card,

look for the Head-Feet
position (Position mode
LPH) of your slice, note it,
and change it to 0. (Fig. 9)

Figure 9

C. On the System card,

type in the old Head Feet
slice position as new Scan
Region Position. The scan Figure 9
assistant will inform you
that the reference images
will be unloaded from the
GSP. Click OK. (Fig. 10)

Figure 10

D. Start scan

111
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

4. How do I localize the

coronary arteries?

STEP BY STEP:
A. Acquire a multi-slice
TrueFISP localizer

B. On a coronal slice, posi-

tion a transverse HASTE
localizer (Fig. 11). If HASTE
image quality is poor, try
a FLASH sequence with fat
sat. The localizers must be
acquired in the same way
as the subsequent 3D
Figure 11
measurements i.e. in inspi-
ration or in expiration. For
free breathing navigator
measurements, use loca-
lizer in expiration.
RCA LAD
C. On the transverse HASTE
images, position a stack
of coronal HASTE slices
(Fig. 12)

D. Examine the images

and identify the coronaries.
In case you cannot find Figure 12
them, repeat the localizers
with thinner slices (4 mm,
no gap), when you have to
deal with very small arte-
ries. Check the timing of
the HASTE acquisition.

112
 CARDIO VASCULAR

In patients with fast RCA

heart rates, better quality
localizer images might
be obtained with a FLASH
sequence with fat satura-
tion than with a HASTE
sequence (Fig. 13).

Figure 13

Instead of transverse slices,

one can use a stack of
4-chamber views to localize
the RCA (Fig. 14).

Figure 14

RCA
E. It is important to scan
during that period of the
cardiac cycle when the
coronaries are not moving.
The localizer should be
acquired at a similar time in
the cardiac cycle as the 3D
images. In most patients,
the time of least motion is
during diastole (Fig. 15).
CINE

Figure 15

113
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

F. Use the 3 point localizer

to define the orientation
and position of your slab/
slice on suitable localizer
images. It is recommended
to perform first a fast
breath-hold 3D acquisition
to check for correct
Figure 16a
positioning (Fig. 16).

Figure 16b

Figure 16c

114
 CARDIO VASCULAR

G. What is the difference

between prospective
triggering and retrospective
gating?

Prospective triggering
The measurement is driven by the
ECG. Data is acquired after a trigger
signal (R-wave) is detected by the R R
PMU. The acquisition window should
be set about 5-10 % less than the
average R to R interval. Only during
this time is data acquired. No data
is acquired during the time between
the end of the acquisition window
and the next R-wave. Acquisition window Acquisition window
Data acquisition Data acquisition

Acquisition window Acquisition window

Measurement

Retrospective gating
The measurement runs continuously window should be set 10-20% higher
and independent to the ECG.Each than the average R to R interval.
measured line gets a PMU time Advantages: the entire cardiac cycle
stamp relative to the trigger event. can be imaged; the number of phases
The data is sorted after the measure- can be defined by the user and this is
ment is finished. The acquisition independent of the measurement time.

115
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Peripheral MRA with iPAT

R. Banach – Planchamp M.D. system which causes strong enhance-

Institut fur Angiologische – ment with only a little amount of the
Kardiologische Kernspintomo- CM.
graphie, Krefeld, Germany The real revolution in peripheral MRA
was the introduction of iPAT. Slice
thicknesses between 1.7 and 1.3 mm
in plane resolutions ranging from
1.56x1.56 to 1.39x1.25 increases the
certainty in diagnosis of most patho-
logies including renal artery stenosis
In this article we shall discuss practical
(Fig. 1). The very fast table motion
experiences with iPAT technique in
which optimizes the workflow is also
the area of “Stepping Table Peripheral
another positive factor which has
MRA”. Today when we talk about
affected our decision in shifting
peripheral MRA, thanks to the Large
to MRA from diagnostic DSA in the
FoV adapter, we think of a coverage
diagnosis of peripheral arterial
starting from the aorta and reaching
diseases. In addition to the use of
down to the distal vessels of the leg.
non-nephrotoxic contrast material
Our institution has possessed and the absence of radiation, MRA
a MAGNETOM Sonata system since images also allow 3D post-processing
December 2001. In an environment so that oblique projections can be
where different clinical departments generated and vessel diameters in
make use of the system, the major stenosis can be more accurately
use of the system has been for cardio- measured. Only a very little amount
vascular imaging. It is a pleasure here of CM that passes through sub-total
to say that thanks to the very convin- stenosis is required for a detailed
cing image quality from day one, the visualization of the distal segment,
1200 bed “Klinikum Krefeld” – our whereas in such situations DSA is
major clinical partner – has replaced generally unsuccessful (Fig. 2). A
diagnostic digital substraction angio- certain amount of information about
graphy (DSA) with MRA. This decision plaque composition can also be
has of course been influenced by the obtained. Target organs like the
fact that MR is a modality without kidneys can also be evaluated with
any x-ray exposure. 3D techniques.
We have been using Gadovist 1M The success of MRA is dependent on
(Schering, Berlin) which allows use of the coordinated efforts and works of
a smaller amount of bolus in compa- clinicians, surgeons and radiologists.
rison to the 0.5 M contrast medium. The surgeon who is to operate has to
It is also worth mentioning here that understand the details of this cross
the control of the CM is a little bit sectional imaging technique and
difficult with 1M. For most applica- related post-processing, where the
tions, a small amount of Gadovist in need for radiological experience is
MRA allows the visualization of apparent.
distal and collateral vessels in cases
of complete occlusion and severe
stenosis. Timing errors, hyperemia or How do we achieve this?
slow table movement can cause an
overlapping signal from the venous MRA has been in routine radiological
system. The high concentration of practice for quite a long time. One Figure 1 Peripheral MRA covering
Gadovist has the same impact in the of the most important challenges of from aorta to distal vessels showing
venous system as in the arterial this application is the prevention of left renal artery stenosis.
116
 CARDIO VASCULAR

venous enhancement which creates

an obstacle by the overlapping of
veins over arteries. This carries more
importance in peripheral MRA exami-
nations where you have to follow
the contrast bolus. This can only be
achieved by fast table motion and
shorter acquisition times. Another
important factor is that the sequences
for distal parts should have the ability
to measure the central Fourier lines
first, followed by the peripheral lines
which will also help obtaining arterial
information in a timely manner.
3D data can be obtained between
10 and 20 secs. The contrast arrival
time can be estimated by test bolus
techniques, or another solution for
timing is to use the real time CARE-
Bolus technique. The first step of
the angiography is the decision point
for Care Bolus, which is the aorta in
our peripheral MRA examination.
This means that after real-time
Figure 2a/b Peripheral MRA showing multiple occlusions and distal filling visualization of the arrival of the CM
through collaterals. and filling of the aorta, the examina-
tion is commenced with an auto-
matic scan of 3 or 4 sequential steps.
The examination time for each
region is 15-20 secs. The distal leg is
scanned in 40 to 50 secs from the
start of the examination, which is
generally sufficient for viewing the
“only arterial” phase. Whenever the
circulation time of the patient is
shorter or there is early venous
enhancement due to arterio-venous
shunts (especially with infections in
extremities), you need shorter scan
times. With 2002B Software, there is
increased speed in table motion and
iPAT also decreases the examination
Figure 2c/d/e show the same patient’s DSA results.
time by 50%, which helps provide a
more accurate diagnosis.

iPAT in Peripheral MRA

In contrast to traditional sequential
measurement techniques, mSENSE
and GRAPPA are parallel imaging
techniques. The spatial resolution of
117
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

the image is no longer determined patients with contractions which do

solely by the acquired, gradient- not permit the placement of coils are
encoded echoes. With mSENSE and also unable to be examined with MR.
GRAPPA, additional spatial informa-
tion is obtained from the spatial
variation in the coil intensity profiles
during measurement with array coils. Patient Preparation
Thus, fewer echoes are measured
with mSENSE and GRAPPA than would The patient has to be comfortable
be needed to obtain the desired but at the same time must not move:
resolution with a traditional technique. this is very important as motion
In simple terms, this is nothing more artifacts can cause additional diagno-
than a measurement with a rectan- stic problems. We use the combina-
gular field of view (RecFOV). The tion of CP Peripheral Angio Array Coil,
only “trick” with mSENSE and GRAPPA CP Body Array coil and CP Body Array
is the elimination of the aliasing that Extender. The use of Large FoV-
occurs with traditional techniques. Adapter allows the extended coverage
This is the result of the additional of the aorta. For iPAT applications it is
information that one can gain from important that there should be a
the intensity profiles of the individual gap between the examined part and
coils during measurement with array the array coils, so we use flat cushions
coils. between and under the coils. Anxious
patients should be sedated. We also
In peripheral MRA, we prefer
use spasmolytic agents to prevent
GRAPPA as it is less sensitive to fold-
bowel motion artifacts which can
over (aliasing) artifacts.
hinder diagnosis in the abdominal-
pelvic area. The use of elastic material
above the ankle joint to prevent the
Indications filling of superficial veins can cause
early filling of the deep venous
Indications for peripheral MRA are all
structures which is very difficult to
arterial diseases, including fistulas
get rid of in post-processing. We
and postoperative states. For the
generally prefer the cubital vein
planning of MRA it is very important
access and inject 15 ml Gadovist with
to know about existing bypasses like
an injection rate of 0.7 ml/sec and
femoro-femoral or more important
follow this with 20 ml NaCl at the
axillo-femoral bypasses which have
same rate. The patient condition
to be included in the scout images:
must always be kept in mind: for
additional slices or oblique projec-
example, the injection rate must be
tions may be required. Furthermore,
higher in patients with heart failure.
certain stents should not be confused
Use of 1M in comparison to conven-
with stenosis or occlusion due to
tional CM will allow you to decrease
the signal loss created by metallic
the volume injected, as mentioned
artifacts (Fig. 3).
before it is a little difficult to control
We prefer to allocate part of the day injection and optimum enhancement
for the examination of peripheral with 1M agents. Of course the bolus
angiography patients and our depart- time will be extended due to the
ment employs two technologists circulation through the heart and
dedicated exclusively for this exami- pulmonary circulation. Here you
Figure 3 Stents in the right common nation. In addition to the usual must be very careful with the timing
iliac and left external iliac arteries. contra-indications for MR, such as and we advise you to start scanning
pacemakers and stimulation systems, after optimal filling of the aorta.
118
 CARDIO VASCULAR

Examination

The Siemens protocols are directly

applicable in routine practice with
just patient-specific small changes
and they allow the examination of
each step in 8-10 secs with an iPAT
factor 2, which is almost twice the
speed of conventional techniques.
The inclusion of all vessel segments
Figure 4a Y prothesis and femoro-popliteal by-pass on the right side. is sometimes difficult due to bypas-
ses (Fig. 4) and sometimes at the
pelvic level the iliac arteries can make
a deep curve. In both situations
you need to add additional slices and
maybe change the number and
orientation of the ToF 2D scout slabs.
Particularly in patients with aneu-
rysms, we use additional TrueFISP
sequences at each level to be able to
show the thrombosis and vessel wall
in detail. With Care Bolus technique
in patients with aneurysms it is
important that the para-sagittal slab
also covers the parts distal to the
aneurysm so that you can adapt your
timing to the delays caused by CM
pooling in these aneurysmal sacs
(Fig. 5).

The Care Bolus technique allows real

time observation of the arriving
contrast bolus and it would be wise
to place the coronal slab over the
whole aorta including part of the
heart. You should commence with
breathing orders as the right ventricle
and pulmonary arteries fill with
contrast. The examination should
start when you see the filling of the
aorta. In the Siemens protocol tree
with “Care Bolus”, the sequences for
Figure 4c Y prothesis and occlusion the distal leg vessels are centrically
of the left superficial femoral artery
reordered which allows you to hinder
venous filling. These centrically
reordered sequences might also be
used for examination of other vessels
where the early filling of venous
structures might cause problems:
a good example would be the hand
Figure 4b Crossover by-pass vessels.
119
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

Figure 5 Aneurysm of distal aorta and iliac vessels.

Post-processing Initially, we always kept in touch with Future Directions

our vascular surgeons and referring
Post-processing includes the steps clinicians in order to develop a iPAT has been a giant step in MRA of
of subtraction, volume rendering or common way for evaluating and the peripheral vessels as, thanks to
MIP. The detailed evaluation of grading stenosis. They were used to its speed, venous overlap seems not
suspicious areas, such as stenosis DSA images and we had to find a way to be a big issue in examination of
evaluation, may be achieved by to encourage them to understand the aorta, iliac vessels, femoral and
dedicated MPR and volume rendering the MRA results in line with their distal vessels. Of course, in the future
techniques (Fig. 6). Another step in previous experiences. Accordingly, we anticipate solutions very similar
evaluation could be the stent size we had and still have regular consul- to DSA practice today, which means
planning by an exact measurement tations with our clinician colleagues that each step is triggered after the
of the vessel’s diameter and the where we compare the DSA results arrival of the bolus and starts scan-
length of the stenosis by state of the with those of MRA. Our grading is as ning centrically allowing real-time
art post processing tools like “Vessel follows: non-stenosing plaque- evaluation of the anatomical area.
View”. A useful tip would be that minimal – middle – high grade The greatest problem we face today
total dependency on post-processing stenosis and total occlusion. High- is due to possible motion artifacts
results is not the right way to go as grade stenosis should be evaluated caused by the time difference between
there is very useful information in with 2D ToF sequences to be able to the non contrast enhanced images of
raw data images which can be over- see the minimal flow through those each step and the contrast enhanced
seen only by looking at the MIP stenotic areas and its direction. images (in MRA each step is scanned
images. Another advantage of raw
first without contrast, then the table
data images is that they allow you to
Other Applications returns to its original position and
see plaques and thrombosis which do
after contrast injection the examina-
not cause any stenotic changes in the iPAT with moving table might also be
tion starts with the arrival of the
MIPs. Peripheral structures seen by used for the evaluation of the upper
contrast and followed by automatic
raw data images will also bring useful extremity. Dynamic MRA with iPAT
movement of the table). A motion
information, especially in the abdo- can be used to evaluate the circula-
correcting post processing algorithm
minal-pelvic area where there might tion in the pulmonary vascular
based on 3D pixel shift would be
be hidden pathologies in the kidneys system. Showing perfusion characte-
extremely useful.
or liver. ristics in aortic dissections and evalu-
ation of dialysis shunts are other
possible applications.
120
 CARDIO VASCULAR

Figure 6 Volume rendered images from peripheral MRA examination.

Institut für
Acknowledgements: Angiologische –
I would like to thank our technicians Kardiologische
A.Hünnekens, W.Kaartz, M.Nitsche, Kernspintomographie,
N. Zimmermann and of course Krefeld, Germany
W.Chwilka.

PD Dr. V. Fiedler,
Image examples: examinations Diagnostic Radiology
were performed with the combination Prof. Dr. HG. Klues,
of CP Body Array, CP Body Array Internal Medicine/Cardiology
Extender, CP Peripheral Angio Array Dr. R. Banach – Planchamp,
Coil, Large FoV Adapter and CP Spine Diagnostic Radiology
Array Coil. At each step the phase
Dr. R. Ott,
encoding direction was from right to
Internal Medicine/Cardiology
left. The PAT factor was chosen as
2 to minimize the examination time
to approximately half that of routine The Institute for Cardiovascular
exams. Each table movement was MRI was established on December
333 mm, FoV 380-400mm. 12, 2001.
4 different table positions with
3 table motions are preferred. For The objective of this private
the abdomen, Body Array Elements initiative was to install the latest
Figure 7 Dynamic MRA showing
anomalous drainage of upper veins 1-2 and spine elements 3-6 were generation magnetic resonance
of the lung into superior vena cava. chosen. For the pelvis, Body Array imaging (MRI) system in Krefeld.
Elemets 3-4, Spine 3-4 and PR 3-4 In addition to patients from private
and PL 3-4 were chosen. For upper practice, patients from the hospital
Future developments in technology leg PR 2-4 and PL 2-4 and lower leg in Krefeld are also being examined
will hopefully allow high resolution PR 1-2 and PL 1-2 were chosen. in the institution, enabling all to
examinations of the micro and benefit from this latest diagnostic
macro-angiopathies in the hands and technology.
feet.
121
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

MAGNETOM World Summit

South Beach, Miami Agenda

September 17–19, 2003
MAGNETOM World Summit 2003, South Beach, Miami

Wednesday, September 17th

06:00–8:00P.M. Welcome Reception

Thursday, September 18th

07:30–8:30 A.M. Breakfast

08:30–9:30 A.M. Opening

Block A: 3 T Imaging
09:30–10:00 A.M. 3T Clinical Imaging
(incl. Orthopedics)

10:00–10:30 A.M. Safety in 3T Imaging

10:30–11:00 A.M. Coffee Break

Block B: Neuro Imaging

11:00–11:30 A.M. Trends in Neuro Imaging

11:30–12:00 A.M. iPAT Neuro Applications

12:00–12:30 P.M. Spectroscopy in Clinical Practice

12:30–1:30 P.M. Lunch

Block C: Cardiac Imaging

01:30–2:00 P.M. Cardiac Viability

02:00–2:30 P.M. Radiologists and Cardiologist –

Working Together

02:30–3:00 P.M. Self-Gated Cardiac Imaging

03:00–3.30 P.M. Coffee Break

Block D: Business Models

03:30–4:00 P.M. Optimizing Clinical Throughput

04:00–4:30 P.M. Tech, Tips & Tricks for Optimizing

Clinical Throughput

04:30–5:00 P.M. Whole Body Screening

05:00–5:30 P.M. Technology – Parallel Imaging –

Benefits

05:30–6:00 P.M. Outpatient Imaging

(Non-Hospital Segments)

07:30–11:00 P.M. Evening Social

122
Friday, September 19th EVENTS
07:30–8:30A.M. Breakfast
Block E: Body Imaging
08:30–9:00 A.M. Pediatric Imaging

09:00–9:30 A.M. Tech, Tips & Tricks (Pediatric Imaging)

09:30–9:45 A.M. State-of-the-art in Breast Imaging

09:45–10:00 A.M. Advances in Breast Imaging with iPAT

10:00–10:30 A.M. Coffee Break

10:30–11:00 A.M. Angiography in Clinical Practice

11:00–11.30 A.M. Musculoskeletal MR

11:30–12:00 A.M. Virtual Colonoscopy

12:00–1:00 P.M. Lunch

01.00–1.30 P.M. iPAT Imaging in Clinical Practice

01.30–2.00 P.M. Perfusion of Kidneys and Lung

with MRI
✂

Registration Form
Please complete this form below. If several people from your institution will be
participating, please complete this form for each attendee. Forms must be
received before July 20, 2003. You may either fax it to 610-448-1534 or mail it
to Raya Dubner, Siemens Medical Solutions, USA, Inc., 51 Valley Stream Park-
way, Malvern, PA 19355, USA.

(Please Print Clearly)

Name:

Title:

Institution:
Terms & Conditions
Mailing Address (Include Country): Upon submission of the registration form
attached, or completion of registration
through SiemensMedical.com/MAGNETOM-
World, you will automatically be registered
for the MAGNETOM World Summit 2003
Meeting on September 17–19, 2003, in South
Telephone (Include Country Code): Beach, Miami.

You do not have to call the hotel to reserve

E–mail address: a room, it will automatically be reserved for
you.
Will you be bringing a guest
Please register no later then August 1, 2003.
❏ YES ❏ NO If you need to cancel, please do so by August
31, 2003.
Arrival Date: Departure Date:

❏ Single Occupancy ❏ Double Occupancy

Name of roommate, if also Ambassador attendee:

Please indicate specific issues that you would like addressed by

Siemens during this session:

123
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

20 Years of Development and a Constantly

Improving Performance = MAGNETOM
Peter Kreisler, Ph.D. An 0.2T prototype system was more than a year. One interesting
Collaborations and Applications , the first Siemens MR to be installed in developmental step was the intro-
Erlangen, Germany a clinical environment. The system – duction of a magnet system with an
based on a resistive 0.2T magnet – integrated helium liquefier: the
was installed at the Medizinische Helicon. However, because of new
Hochschule of Hanover (MHH), magnet designs and helium saving
Germany. In 1983, the first developments, the direct integration
MAGNETOM with a super-conducting of a liquefier turned out to be no
0.35T magnet was delivered to the longer economically beneficial and
Mallinckrodt Institute in St. Louis/ the development was discontinued.
USA. This system was the first Today’s magnet trends are towards
member of a product family that has increased openness, lower helium
increased in size and in technical and consumption and lower total costs.
clinical performance.
Let’s look at some of the components
and subsystems.
Space requirements
The magnet’s fringe field is one of
the parameters that define the space
Magnets requirement of an MR system.
Another parameter is the amount of
The early super-conducting magnets
hardware needed. The first systems
Figure 1 The first MR image from were relatively large (2.55 m long)
in the 1980s comprised a total of 12
Siemens: Red pepper and heavy (~8 tons for 1.5T), they
cabinets fully packed with electro-
had a large fringe field since they
nics. As we all know from the revolu-
Working in the field of MR for almost were not shielded at all, and they
tionary changes in computer techno-
20 years, it has been really impressi- required very frequent liquid gas
logy, electronics became integrated
ve to see the developmental steps refills (nitrogen every two weeks and
to a very high degree. The entire
that have taken place over this time. helium every 6 weeks). Over the
system electronics and supplies can
Siemens’ involvement with MR years passive iron shielding was
be put into two cabinets today, with
development began in the late introduced – with weights of 21 t
a much higher performance than in
seventies, but it was the first images and 31 t (Fig. 2); active shielding was
the past.
of a red pepper in1980 which were created; the magnets became smaller
to some extent the “starting signal” and lighter; additional nitrogen was
to set Siemens off to a flying start in no longer needed and the refill
intervals for helium were extended to
Gradients
the field of MAGNETOM product
development (Fig. 1). The gradients used for spatial
encoding – as for several contrast
mechanisms – are one of the essen-
tial components for MR imaging.
Tremendous improvements have
been developed and implemented
over the last two decades.
The following table summarizes the
main steps.

Figure 2 Magnets with passive

shielding. 21 t or 31 t of iron was
needed to reduce the magnetic
fringe field.
124
 TECHNOLOGY CORNER

2003
MAGNETOM Trio

MAGNETOM Maestro Class

MAGNETOM Rhapsody

MAGNETOM Harmony, Symphony,

Sonata (syngo based), Concerto

MAGNETOM Allegra

MAGNETOM Harmony, Symphony, Sonata

MAGNETOM Vision Plus, Open Viva

MAGNETOM Impact Expert

MAGNETOM Vision, Open

MAGNETOM Impact, P8

MAGNETOM SP and SP 4000

1983

MAGNETOM 42/63 (GBS 2)

MAGNETOM M/H (GBS 1)

0.2T Prototype
125
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

1983 RF System Some of you will remember the

manual tuning of these special coils
MAGNETOM M 3 mT/m 1.5 ms The first units were delivered with an with the two long sticks, whilst
integrated body coil and a head coil – staring at the small digital display.
1986 nothing more. Knowing that a higher
MAGNETOM SP 10 mT/m 1 ms signal-to-noise ratio was essential All these coils were based on an
for the future success of MR, our LP (linearly polarized) design. With
1991 MAGNETOM 42 and 63 (GBS2
physicists and engineers started the
MAGNETOM Vision development of dedicated surface systems), CP coils (circularly polari-
25 mT/m 0.6 ms coils and smaller volume coils: they zed) were introduced, with a gain in
created the 10 cm eye/ear coil (Fig. signal-to-noise of 40%. In 1991, the
1999 first prototypes of array coils were
3), a breast coil and an extremity coil,
MAGNETOM Sonata delivered, a development which
and a spine coil would follow. also
40 mT/m 0.2 ms resulted in the Integrated Panoramic
soon be available.
1999 Array (IPA) concept, introduced with
MAGNETOM Harmony and Symphony
MAGNETOM Allegra (Fig.4). And today, the IPA coils
40 mT/m 0.1 ms form the basis for the parallel imaging
techniques like mSENSE and Grappa
And the development continues. which are now integrated into the
In 2002, the prototype of a gradient MAGNETOM Maestro Class product
insert coil, especially for head and line.
small animal studies, has been
created with a gradient strength of All these developments have helped
80 mT/m and a rise-time as short as to broaden the range of applications
0.1 ms (800 T/m/s). by increasing the signal-to-noise
and/or by increasing the speed of the
Figure 3
examinations.

Even more important than these

horse power numbers are the impro-
ved and advanced applications that
became available based on this
powerful hardware. Think about the
fast imaging techniques in ce-MRA
and abdominal imaging, think about
EPI in diffusion weighted scans,
or look at all the “bread and butter
scans” – like the fast T2-weighted
sequences routinely used today. Figure 4 IPA Coil Combinations, iPAT compatible!

126
 TECHNOLOGY CORNER

Computer configuration variability between the human using Gadolinium-based contrast-

and data handling tissues, and additional contrasts and agents and CARE-Bolus techniques. A
parameters are used for diagnosis. 3D scan of the carotid arteries takes
As already mentioned, computer only a few seconds. Dynamic angio
development has been terrifically Scan times were rather long in the
scans can be performed with good
fast. This has also been reflected in early 80’s. A T2 weighted scan using
temporal resolution. Today, MR-
the changes of the computer confi- a spin-echo sequence took easily
Angio is applied from head to toe.
guration in the MAGNETOM systems: a quarter of an hour. All developers
sought faster sequences. Let’s look at Over the years, therefore, Siemens
VAX11/730 and VAX 11/750 together some steps: has been the first to develop unique
with a BSP11 image processor in the sequences and imaging techniques
GBS1 systems, MicroVax2 and later that increased speed and resolution,
Microvax 4000 in the MAGNETOM SP 1983: or offered new contrasts or new
systems, then replaced by Sparc2 and applications, such as MP-RAGE, CISS,
turboSparc in combination with the Spin Echo
DESS, HASTE and TrueFISP.
SMI 5 for fast image reconstruction 1985: And finally, let’s not forget spectros-
and today the combination of high
Half Fourier copy, the oldest MR technique.
performance PC systems with GHz
Spectroscopy has been a tool for
processors. 1987: chemical research since the 1940’s.
Just remember the increase in speed Gradient Echoes FLASH and FISP And the MAGNETOM systems offered
for the image reconstruction by using spectroscopy capabilities almost
the 2D Fourier transformation.
1989: from the start. In 1984, 1.5T
1984: 6.8 seconds per image in full Turbo-FLASH MAGNETOM systems allowed phos-
2562 matrix, and today less than 6 ms. phorus spectroscopy, in 1985 a
1990: sodium head coil was available as a
Or consider the amount of data Turbo Spin Echo product together with sequences for
generated. In 1983, typically much imaging, and shortly after fluorine
less than 100 images per patient spectroscopy was put into the
were measured. The images were followed by hybrid-techniques like product. Today, clinical spectroscopy
filmed with analog monitor based Turbo Gradient-Spin-Echo, and the is mainly done with hydrogen pro-
cameras like the MULTISPOT M. Some single shot techniques , tse240, tons, but there is still a lot of interest
of the “most interesting” images HASTE, segmented gradient-echo in the use of other nuclei. To bring
were stored digitally on a floppy disc sequences, and finally EPI. spectroscopy to clinical routine, its
(three images per side). Today hund- use – scanning and post-processing –
reds to thousands of images are the In the meantime, EPI has become an
must be easy. With the syngo based
result of a complete patient examina- indispensable tool in brain-imaging
software, a lot of effort has been
tion with new challenges for proces- and brain-research. The single
put into a stream-lined workflow for
sing, networking and archiving. shot scan times can be cut down to
spectroscopic examinations.
less than 50ms for a single image.
Overall, we can look back over twenty
Or remember the steps in MR-Angio-
Sequences years of exciting and fascinating
graphy, starting in 1985/86 with
developments. And we are looking
FLASH2D for sequential slice-by-slice
The NUMARIS software for the first forward to further developments that
measurement in a time-of-flight
MAGNETOM system enabled the user will make the future even more
manner. The technique became
to perform Spin-Echo measurements exciting.
extended to 3D, to automized 3D
– T1 and T2 weighted – and T1
multi-slab and to the faster Turbo-
weighted Inversion-Recovery scans.
MRA. No contrast agent is required.
Virtually from the start, quantitative Nevertheless, the MR-angio scan of
T1 and T2 calculations could be the carotids typically took more than
performed, hoping that by knowing 10 minutes. And now? More and
T1 and T2, all tissue types were more MRA scans are performed with
characterized. But there is a larger fast 3D-gradient-echo sequences,
127
www.SiemensMedical.com/MAGNETOM-World
 MAGNETOM FLASH

1983

128
 TECHNOLOGY CORNER

2003

129
www.SiemensMedical.com/MAGNETOM-World
MAGNETOM FLASH

130
free of charge +++ free of charge +++ free of c

Order your personal MAGNETOM FLASH

magazine for one year
Your subscription is free.
Please complete the form below
and fax it today!

Issue no. 1.2003

MAGNETOM Fax-Answer:
F L A S H
+49-9131-84-2186
Yes, I would like to order the MAGNETOM Flash magazine
for one year free of charge.

Name:

MAGNETOM World Meeting

Sheraton Perdana Hotel
Langkawi, Malaysia
17.-18. Jan 2003
Title:

s
medical Institution:

Department:

Street:

Postal Code/City

Country:

E-mail:

MR-Systems in Institution
Siemens AG Medical Solutions
Yes, I consent to the above information being used for future contact regarding
Magnetic Resonance, MRM Blue product updates and other important news from Siemens Medical Solutions.
Team
Henkestrasse 127
D-91052 Erlangen
Germany Date Signature
MAGNETOM FLASH

The information in this document contains general

descriptions of the technical options available, which
MAGNETOM Flash –
do not always have to be present in individual cases. Reader Service
The required features should therefore be specified in Letters to the Editor – We welcome your comments
each individual case at the time of closing the contract. about the content of MAGNETOM Flash. Please send
comments to the Editor. Include your name, address,
and phone number or e-mail.
Siemens reserves the right to modify the design and
specifications contained herein without prior notice. World Wide Web – Visit us at
Please contact your local Siemens Sales representative www.siemensmedical.com and
for the most current information. www.siemensmedical.com/MAGNETOM-World
This sites provides information about all Siemens
Original images always lose a certain amount of detail
medical products.
when reproduced.
Publish articles? – You are invited to publish articles in
This brochure refers to both standard and optional
the newsletter to share your experience with
features. Availability and packaging of options varies by MAGNETOM MR users all over the world. To submit an
country and is subject to change without notice. article please contact the Editor.
Some of the features described are not available for
commercial distribution in the US. Subscription – You have seen the newsletter and want
to get it on a regular basis? In the US, please contact the
Applications Helpline (phone 800-888-SIEM) and give
Please contact in the USA: us your name and business address (no home
Siemens Medical Solutions USA, Inc. addresses, please). Outside the US, MAGNETOM Flash is
distributed through the local Siemens offices. Please
51 Valley Stream Parkway contact the Editor and we will make sure that you are
Malvern, PA 19355 included on your local support office’s distribution list.
Tel.: +1 888-826-9702 Editor
Tel.: 610-448-4500 Ali Nejat Bengi, M.D, [email protected]
Fax: 610-448-2254 Published by
Siemens AG Medical Solutions
in Asia: P.O.Box 3260, D-91052 Erlangen

Siemens Medical Solutions Correspondence and

Asia Pacific Headquarters International Distribution
Ali Nejat Bengi, M.D., Editor in Chief
Blk 28 Ayer Rajah Crescent #06-06
MAGNETOM FLASH
Singapore 139959 Siemens AG Medical Solutions,
Tel.: +65 6341 0990 MR Marketing
Allee im Röthelheimpark 3
Fax: +65 6778 6722 D-91052 Erlangen
Phone: 49 - 91 31 - 84 - 75 99
in Japan: Fax: 49 - 91 31 - 84 - 21 86

Siemens-Asahi US Distribution

Medical Technologies Ltd. MR APPLICATIONS HELPLINE

Siemens Uptime Service Center
Takanawa Park Tower 14 F 110 MacAlyson Court
20-14, Higashi-Gotanda 3-chome Cary, NC 27511
Shinagawa-ku Phone: 800 - 888 - SIEM
Fax: 919 - 319 - 28 64
Tokyo 141-8641
All articles represent the techniques and opinions
(03) 54 23 40 01
of the authors and may not represent specific
recommendations or endorsements from Siemens
Or contact your local Siemens Medical Solutions. Contact the authors directly for
further information about their techniques and
Sales präsentation opinion.

Siemens AG, Medical Solutions

Magnetic Resonance
Henkestr. 127, D-91052 Erlangen,
Germany
Order No. A91100-M2220-F000-4-7600
Telephone: ++49 9131 84-0 Printed in Germany
www.SiemensMedical.com CCA 60000 WS 050320.