LUMBAR SCANNING & ABDOMEN SCANNING

When imaging the abdominal organs, the use of breath-holds or respiratory gating
is necessary, due to the constant motion of the abdomen from patient respirations.
Faster imaging techniques typically allow for scan performance in a single breath-
hold. Expiration is preferred, as the position of the organs (at least the kidneys)
remains more constant on expiration, as compared to inspiration. The Breath-hold
field is located on the Dynamic tab on the Altaire, AIRIS Elite, and AIRIS II systems.
Once the Breath-hold field is set to On, a Timing field becomes available, where the
technologist can insert a pause before the First acquisition, or before Every
acquisition. The technologist can perform breath-holds manually, by giving
instructions to the patient each time using the microphone. Some systems have the
Auto Voice option, which is selected in the Voice field on the Others tab. The specific
breathing instructions and their timing can be selected in the Auto Voice Set Tool.
These instructions will be automatically relayed to the patient when both the
Breath-hold field and the Voice field are selected.
On the Oasis, Echelon, and Echelon OVAL systems, breath-holds can be acquired by
setting the Wait mode field to ON. This field is found under the Scan Control section
of parameters. Breath-hold instructions can be given manually, by speaking to the
patient over the microphone each time, or Auto Voice may be used. The Auto Voice
Setting window can be found under the System Settings launcher button. Breathing
instructions and timing settings can be selected and saved with specific names.
Saved selections are displayed in a dropdown listing for the Auto Voice field, which
is also found in the Scan Control section.
If your patient is unable to perform breath-holds, or your scan time precludes the
use of breath-holds, respiratory gating can be used. The patients expirations trigger
the sequence acquisitions. The respiratory bellows must be positioned and secured
on the patient before scanning begins. The respiratory waveform is monitored to
acquire the average respiratory rate. The average number of respirations is then
input in the Beat Rate field under the Gating section of parameters, or on the Gating
tab. Numerous additional Gating parameters can be manipulated.
Respiratory gating equipment for the Altaire, AIRIS II, and AIRIS Elite systems
consists of a respiratory sensor, respiratory belt, and respiratory sensor tubing, as
seen in Figure 1. Briefly observe the patients breathing to determine proper
placement of the respiratory belt and sensor. The belt must be tight enough so the
sensor can react to the patients breathing, but not too tight as to constrict the
patients breathing. One end of the respiratory sensor tubing is plugged into the
respiratory sensor, and the other end is plugged into the monitoring module on the
MRI system. The Waveform window should be open to monitor the respiratory
waveform before scanning begins (Figure 2). This is done to ensure proper
placement of the respiratory gating equipment on the patient, as well as to ensure
proper working order of the equipment, resulting in a strong, steady signal.
Respiratory gating equipment for the Oasis and Echelon systems consists of
respiratory bellows, a respiratory belt, and a respiratory hose, as seen in Figure 3.
Briefly observe the patients breathing to determine proper placement of the
respiratory bellows and belt. The belt must be tight enough so the bellows can react
to the patients breathing, but not too tight as to constrict the patients breathing.
The respiratory hose is plugged into the monitoring module on the MRI system. The
Waveform window should be open to monitor the respiratory waveform before
scanning begins (Figure 4). This is done to ensure proper placement of the
respiratory gating equipment on the patient, as well as to ensure proper working
order of the equipment, resulting in a strong, steady signal.

TIGRE is a grouping of scan parameters that results in a fast T1-weighted 3D RSSG

sequence with fat suppression. It is available on the Echelon, Oasis, and Echelon
OVAL systems. TIGRE delivers high spatial resolution, as well as high temporal
resolution, and is outstanding when used for dynamic, contrast-enhanced imaging
of the abdomen (Figure 10). The use of a segmented fat sat pulse maintains fat
suppression throughout the scan. TIGRE also uses an echo allocation method called
TPEAKS (Triggered Peak Enhancing Artery K-space filling Sequence). This method
involves the filling of k-space in an elliptic centric fashion, which ensures the
consistent capturing of the critical arterial phase of contrast enhancement.

When positioning a patient for an abdominal exam in an open MRI system, it is

important to consider the choices you have for coil selection and patient setup.
Positioning that will result in both the coil and the anatomy at isocenter in all three
planes will have a positive impact on the image quality of your study.
Components of positioning to consider include coil selection, table pads and
accessory pads, and proper laser light centering. Coil selection will be influenced by
the patients size and body habitus. The extensive inventory of table and accessory
pads should be used for proper centering, as well as patient comfort and stability
(Figure 11). The use of trough pads and thick or thin table pads are keys to
achieving coronal centering of both the patient and the coil. When scanning on open
MRI systems, it is extremely important to center the anatomy of interest in the laser
lights (Figure 12) in all three directions: head-to-foot (axial or transverse plane),
right-to-left (sagittal plane), and anterior-to-posterior (coronal plane).

The coil of choice for a study of the liver, pancreas, or kidneys is the RAPID body
coil. Fit the base of the coil in the table trough. The longitudinal center mark on the
coil will be centered at the midline of the table. The horizontal center mark on the
coil should be between the marking on the patient table and the end of the table
nearest the magnetic field. This will allow for sufficient table travel while still
achieving isocenter positioning. The patient should be positioned supine on the
base portion of the coil, with their midline aligned with the longitudinal center mark
on the coil. A point approximately three fingers below the patients xiphoid process,
at the lower costal margin, should be aligned with the horizontal centering mark on
the coil. Coil pads, as well as table pads and sponges, can be added to or removed
from the coil to maintain the patient in the center of the coil in the coronal plane.
Coronal centering is especially important for MRI of the kidneys, as these organs are
retroperitoneal, and lie posterior to the liver and pancreas. The upper portion of the
coil is then placed on the base and pushed firmly into place to lock the coil (Figures
17 and 18). The patient should now be centered in all three planes - centered on the
middle of the abdomen in the coronal and axial planes, and centered midline in the
sagittal plane.

The flexible body coils can be used for abdominal scanning to accommodate larger
patients. However, they do not have RAPID capabilities, and should not be used with
protocols that are labeled as RAPID. Trough and/or table pads should be placed on
the table to help center the flexible coil in the coronal plane. The horizontal center
of the flexible body coil should be between the marking on the patient table and the
end of the table nearest the magnetic field. This will allow for sufficient table travel
while still achieving isocenter positioning. The longitudinal center mark on the
bottom of the coil should be aligned with the sagittal laser light. The patient should
be positioned supine on the coil, with their midline aligned with the longitudinal
center mark on the coil. A point approximately three fingers below the patients
xiphoid process, at the lower costal margin, should be aligned with the horizontal
centering mark on the coil. Depending on the patients body habitus, table and/or
accessory pads may have to be adjusted to maintain coronal centering. Close the
flexible body coil around the patient and secure the latches. Accessory pads can be
placed between the flex coil and the patient to maintain the anterior portion of the
coil in a level position, which will minimize stress on the latches (Figure 19). Table
straps may be used to further secure the flexible coil. The patient should now be
centered in all three planes - centered on the middle of the abdomen in the coronal
and axial planes, and centered midline in the sagittal plane (Figure 20).

Liver
MRI may be requested for: Detection and characterization of benign lesions
Metastasis
Hepatocellular carcinoma
Status of chronic liver disease

Green - psoas muscle

Yellow - descending colon
The portal veins are demonstrated as a signal void on most standard pulse
sequences.
Transverse views more informative because of anatomic landmarks and
relationships

1, Liver.2, Superior mesenteric vein.3, Inferior vena cava.4, Left renal vein. 5,
Abdominal aorta. 6, Superior mesenteric artery.7, Right kidney.8, Left kidney.
9,Spleen. 10, Colon.

1umbilicus 2UB 3sigmoidcolon 4rtlobeofliver 5bodyofpancreas

Abscess, AAA
Renal cell carcinoma, Hepatic Hemangioma
Hemangioma
- m.c. benign tumor of liver; benign vascular tumor
- m.c. found in posterior segment of right hepatic lobe; m.c. in women
- initial image: peripheral discontinuous nodular contrast enhancement
- delayed images: more uniform contrast enhancement of lesion
- T2 weighed MR image: very bright

Cirrhosis
Small, nodular liver with cirrhosis;enlarged spleen from portal hypertension.
Cirrhosis may lead to a decrease in the superoinferior span of the liver, as well as
caudate lobe hypertrophies (Figure 37). Over time, jaundice and portal hypertension
may result. Jaundice, an accumulation of bile pigment in the blood stream, can be
caused by the obstruction of the bile duct system, which is part of the anatomy of
the liver.
Hydronephrosis
Portal vein thrombosis

Multiple gall stones

Acute pancreatitis
Crohns ds
Ulcerative colitis

Figure 38. Hepatocellular carcinoma with Gad shows hypervascularity on arterial

phase images (A); mass fades to
isointensity on subsequent portal venous (B) and equilibrium phase images (C).
Figure 39.Cholangiocarcinoma (indicated by white arrows in images);
(A) T2-weighted FSE with fatsat; (B) T2-weighted FSE without fatsat;
(C) T1-weighted pre-contrast gradient echo; (D) T1-weighted contrast-enhanced
gradient echo in portal phase; heterogeneous lesion with remarkable
contrast mean uptake; note mild, adjacent hepatic capsular retraction.
MR imaging of the liver is important for characterization of metastases or primary
liver tumors, as well as identification of benign lesions. In MR imaging, spoiled
gradient echo sequences are typically ideal for T1-weighting (Figure 38). In-phase
sequences also give strong T1-weighting, and can typically be acquired in one
breathhold. They can also minimize effects from magnetic susceptibility. FSE or
single shot techniques, often combined with fat suppression, are the most
commonly used T2-weighted sequences. Patients with chronic liver disease (i.e.,
cirrhosis, hepatitis B and C) are at higher risk for developing hepatocellular
carcinoma (HCC), which is the most common primary liver cancer.
Cholangiocarcinoma, the second most common primary malignant liver tumor, is an
adenocarcinoma that originates in the epithelium of the biliary ducts (Figure 39). Its
origin can be in secondary intrahepatic ducts, or in the main right and left hepatic
ducts closer to the hilum. Primary liver cancers can spread by draining into the
hepatic lymph nodes at the portahepatis, as well as by moving into the lymph nodes
in the hepatoduodenal ligament.
Figure 40. Three phase MR [(A) Arterial, (B) Portal Venous, (C) Equilibrium] on
patient with lung cancer and diffuse liver
metastases; hypovascularmets are best shown on portal venous phase image (B),
obtained 60 seconds after IV gad injection.
Due to its high amount of vascularity, the liver is one of the most frequently
involved organs as a site of metastasis, second only to the lymph nodes. Hepatic
metastasis is the most frequently found malignant lesion of the liver. Metastatic
spread to the liver is most common from tumors of the colon, lungs, pancreas, and
stomach (Figure 40). Most metastases are hypovascular and present as
hypoattenuating nodules in relation to the hepatic parenchyma in the portal-venous
phase, with heterogeneous or ring-shaped contrast-enhancement.

Figure 43. Hepatocellular carcinoma shows arterial phase hypervascularity (A) with
washout of contrast in
portal venous (B) and equilibrium phases (C); note delayed pseudocapsule
enhancement.
A liver lobe can be removed from a live donor for transplant. Intraoperative
ultrasound is often used during transplant procedures to delineate blood vessels
and bile ducts. The liver is the only human organ capable of natural regeneration of
lost tissue. Starting with as little as 25-percent of the original liver, a whole liver can
be regenerated. This is not true regeneration, but rather compensatory growth. A
removed lobe does not regrow; liver growth is measured as a restoration of original
function, not original form. In true regeneration, both original function and form are
restored.
MR of the liver is highly dependent on the administration of contrast, especially
when the detection and characterization of focal lesions are the main issues.
Dynamic MRI with multiple phases (arterial, portal, and late phase) after IV contrast
administration offers important information (Figure 43). Arterial phase imaging is
critical for the early detection of hepatocellular carcinoma, as arterially enhancing
lesions greater than 1cm are likely to be malignant. In addition, malignant lesions
are typically T2 hyperintense. Normal gadolinium chelate contrasts offer only a brief
window of time (seconds) for imaging before the contrast diffuses to the interstitial
space of both healthy liver and liver lesions, reducing the contrast gradient
necessary for easy lesion detection. When combined with MRCP, liver MRI is very
useful in the evaluation of patients with hepatic and biliary disease. Hepatobiliary
contrast agents are available that are specific for liver uptake and excretion via the
biliary system. Normal hepatocytes will take up the paramagnetic substance in the
contrast agent (i.e., manganese, gadolinium). Diseased liver tissue will not include
hepatocytes, or may include those whose function is disturbed. The end result is an
increase in signal of healthy liver tissue on T1 weighted sequences, and no increase
in signal in liver lesions. Hepatobiliary contrast media are quickly excreted through
the biliary system, allowing better opacification of the biliary ducts and the gall
bladder. Superparamagnetic iron oxides are another type of liver imaging contrast
agent, which may increase the accuracy of detection of small metastases. These
particles accumulate in the reticuloendothelial system of the liver, darkening the
healthy liver tissue in T2 weighted images. In altered tissue with either reduced or
no reticuloendothelial activity, the contrast agent concentration is low or non-
existent, which improves the overall liver to lesion contrast. One drawback is that
the reticuloendothelial-targeted agents remain in the body longer, which could
increase possible side effects.

Figure 41. Hepatic hemangioma (indicated by white and black arrows in images);
(A) T2-weighted FSE with fatsat; (B) T2-weighted FSE without fatsat;
(C) T1-weighted pre-contrast gradient echo; (D) T1-weighted contrast-enhanced
gradient echo in portal phase; note persistent hyperintense signal on
T2-weighted images (A)(B) and peripheral, globular uptake
in post-contrast portal phase (D).
Figure 42. Focal nodular hyperplasia (indicated by white arrow in each image);
(A) T2-weighted FSE with fatsat; (B) T1-weighted gradient echo with fatsat;
(C) T1-weighted contrast enhanced gradient echo in arterial phase;
(D) T1-weighted contrast-enhanced gradient echo in equilibrium phase;
note remarkable arterial enhancement (C) and washout in equilibrium phase (D);
central scar presents hypointense signal on T2-weighted image (A) and
delayed enhancement in equilibrium phase (D).
Common benign liver lesions, such as hemangiomas, focal nodular hyperplasia
(FNH), and adenomas, benefit from MR imaging for lesion detection as well as lesion
characterization. Hemangiomas are the most frequent benign tumor of the liver.
They typically display on MR imaging with well-defined margins, and hyperintense
signal on T2-weighted sequences (Figure 41). Focal nodular hyperplasia (FNH) is the
second most frequent benign hepatic tumor. It is defined as a nodule with
apparently normal hepatocytes that occurs in a liver with normal histology. It is
more common in women and young patients, sometimes in association with hepatic
hemangiomas. Vascular malformation and/or vascular injury are suggested as
probable mechanisms for the development of focal nodular hyperplasia. It often
presents with a hypointense lesion on T1-weighted images, and a subtle
hyperintensity on T2-weighted images (Figure 42). In a large majority of FNH
lesions, a central scar can be identified with a higher intensity signal than the rest
of the lesion on T2-weighted images. Hepatocellular adenomas are rarer, and
usually found in women with a history of long-term use of oral contraceptives.

Figure 46.Hypervascularhepatoma in arterial phase (A), portal venous phase (B) and
equilibrium (C).
Figure 57. Axial arterial-phase gad-enhanced T1-weighted fat-suppressed
gradient-recalled echo MR image shows normal homogeneous enhancement
of head of pancreas (arrow) without mass; pancreatic mass suspected
on previous CT scan.
Figure 58. Newly diagnosed pancreatic cancer with
peritoneal mets; axial venous-phase gad-enhanced
T1-weighted fat-suppressed gradient-recalled echo
MR image shows rt-side peritoneal implant (black arrow);
hypointense pancreatic mass (open arrow);
pseudocyst (short white arrow); mass in left adrenal
gland (long arrow) may represent
mets or lipid-poor adenoma
Figure 59. Patient had acute recurrent pancreatitis, proved
to have pancreatic carcinoma; axial unenhanced T1-weighted
fat-suppressed gradient-recalled echo MR image shows
mass (arrow) in body of pancreas; bowel seen
adjacent to mass (arrowhead).
Figure 67.Intraductal papillary mucinous neoplasm.

Figure 75. Image resulting from coronal 2D radial

sequence; radial slice position was -20 degrees
Figure 76.Images resulting from MIP of 3D MRCP source images with right to left
rotation.
Magnetic Resonance CholangioPancreatography, or MRCP

Figure 94. MRI of simple right renal cyst; (A) T2-weighted SS FSE; (B) Unenhanced
T1-weighted out of phase;
(C) Contrast-enhanced, T1-weighted, high-resolution isotropic volume exam.
Figure 98. Coronal MIP excretory MR urography shows
complete proximal ureteral obstruction (arrow) and
mild dilatation of the collecting system.

Enterography
Figure 105. Coronal partial-volume MIP image from
contrast-enhanced fat-suppressed T1-weighted 3D GE shows
segmental bowel wall thickening and intense mucosal
enhancement (white arrows); lymphadenopathy (white
arrowheads); mesenteric venous collaterals (black arrow);
patient was 60-year-old female with Crohns disease and
chronic superior mesenteric vein thrombosis.
Figure 106. Coronal contrast-enhanced, fat-suppressed,
T1-weighted 3D GE shows fistulous tract between distal
ileum and small abscess (arrow); acute and chronic
transmural inflammation with fistula formation confirmed at
surgery; penetrating disease with early abscess formation in
47-year old female with Crohns disease.

> A satisfactory written consent form must be taken from the patient before
entering the scanner room
> Ask the patient to remove all metal object including keys, coins, wallet, any cards
with magnetic strips, jewellery, hearing aid and hairpins
> Ask the patient to undress and change into a hospital gown
> Contrast injection risk and benefits must be explained to the patient before the
scan
> Gadolinium should only be given to the patient if GFR is > 30
> If possible provide a chaperone for claustrophobic patients (e.g. relative or staff)
> Offer earplugs or headphones, possibly with music for extra comfort
> Explain the procedure to the patient
> Instruct the patient to keep still
> Note the weight of the patient

Localizer
Localizers can have a maximum time of 25 seconds (less than 25 seconds)
T2 TSE Sagittal
FOV must be big enough (normally 350mm)
T1 TSE Sagittal
T2 TSE Stir Sagittal
T2 TSE Axial
T1 TSE Axial
Contrast Enhancement
T1 TSE Sagittal Fat Sat Post GD
T1 TSE Axial Fat Sat Post GD

Green - L2 Spinous process

Yellow - intervertebral disc L3-L4
Green - zygopophyseal joint
Star - lumbar vertebrae
Disk herniations
This T2 weighted MRI shows a disc prolapse of the L5/S1 disc with protrusion into
the spinal canal. The cord shows as a grey line with the CSF it is bathed in as white.
The discs between the lower two vertebral bodies are darker than the normal upper
two as they are dehydrated and degenerate.
Disc prolapse may by precipitated by something as innocuous as a sneeze, or lifting
a relatively light object. The intervertebral disc is the shock absorber between the
vertebral bodies in the spine. These consist of the annulus fibrosus surrounding the
semifluid nucleus pulposus. In a disc prolapse the nucleus pulposus herniates
through the annulus fibrosus into the spinal canal. This on its own is not enough to
cause radicular pain however. The disc must prolapse to the extent that it causes
compression of one of the nerve roots or the central cord.

Gradual development of central vertebral canal stenosis where there is compression

of the nerve roots in the thecal sac (Figure 4) often results in progression of
decreasing mobility and neurogenic claudication. In instances where an acute event
has occurred, the initial presentation may occur as caudaequina syndrome, urgent
surgical decompression is required.
The causes of central vertebral canal stenosis can be divided into congenital and
acquired conditions, such as neoplastic and degenerative changes. Degenerative
changes include facet osteophytes, ligamentumflavum hypertrophy and disc
herniations. While some conditions have a specific/dominant cause, most central
vertebral canal stenoses are caused by a combination of conditions.
The severity of central vertebral canal stenosis is visually graded and currently no
universal grading scale is being used. Several centres have assessed various
grading methods, including measuring the cross-sectional area and morphology of
the thecal sac.10 However, using imaging alone to assess severity is inadequate as
there is often a mismatch between the symptomology and MRI findings,11 as well
as inter-observer variation between radiologists.

Ankylosing spondylitis begins at the sacroiliac joints causing bilateral and usually
symmetric involvement
Plain radiography of the affected joints remains the initial imaging method for
patients with suspected ankylosing spondylitis. However, clinicians are using MRI
more frequently to diagnose this condition and to monitor treatment response. The
main features on MRI of the lumbar spine include features demonstrating underlying
inflammation and its effects, such as bone marrow oedema, squaring of the
vertebral bodies (Romanus lesions), syndesmophyte formation, ankylosis and
erosions (Figure 5). The clinical and imaging aspects of this condition are complex
and beyond the scope of this article. They are discussed in detail by a group from
the United Kingdom

Spondylolisthesis
Spondylolisthesis is defined as a condition where there is malalignment of the
lumbar spine in the form of a vertebra slipping out of its normal position relative to
the inferior vertebra. This can result in narrowing of the lateral neural foramen and
the central spinal canal (Figure 6). Furthermore, pars defects and lumbar
spondylosis are commonly associated with spondylolisthesis. The chronic nature of
pain experienced by the patient as well as the complex mechanical issues revolving
spinal malalignment can often result in failure of conservative treatment and
surgical fusion of the affected level maybe required.
The role of MRI is to determine the severity of any central spinal canal stenosis or
neural foramen and to identify a potential cause such as a pars defect. However,
due to the static nature of MRI imaging acquired with the patient lying down,
stability at the affected level is uncertain. Spinal surgeons have used dynamic
lumbar spinal plain X-rays to assess any potential exaggeration of spinal
malalignment, which implies further stenosis and nerve impingement. The addition
of rigorous dynamic MRI spinal imaging studies in the future may offer a better
alternative.