Handbook of MRI Scanning
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HANDBOOK OF MRI SCANNING ISBN: 978-0-323-06818-5
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional
responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the Authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-323-06818-5
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Printed in the United States of America
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Dedication
We would like to thank our families for their continued support
and encouragement throughout this lengthy process
and
We acknowledge our colleagues at New York Presbyterian Hospital
for their dedication to this ever-evolving segment
of Diagnostic Imaging.
iii
Foreword
Those of us witnessing the development of magnetic resonance MRI scanners are humming with patients late at night long
imaging (MRI) technology in the early years could hardly envi- after computed tomography, ultrasound, and nuclear medi-
sion the extent to which routine MRI and MR angiography cine have closed down for the evening. Heightened concern
(MRA) is performed on every organ system of the body today. over exposure to ionizing radiation, exquisite soft tissue detail,
Those primitive time-consuming early simple scans involving and availability of extraordinarily safe contrast agents have all
primarily T1- and T2-weighted imaging have evolved into fast, contributed to the appeal of MRI. Claustrophobia, a down-
complex examinations involving many more contrast mecha- side to the top-of-the-line high-field magnets, is being gradu-
nisms, often with very precise positioning of the imaging plane ally eliminated with shorter, larger-bore magnet architectures.
relative to the anatomic structures. This has resulted from a This growing demand and complexity of MRI and its expan-
spectacular explosion of refinements to MR capability involv- sion into all parts of the body are making it imperative that
ing improvements in magnets, shimming, gradient coils, rf we find a way to rapidly and effectively train technologists and
coils, pulse sequences, data transmission, image reconstruction radiologists in applying this technology to best advantage.
algorithms, user interfaces, and contrast agents. Along with This book presents an outstanding, comprehensive intro-
these advances have been some much needed automation and duction to MRI throughout the body in a practical, realistic
simplifications to the operation of MR scanners. However, on approach that avoids confusing physics and equations. Starting
the whole, the MR scanners are fantastically more complicated, out with safety, it then systematically steps through the body by
demanding technologists and radiologists of the highest caliber MR anatomic regions, treating each in a standardized fashion so
for successful implementation of the latest techniques. that the information is easily assimilated. The basic approaches
In spite of the complexity of MRI today, the demand for MRI to each body part are supplemented with myriad insights,
remains insatiable. In radiology departments around the world, reflecting the genius and wealth of experience of the authors,
Carol Finn and Geri Burghart. Carol Finn has been an MRI to our technologists as they have acquired more knowledge and
specialist for more than 20 years, with experience in academic mastered each stage of the process. This has proven to be a very
universities, private practice, and imaging centers, as well as workable relationship and because our technologists have taken
extensive experience teaching MRI and training technologists “ownership” of the process, they routinely take the initiative to
and radiologists. Geri Burghart is an Associate Professor and adapt paradigms and find creative ways to compensate for the
has also been an educator in radiologic technology for more many limitations we encounter in our challenging neurological
than 20 years. Accordingly, this book represents a must-read for ICU patient population. This integral role of the technologist in
all beginning MRI technologists and will be a great resource for the process of performing fMRI studies emphasizes the need for
experienced technologists and MR radiologists. technologists to have an in-depth understanding of the scien-
tific underpinnings of fMRI. This also applies to the acquisition
Martin R. Prince, MD, PhD, FACR of other specialized “functional” MRI studies, including diffu-
Professor of Radiology Weill Cornell Medical Center and sion, diffusion tensor, perfusion and spectroscopy. The fMRI
Columbia College of Physicians and Surgeons, section in Chapter 1 provides an overview of these advanced
New York City, September 20, 2010 MRI techniques to help technologists get started developing the
knowledge base they will need to participate as a key member of
The fMRI Team the imaging team doing advanced MRI studies.
Performing clinical fMRI studies is a complex process that
requires close cooperation and team work between the physi- Robert L. DeLaPaz, MD
cian and the technologist. The physician is responsible for plan- Director of Neuroradiology
ning and interpretation of these studies but cannot perform the CIO & Director of PACS
fMRI acquisition without the help of the technologist. In addi- Department of Radiology
tion, at our institution, after the physician sets the protocol and New York Presbyterian Hospital, Columbia Medical Center
explains the fMRI process to the patient, it is the technologist New York City, September 25, 2010
who assumes the responsibility for monitoring the performance
of the fMRI tasks. We have progressively given this responsibility
v
Reviewers
Lynda Donathan, MS, RT(R)(M)(CT)(MR) Michael Teters, MS, DABR
Assistant Professor of Imaging Sciences Assistant Professor
Morehead State University UMDNJ-SHRP
Morehead, Kentucky Scotch Plains, New Jersey
Cheryl O. DuBose, MSRS, RT(R)(MR)(CT)(QM) Patricia L. Tyhurst, BAEd, CPC, CPCH
MRI Program Chair Department Chair
Arkansas State University University of Montana
Jonesboro, Arkansas Helena, Montana
Acknowledgments
In addition to the reviewers listed separately, the authors would Cindy R, Comeau, BS, RT(N)(MR)
like to thank the following individuals for their contributions: Advanced Cardiovascular Imaging, NY, NY
Provided images for the cardiac section
Robert DeLaPaz, MD
Professor of Radiology Cover image courtesy of Mitsue Miyazaki from Toshiba
Director of Neuroradiology, Medical Systems Corp.
NYP Columbia Medical Center Caption: The entire arterial vasculature is depicted with
Foreword “MD-Technologist interaction” and ƒMRI section exquisite clarity using noncontrast angiography techniques.
images and context. The fresh blood imaging (FBI) technique was used to depict
the pulmonary system, subclavian arteries, and runoff vessels,
Martin R. Prince, MD, PhD, FACR from the abdominal aorta to the pedal arteries. The time-spa-
Professor of Radiology at Cornell & Columbia Universities tial labeling inversion pulse (Time-SLIP) technique was used to
Foreword and review of the contrast section depict the carotid arteries through the Circle of Willis.
vii
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Contents
Preface Soft Tissue Neck
Patient Preparation Magnetic Resonance Angiography of Carotid Arteries and
Safety Guidelines Carotid Bifurcation
CHAPTER 1 MRI of the Head and Neck CHAPTER 2 MRI of the Spine and Bony Pelvis
Important Considerations for Scan Acquisition MRI of the Spine and Bony Pelvis—Considerations
Routine Brain Scan Routine Cervical Spine
Brain for Pituitary Cervical Spine for Multiple Sclerosis
Brain for Internal Auditory Canals (IACs) Routine Thoracic Spine
Brain for Orbits—Optic Nerves Lumbar Spine
Brain for MS Sacroiliac Joints—Sacrum and Coccyx
Brain for Epilepsy—Temporal Lobe MRI of the Bony Pelvis
Brain for TMJs
MRA—Circle of Willis CHAPTER 3 MRI of the Upper Extremities
MRV—Superior Sagittal Sinus MRI of the Upper Extremities—Considerations
Brain for CSF MRI of the Shoulder
Brain for Stroke MRI of the Humerus
fMRI—Functional MRI MRI of the Elbow
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CONTENTS
MRI of the Forearm Cardiac MRI
MRI of the Wrist MRA of the Great Vessels of the Theray
MRI of the Hand and Digits MRI of the Brachial Plexus
CHAPTER 4 MRI of the Lower Extremities CHAPTER 6 MRI of the Abdomen and Pelvis
MRI of the Lower Extremities—Considerations MRI of the Abdomen and Pelvis—Considerations
MRI of the Hips MRI of the Abdomen—Kidneys
MRI of the Femur MRI of the Abdomen—Portal Vein
MRI of the Knee Magnetic Resonance Cholangiographic Pancreatography
MRI of the Lower Leg MRI of the Adrenal Glands
MRI of the Ankle MRI of the Female Pelvis—Uterus
MRI of the Foot and Digits MRI of the Male Pelvis—Prostate
MRA of the Renal Arteries
CHAPTER 5 MRI of the Thorax MRA Runoff—Abdomen, Pelvis, and Lower Extremities
MRI of the Breast
Bilateral Breast
Preface
As both technologists and educators, we strongly believe there line of defense against MR related accidents. Included in this
is a need for a comprehensive reference for MR scanning. This text is an overview of MR safety including issues related to
includes not only the accurate and consistently standardized administration of contrast agents .We urge all MR personnel to
acquisition of images, but also a place to reference standard adhere to all safety protocols to avoid accidents that can injure
and advanced protocols for imaging the vast range of medical patients, staff and equipment.
conditions and body habitus presented.
We feel this book is both basic and broad enough to meet
Organization and Content
the needs of students and experienced technologists. It is
intended to provide not only a baseline for MR image acquisi- • A safety section, including MR suite configuration, patient
tion but also a standard of quality that should be consistently screening and personnel classifications, provides a solid
duplicated to provide the health care team with quality diag- foundation for secure operating parameters within the
nostic images. highly volatile MR environment.
In our tables we have suggested scan protocols with techni- • A section on Gadolinium Based Contrast Agents (GBCAs)
cal parameters for both 1.5T and the more advanced 3T mag- provides background on safety considerations as outlined
nets. In addition we have provided blank tables to modify your by the ACR, pharmaceutical vendors, including appropriate
site protocols to accommodate the capabilities of your specific dosing and off label use.
equipment. We suggest you enter all data on your site tables in • Each section is logically divided into protocols for acquisi-
pencil to modify as protocols and software change. tion in the axial, coronal and sagittal planes, with suggestions
Of utmost importance, regardless of the field strength of for scan parameters and sequences for both 1.5T and 3T.
your specific equipment, is MR safety. MR safety guidelines, • Tables suggesting protocols and sequences for both 1.5T and
as set forth by your facility and the MR technologist, is the first 3T magnets.
xi
preface
• Each pilot, or scan plan, is followed by a relevant midline Each chapter has
image from the sequence and a detailed anatomical refer- • Scan Considerations
ence of the pertinent anatomy. • Coils
• The parameters for coil type, proper patient position- • Pulse Sequences
ing, consistent and accurate slice placement and ana- • Options
tomical coverage are detailed for each sequence. In • Scanning Tips
addition, a “Tips” section will assist with techniques • Scan Planning
designed to perfect each scan and ensure patient safety • Anatomic Midline Image
and comfort. • Anatomic Drawing
• The fMRI section at the end of Chapter 1 gives insight to
some of the most current techniques and applications of
Ancillaries
MRI.
• The cross-vendor reference acronym chart allows replica- • The images from the book are available online on Evolve at
tion of sequences from one vendor to another. http://evolve.elsevier.com/BurghartFinn/MRI
Patient Preparation
• The patient should be “properly identified” by name, date of • Many patients are anxious when having an MRI. Make sure
birth and facility medical record number (when appropri- you explain the examination to the patient. A conversation
ate), which should be compared to the patient's requisition with the patient prior to scanning usually puts the patient's
and schedule. fears to rest.
• Have the patient fill out a MRI questionnaire while in • Explain the importance of holding still.
zone 2. • Explain that the scanner makes a loud knocking sound and
• The MRI questionnaire should be reviewed by the MRI they should try to relax.
staff, particularly nurse and the technologist who are the • Explain that you will be talking to them between scans.
“gatekeepers”. Give patient a call bell and instructions to use only when
• The MRI questionnaire should be discussed with the patient necessary.
making sure they understand the questions. • When they speak to you, make sure you listen to what they
• The patient should be screened for implanted devices, such say so you can address their needs if necessary.
as a pacemaker, defibrillator, neuro-stimulator, aneurysm • Make sure ear plugs are securely fitted into the patient's ears.
clip, hearing aid and prosthetic devices. • Secure the head with side sponges, and tape with gauze
• Patient should be screened for the possibility of renal disease across the forehead.
when contrast is ordered. • Secure the patient in a comfortable position, with cushions
• Have the patient go to the bathroom prior to coming into under their knees to relieve back pressure.
the MRI suite. • Put sponges or sheets along the side of the patient to pre-
• All patients should undress and put on a gown or scrubs. vent their arms and torso from touching the sides of the
Make sure all metal is removed. magnet.
xiii
Safety Guidelines
MR environments can pose a wide array of potential risks for 3T MR vendors provide SAR monitors with their 3T magnets.
patients, health care workers, and ancillary personnel who These monitors should be observed while scanning.
enter the magnetic field. Strict policy and procedures should As practitioners and educators, we strongly suggest the
be in place and adhered to, to ensure safe operation. Areas to American College of Radiology (ACR) Guidance Document
be considered are zoning of the MR suite, identification and for MR Practices: 2007 (listed in the references to these Safety
education of qualified MR personnel, guidelines for screening Guidelines) be referenced and adhered to for implementation
patients and accompanying family members, administration of of safety guidelines in all MRI departments. Further informa-
contrast, implant, and device screening and cryogens. tion for safe practice can be accessed at the Joint Commission
The inherent risks for accidents caused by the magnetic field Sentinel Event Alert on MRI Safety and at NIH.gov/mri (both
continue to be similar at 1.5T and 3T. However, as the static links are found in the references to these Safety Guidelines). A
magnetic field strength increases, the probability for move- brief overview of ACR guidelines are discussed below.
ment of ferromagnetic material, metallic implants and the pro-
jectile effect become increasingly problematic. To avoid tissue
ZONING OF THE MR SUITE
heating, which is caused by the time-varying magnetic field,
the FDA provides guidance on the rate of energy that may be The architectural plan for the MR suite should support safety
deposited in tissue, which is termed specific absorption rate and be designed with barriers to prevent harm to patients
(SAR). In addition, the time-varying magnetic field can affect and personnel. The four-zone plan suggested by the ACR is
acoustic noise and induce voltage. At 3T, SAR can becomes a described below. Whatever system is adopted, it should be
greater concern, particularly with fast spin echo sequences, strictly adhered to. The entrance to each zone should be clearly
especially as the echo train length increases. For this reason, all marked.
Zone I—All areas that are outside the MR environment and MR personnel and are typically divided into two categories—
are accessible to the general public. In this area, no risk is posed level 1 and level 2 MR personnel.
to the general public. Level 1 personnel—Anyone who has completed basic MR
Zone II—This is the area that bridges the contact between training and will be permitted in Zones I–III.
Zone I and the more strictly supervised areas of Zone III and Level 2 personnel—It should be the responsibility of the MR
IV. This is the area where patients are typically screened and safety officer to identify the personnel who qualify as level 2
history is taken. personnel. They should possess comprehensive MR training
Zone III—This is a restricted area for all who are not MR and understand the potential for hazardous situations that may
personnel. Because the magnetic field is three-dimensional and arise from a wide variety of risks associated with Zones III and
may project through walls and floors, this area should be clearly IV. Level 2 personnel will primarily consist of the MR technolo-
marked as potentially hazardous. The five-gauss line, which is gist and the MR nurse.
the exclusionary zone, should be clearly delineated. Signage MR Technologist—As stated by the ACR, all MR technolo-
should be posted to ensure that all patients or staff with pace- gists should be American Registry of Radiologic Technologists–
makers or defibrillators do not enter this area. certified radiologic technologists (RTs). All MR technologists
Zone IV—This is the room in which the MR scanner is should maintain current certification by the American Heart
housed and is the area that poses the most potential risk. It Association in basic life support at the health care provider
should be clearly marked with proper signage stating: “The level.
Magnet is Always On,” and that you are entering Zone IV.
GUIDELINES FOR SCREENING PATIENTS
MR PERSONNEL AND NON-MR PERSONNEL
Considering the potential dangers that can occur in the MR Several components of patient screening can and should take
suite, all individuals working within this environment should place during the scheduling process. Typically at this time, it
be annually certified in the completion of safe practice edu- is determined whether the patient has any contraindicated
cational training. These practitioners should be designated as implants such as a pacemaker or internal cardiac defibrillator,
xv
safety guidelines
or whether there is a medical condition such as renal disease Determination to scan a patient with an implanted medi-
or pregnancy that may need special considerations before cal device or foreign body should be made by the attending
scanning. MR radiologist via plain x-ray films or computed tomog-
All patients and personnel who attempt to enter Zone raphy. For other implantable devices, further investigation
III must be formally screened and documented in writing. for compatibility should be made and documented by MR
Only MR personnel are qualified to perform the screen- personnel.
ing process before permitting non-MR personnel into
Zone III. MR screening should be performed by at least two
PEDIATRIC CONCERNS
separate individuals, one of whom should be a level 2 MR
personnel. Because children and teens are often unreliable sources of med-
Screening should typically take place in Zone II, where the ical history, they should be questioned both in the presence of
patients should remove all outer clothing, jewelry, and prosthet- a parent or guardian, as well as alone to ensure that a complete
ics, and change into a gown. The formal institutional screen- history is disclosed.
ing questionnaire should include confidential information and Children comprise the largest group of patients for whom
a MR hazard checklist, which would be reviewed along with sedation is necessary. Although protocols will vary, strict adher-
comprehensive discussion of the patient's medical history. The ence to guidelines and constant monitoring is mandatory. For
screening forms for patients and non- MR personnel who may infants, special attention must be paid to monitoring body
accompany the patient, or enter the scan room, should essen- temperature for both hypo- and hyperthermia.
tially be the same.
Everyone entering Zone III must be physically screened for
PREGNANCY AND MR
the presence of ferromagnetic materials, which, regardless of
size, can become hazardous projectiles to the patient and the Pregnant MR personnel are permitted to work within the
MR scanner. The use of a ferromagnetic detector and wand confines of Zone IV during all stages of pregnancy but it is
that differentiates between ferrous and nonferrous material is recommended that they not enter the MR room when the
recommended. radiofrequency (RF) is on during the scanning process.
