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ABDOMINAL MR IMAGING Evolving protocols

ABDOMINAL MR IMAGING Evolving protocols. DR.MANOJ.K.S MD,DNB RD METRO SCANS,TRIVANDRUM. INTRODUCTION. With the advent of fast 3D gradients it was possible to image Liver and abdominal organs with high speed and resolution .

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ABDOMINAL MR IMAGING Evolving protocols

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  1. ABDOMINAL MR IMAGINGEvolving protocols DR.MANOJ.K.S MD,DNB RD METRO SCANS,TRIVANDRUM

  2. INTRODUCTION With the advent of fast 3D gradients it was possible to image Liver and abdominal organs with high speed and resolution . The breath hold and single shot techniques helped in fighting the problem of motion in abdominal imaging Diffusion imaging has added another valuable dimension Perfusion and MRS now coming up

  3. BODY MR PULSE SEQUENCES • T2 WEIGHTED IMAGING • FSE - FRFSE +_ Fat suppression • SSFSE • IR • STIR • BALANCED SEQUENCES • FIESTA +/-fat sat

  4. BODY MR PULSE SEQUENCES • T1 WEIGHTED IMAGING • LAVA • FSPGR • DUAL ECHO • FSE T1WI

  5. DIFFUSION IMAGING - BODY DIFFUSION • "DW MR imaging should be considered in evaluation of cancer patients when there is a need to minimize radiation exposure (children and pregnant women) , cases where contrast-enhanced body CT evaluations are of inadequate quality (patients with renal failure, poor venous access, contrast medium allergies), or cases when there is a need to survey the entire bone marrow • Anwar R. Padhani, Dow-Mu Koh, and David J. Collins • Whole-Body Diffusion-weighted MR Imaging in Cancer: Current Status and Research DirectionsRadiologyDecember 2011 261:3 700-718; doi:10.1148/radiol.11110474

  6. BODY DIFFUSION /PET-CT • Newly Diagnosed Lymphoma: Initial Results With Whole-Body T1-Weighted, STIR, and Diffusion-Weighted MRI Compared With 18F-FDG PET/CTAJR March 2011 vol. 196no. 3 662-669

  7. Enhanced DWI1 "In our facility, we have found that the high image quality of the IR-prep DWI sequence is applicable for a broad range of oncology studies and treatment monitoring“ Dr T. La Folie, HIA Laveran Ste Anne Hospital, Paris, France • Improved ADC quantification • Improved SNR and contrast … • Reduced scan time … smart averaging • Improved spatial resolution … 3-in-1 mode • Flexible fat suppression 1 Compared to conventional DWI technique b=600 b=50 b=200 b=1000 Respiratory Triggered eDWI at 3.0T Liver mets 3in1 , b=500, 4 NEX Breath-hold Courtesy: Keio University, Japan; Sharp & Children, USA; St. Joseph, France

  8. Enhanced DWI1 • Improved ADC quantification • Improved SNR and contrast … • Reduced scan time … smart averaging • Improved spatial resolution … 3-in-1 mode • Flexible fat suppression eDWI control panel 1 Compared to conventional DWI technique 3in1 192 x 224 in 30 s Increased confidence in lesion detection DWI T2w b20 1NEX b500 3NEX b800 3NEX T1w Courtesy of Sharp and Childrens, USA; CCN, France

  9. eDWI WBI eDWI at 1.5T PROPELLER 3.0 eDWI b1000 8 mm, 128x192, 1:04 min Resp Trig. 3 in 1 ADC Map MR 450 1.5T: Colorectal tumor b-value 1300, 3.5 mm slice DWI/T2w fusion overlay Bone metastases Prostate cancer at 3.0T Courtesy of Hospital Vera Cruz, Brazil, Yokohama Sakae Kyosai Hospital, Japan, Sharp and Children San Diego, USA ; CCN, France and Creil, France

  10. DIFFUSION IMAGING : BODY DIFFUSION “Whole-body diffusion-weighted MRI can be used for tumor staging and assessment of treatment response. Meticulous technique and knowledge of potential interpretive pitfalls will help to avoid mistakes and establish this modality in radiologic practice” Whole-Body Diffusion-Weighted MRI: Tips, Tricks, and Pitfalls Dow-Mu Koh, Matthew Blackledge, Anwar R. Padhani ,Taro Takahara, Thomas C. Kwee,  Martin O. Leach and David J. Collins 10.2214/AJR.11.7866AJR August 2012 vol. 199no. 2 252-262

  11. “Virtual Biopsy” • Prof. Diego R. Martin, M.D., Ph.D. The Cosden Professor and Chair Department of Radiology University of Arizona College of Medicine Tucson • Has termed the current MR sequences and contrast studies as equivalent to doing a virtual biopsy since by MR imaging many benign and malignant lesions could be diagnosed without any additional pathologic proof.

  12. LIVER SPECIFIC CONTRAST • MULTIHANCE - Gadobenate dimeglumine • PRIMOVIST - Gadoxetic acid

  13. LIVER • CHRONIC LIVER DISEASES - CIRRHOSIS • DIFFUSE LIVER DISEASES • BENIGN FOCAL LESIONS • MALIGNANT LESIONS • BILIARY ,PORTAL TRACT DISEASES

  14. CLD – FIESTA Fatsat images

  15. LAVA

  16. Cirrhosis

  17. Cirrhosis

  18. PROTOCOL FOR HCC • FRFSE fat sat • DWI • LAVA MULTIPHASIC CONTRAST • Arterial phase -early/late 30 s • Portal Venous phase 70s • Immediate delayed 180s • Equilibrium phase 5-7 mt • Hepato-biliary phase 20 mt (primovist) • 60-120mt with Multihance

  19. Consensus guidelines of the APASL &AASLD on the definition of imaging features of classical HCC. The presence of arterial hypervascularity and washout are generally considered to be highly specific for the diagnosis of HCC -referred to as “classical imaging features” Arterial hypervascularity is defined as increased enhancement of the lesion in the hepatic arterial phase of imaging relative to the background liver. Since HCC receives predominant vascular supply via the hepatic artery Washout” of the lesion is based on the fact that HCC contains predominantly arterial blood and so, by the time portal venous and delayed images are acquired, the lesion is observed to be hypoattenuating on CT (or in the case of MRI, “hypointense”) to the surrounding liver at the portal venous or equilibrium phase.

  20. MR Protocol Contrast-enhanced dynamic MRI, 0.025mmol kilogram 21 of body weight of gadoxetic acid disodium (Primovist; ) injection rate of 2 ml s21 as a rapid bolus followed by a saline flush of 20 ml. 3D spoiled gradient-recalled-echo sequence with chemically selective fat suppression during suspended respiration 30–35 s (arterial phase), 60–70 s (portal phase), 90–100 s (hepatic venous phase) 120–150 s (equilibrium phase) after the intravenous injection of the contrast agent. Additional hepato-biliary phase images were obtained at 20 min after injection Differentiation of early hepatocellular carcinoma from benign hepatocellular nodules on gadoxetic acid-enhanced MRI H RHEE, MD, 1,2M-J KIM, MD, PhD, 1,2M-S PARK, MD, PhD and 1K A KIM, MD 1Department of Radiology, Yonsei University Severance Hospital, Seoul, Republic of Korea, and 2Research Institute of Radiologic Science, Yonsei University Severance Hospital, Seoul, Republic of Korea May 2, 2012 BJR

  21. MR Protocol Gadoxetic acid-enhanced MRI, Unenhanced, arterial phase (20–35 s; via a bolus triggered technique under fluoroscopic guidance), Portal phase (60 s), Late phase (3 min), 20-min delayed Hepato-biliary phase Small (<2 cm) hepatocellular carcinoma in patients with chronic liver disease: comparison of gadoxetic acid-enhanced 3.0 T MRI and multiphasic 64-multirow detector CT J HWANG, MD, S H KIM, MD, M W LEE, MD and J Y LEE, MD Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea The British Journal of Radiology, 85 (2012), e314–e322BJR July 1, 2012 vol. 85 no. 1015 e314-e322

  22. MR Protocol Dynamic fat-saturated T1-weighted gradient-echo images with 3D LAVA Non Contrast phase 20–30 seconds (arterial phase, fluoroscopic triggering technique), 60 seconds (portal venous phase), 2 minutes (late phase), 5, 10, and 20 minutes (hepatocyte phase) Gadoxetic acid administration bolus (0.025 mmol per kilogram body weight) rate of 1 mL/sec flushed with 20 mL of saline Imaging Study of EarlyHepatocellular Carcinoma: Usefulness of Gadoxetic Acid–enhanced MR Imaging Katsuhiro Sano, MD, PhD, etal December 2011 Radiology, 261, 834-844. From the Departments of Radiology (K.S., T.I., U.M., H.S., A.M.M., T.A.), Surgery 1 (M.M., M.A., H.F.), Pathology (T.N.), and Internal Medicine 1 (T.K., N.E..), University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan; Department of Diagnostic Pathology, Tokyo Women’s Medical College Yachiyo Medical Center, Yachiyo, Japan (M.N.); and Department of Pathology, Keio University, Tokyo, Japan (M.S.).

  23. Small HCC • Hypervascular Hepatocellular Carcinoma 1 cm or Smaller in Patients With Chronic Liver Disease: Characterization With Gadoxetic Acid–Enhanced MRI That Includes Diffusion-Weighted Imaging • Department of Radiology and Center for Imaging Science, Sungkyunkwan University School of Medicine, Samsung Medical Center, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea. • AJR June 2011 vol. 196 no. 6W758-W765 • Hypovascular Hypointense Nodules on Hepatobiliary Phase Gadoxetic Acid–enhanced MR Images in Patients with Cirrhosis: Potential of DW Imaging in Predicting Progression to Hypervascular HCC • Radiology October 2012 265:1 104-114; • Small (≤2 cm) hepatocellular carcinoma in patients with chronic liver disease: comparison of gadoxetic acid-enhanced 3.0 T MRI and multiphasic 64-multirow detector CT • BJR July 1, 2012 vol. 85 no. 1015 e314-e322 • Small Hepatocellular Carcinomas: Improved Sensitivity by Combining Gadoxetic Acid–enhanced and Diffusion-weighted MR Imaging PatternsRadiology September 2012 264:3 761-770 • Min Jung Park, Young Kon Kim, Min Woo Lee, Won Jae Lee, Young-Sun Kim, Seong Hyun Kim, Dongil Choi, and Hyunchul Rhim

  24. Rationale for the new MR protocols “Hepatocarcinogenesis is a multifactorial process that includes changes in architecture, cellular density, hepatocyte function, and Kupffer cell numbers or function . Accordingly, combining gadoxetic acid and DW imaging has the potential to be robust liver MR protocol in that it is targeting three processes of hepatic carcinogenesis: hemodynamic changes, hepatocyte function, and tissue diffusivity” Imaging Study of Early Hepatocellular Carcinoma: Usefulness of Gadoxetic Acid–enhanced MR Imaging Katsuhiro Sano, MD, PhD, etal December 2011 Radiology, 261, 834-844.

  25. MR Diagnostic criteria A size cut-off value (>/=1.5cm diameter) MRI findings of T1 hypointensity, T2 hyperintensity, DWI hyperintensity on both low and high b-value images (b550 and 800 s mm22, respectively), arterial enhancement, late washout and hepato-biliary hypointensity Differentiation of early hepatocellular carcinoma from benign hepatocellular nodules on gadoxetic acid-enhanced MRI H RHEE, MD, 1,2M-J KIM, MD, PhD, 1,2M-S PARK, MD, PhD and 1K A KIM, MD 1Department of Radiology, Yonsei University Severance Hospital, Seoul, Republic of Korea, and 2Research Institute of Radiologic Science, Yonsei University Severance Hospital, Seoul, Republic of Korea May 2, 2012 BJR

  26. Cholangiocarcinoma • FRFSE fat sat • DWI • MRCP • MR CONTRAST ANGIOGRAPHY • LAVA CONTRAST • Venous phase 70s • Immediate delayed 120s • Hepato-biliary phase 20 mt (primovist) • 60/120mt with Multihance

  27. Choangiocarcinoma

  28. HBP phase enhancement

  29. Infiltration by metastases

  30. DWI in metastases

  31. MR Protocol for FNH • FRFSE fat sat • DUAL ECHO SPGR • LAVA MULTIPHASIC CONTRAST • Arterial phase -early/late 30 s • Portal Venous phase 70s • Immediate delayed 180s • Equilibrium phase 5-7 mt • Hepato-biliary phase 20 mt (primovist) • 60-120mt with Multihance

  32. FNH

  33. FNH

  34. FNH

  35. FNH

  36. KIDNEY – MULTIPHASIC MR ANGIOGRAPHIC/ CORTICOMEDULLARY NEPHROGRAPHIC UROGRAPHIC PHASE Renal Cortical Tumors: Use of Multiphasic Contrast-enhanced MR Imaging to Differentiate Benign and Malignant Histologic Subtypes Radiology September 2012 264:3 779-788; Published online July 24, 2012,doi:10.1148/radiol.12110746

  37. Multiphasic contrast-enhanced MR imaging protocol precontrast, corticomedullary phase, nephrographic phase, and excretory phase. (SmartPrep; GE Medical Systems) to synchronize the contrast material administration with the image acquisition. The first postcontrast sequence 5 seconds after peak arterial enhancement, followed by 70 seconds after contrast material administration and 3–4 minutes after contrast material administration. Subtraction of the precontrast images from the postcontrast images was performed at the console.

  38. 50 yr male pt with severe UTI

  39. pt with UTI

  40. LAVA CONTRAST

  41. LAVA Delayed excretion phase

  42. Thank You All Thanks to Dr.SureshBabu, Metro scans

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