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Preface
Body MR imaging
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Introduction to physics of MR
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Fig. 1. One-dimensional example illustrating how ghost images are formed in the presence of an oscillating phase variation
introduced by motion of the object being imaged. The data for the true image (a) in the absence of motion produces a perfect
image (b), but is often modulated by a phase variations due to motion (c) resulting in corrupted data (e). This can also be thought
of as the true image convolved with the FT of the periodic phase variation, which is shown in (d), and which yields the same
image set containing ghosts (f).
images that are close together, whereas higher-frequency oscillations will move these ghosts further
apart. Multiple components of these phase variations
will produce multiple ghosts, which may constructively or destructively interfere with one another.
Image data
In practice, an image is formed from a twodimensional (2D) or three-dimensional (3D) data
set that is comprised of many damped sinusoids in
the x-direction, y-direction, and in 3D aquisitions in
the z-direction. The data space is often referred to as
k-space because of the mathematical notation
typically used to describe points in this space. The
k-space data encodes the spatial information for the
MR signals in terms of frequency (how fast the sinusoid is oscillating) in the readout x-direction, and
in terms of phase (whether it is at a peak, trough, or
Motion artifacts
If motion occurs between the acquisition of the
different ky lines, then an incorrect phase will be
assigned to the ky line being acquired. In the phase
encode or y-direction, because the phase of the signal
recorded assigns position in this direction, phase errors
will result in position errors in the y-direction. Completely randomized motion adds completely randomized phase errors to each line of data, which results in a
randomized placement (or displacement) of intensities
in the phase-encode direction of the image. Periodic
motion (such as that occurring from respiration or flow
effects), on the other hand, will add cyclic phase
variations. In the phase-encode direction, phase determines position; therefore incorrect phase will lead to
intensity misplacements and hence ghosts (if the misplacements vary periodically) or intensity streaks (if
the misplacements are closer to randomly distributed).
Motion artifacts are referred to as ghosts because
they lead to additional ghostlike images of the moving structure within the imaging FOV. In most cases,
motion causes the worst artifacts to be propagated in
the y-direction due to the slow process of encoding
phase [4]. In conventional imaging sequences, a
single line of k-space data is acquired every time of
repetition (TR). Thus, to completely fill k-space,
requires Ny TR, where Ny represents the number
of phase-encode steps. This slow acquisition process
allows plenty of opportunity for motion to occur. The
frequency encoding typically takes place on the order
of less than 10 milliseconds, and thus only the most
rapid or severe motion causes artifacts in the frequency encode direction.
It is clear then that one of the biggest challenges in
body MR imaging is to collect the data without the
Fig. 2. Illustration of raw data (left) and the image derived from the raw data (right), by using 2D FT, analogous to the 1D
example shown in Fig. 1. In the absence of motion, the data do not have phase errors and a true image is reconstructed. (a)
Motion may introduce an oscillating phase variation, in the phase-encode (vertical ) direction, which translates into ghosts
(b, lower right ).
not arise across the data in the phase-encode direction. One of the first highly successful approaches
to this problem is called respiratory ordered phase
encoding (ROPE) (see Bailes et al [5]). This approach
makes use of respiratory bellows to measure the
cyclic nature of the patients breathing pattern before
image acquisition, and then the different phaseencode lines are collected in a temporal order
designed to create a single-phase ramp across
the data instead of an oscillatory phase variation. A
phase ramp across the data will result in a small
displacement of the object but will have little impact
on the image quality with no ghosting. Typically, the
Fig. 3. Examples of different manifestations of motion artifacts. (a) The motion artifacts are produced by the moving myocardial
wall. (b) Flow in a vessel produces a streak artifact in the phase-encode direction. (c) The entire body is moving introducing
ghosts that involve the entire FOV. In all cases, the phase-encode direction is vertical.
with only a single echo with no phase-encode gradient applied. Therefore, navigators can be obtained
in as little as 8 milliseconds or less and do not
significantly impact imaging time.
Although much of this discussion has focused on
motion artifacts in the phase-encode direction, constant flow can produce displacement artifacts and
signal loss in the x-direction. These are particularly
troublesome in MRA applications, but can be minimized using gradient moment nulling methods [17
19]. In this approach, both the zero-order and firstorder gradients are nulled, such that spins moving at
constant velocity will have zero phase at the center of
the echo. This approach increases the demands on the
gradient hardware and may increase the minimum
echo time (TE) obtainable because of the additional
gradient lobes, which must be included but otherwise
do not affect the image acquisition strategy. This
approach not only reduces flow effects in vessels,
but also has been shown to improve imaging of the
spine [18,20]. Gradient moment nulling does not
abrogate the possibility of using the ROPE method,
and the two are combined easily to further reduce the
sensitivity to motion.
Two additional approaches for reducing motion
artifacts are (1) fast imaging pulse sequences to freeze
the motion, and (2) imaging acquisition strategies
that allow for the production of excellent images
from reduced data sets. These approaches are linked
in that one can collect the data faster, or one can
collect less data, which also leads to faster imaging.
The approaches are discussed separately, but the
reader should be aware that one or more of these
approaches may be applied together to reduce the
effects of motion.
Fig. 4. (a) Pulse sequence diagram for FSE imaging. The horizontal axis represents time, the vertical axis indicates when
gradients and rf pulses are on or off, as well as the polarity of the gradient applied. For the FSE sequence shown, 5 echoes are
collected (one after each 180 rf pulse), each with a different amount of phase encoding, with the colored fill of the
data acquisition windows, related to the actual lines in k-space that are collected, as shown in (b). In this example, the center of
k-space is acquired at the fifth echo, and thus the effective TE is the time between the initial 90 pulse and the fifth echo.
Fig. 6. (A) A blipped gradient echo, EPI pulse sequence. A sequence diagram demonstrates that a large Gy gradient is applied to
move to the bottom of ky-space, and then each subsequent Gy blip moves the trajectory up one line. The oscillating Gx gradient
moves the trajectory back and forth along the kx axis. The sharp transitions between positive and negative Gx place great
demands on the gradient system. This approach, however, can collect all of the k-space data following a single a excitation
pulse. The gradient echo spiral sequence shown in (B) is similar, but the smooth oscillating of the Gx and Gy gradients does not
demand the same high-performance ramping as in EPI. The spiral trajectory begins in the center of k-space (providing any TE
desired) and spirals to the outskirts of both kx and ky (a spiral-out sequence). A spiral-in sequence simply reverses the Gx and
Gy gradients shown and the minimum effective TE is much longer.
10
Fig. 8. Motion artifacts in multishot EPI. Much like in conventional imaging, multishot EPI is sensitive to motion that occurs
between shots and can produce multiple ghost images of the entire object as shown in (A) or they can manifest as discrete ghosts
from pulsatile flow in vessels as shown in (B).
Fig. 9. Schematic demonstrating moving window image reconstruction from a real-time four-shot spiral imaging sequence. As
each new spiral is acquired, it replaces the previous acquisition of that spiral and a new image may be reconstructed. Images are
reconstructed at the same rate that the spirals are obtained. Such an approach allows either real-time scanning, or it provides a
high temporal resolution approach for bolus tracking of contrast agents.
11
Fig. 10. The true FISP sequence is a fully balanced gradient echo imaging sequence. All gradients are balanced in this sequence
in either 2D mode (A) or in 3D mode (B). This approach is highly insensitive to motion, and provides very short TEs and TRs for
fast data acquisition.
12
Fig. 11. Imaging time may be reduced by using an asymmetric FOV. If every other line of data is acquired, thereby reducing the
data from 256 256 (a) to 256 128 (b), then the FOV in the image will be reduced by one half in the phase-encode direction,
whereas image resolution will remain constant. If the sampling rate is reduced furtherfor example, down to 256 96 (c), the
FOV will be reduced further, eventually resulting in image wrap around artifacts. These artifacts place a limit on how sparsely
the data can be sampled. If a multicoil acquisition is used, however, the sensitivity profiles of the coils may be used to unwrap
these images and produce a wrap-free image at very low sampling rates (and hence very short image acquisition times). This
multicoil approach with coil sensitivity profile data forms the basis of the SMASH and SENSE methods.
The asymmetric FOV sampling approach is different from the SENSE and SMASH imaging
approaches in that the sampling rate in the ky
direction is decreased (sampling every other line,
for example) in SENSE and SMASH, whereas the
sampling rate in asymmetric FOV is held constant but
the entire k space is not covered.
Recall also that many of the techniques described
above can be combined together to further reduce
imaging time while maintaining resolution and image
quality. For example, the half-acquisition single-shot
turbo spin echo [47] imaging sequence, as the name
implies, combines the TSE acquisition approach with
the half-k-space acquisition approach and takes
advantage of two of the approaches discussed in this
article to minimize imaging time and provide highquality images in the abdomen.
Overall, the combination of gradients that can
ramp up and down quickly, multicoil receivers, and
fast imaging pulse sequences, have led to highquality body imaging strategies. High-quality gradients allow for the fast traversal of k-space required
for most rapid imaging pulse sequences. Multicoil
13
Fig. 12. Another approach to reducing imaging time is to asymmetrically sample k-space. A complete image can be reconstructed
from just over one half (b), or one quarter (c) of the k-space data. The Hermitian symmetry of k-space data (kx and ky are
complex conjugates of kx and ky for real objects) can be exploited to fill in the rest of k-space. This approach may be
combined with any of the fast imaging sequences shown in the other figures to further reduce imaging time.
References
[1] Keogan MT, Edelman RR. Technological advances
in abdominal MR imaging. Radiology 2001;220:
310 20.
[2] Haacke EM, Brown RW, Thompson MR, Venkatesan R.
Magnetic resonance imaging: physical principles and
sequence design. New York (NY): Wiley Liss; 1999.
14
[26]
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15
Cardiac MR imaging
Ernesto Castillo, MD, David A. Bluemke, MD, PhD*
The Russell H. Morgan Department of Radiology and Radiological Sciences, MRI Division,
The Johns Hopkins University School of Medicine, MRI-143 Nelson Basement, 600 North Wolfe Street,
Baltimore, MD 21287, USA
Rest imaging
The simplest approach for determining viability is
to assess end-diastolic wall thickness (EDWT) and
systolic wall thickening (SWT) on bright blood cine
images. EDWT is approximately 90% sensitive, but
only approximately 55% specific for predicting
whether there will be functional improvement postrevascularization [3,4].
Stress imaging
To improve the specificity of cine MR imaging,
dobutamine stress MR (DS-MR), using a low dose
(5 15 mg/kg/min) of dobutamine, can be performed.
The rationale for DS-MR is that contractile function of
viable tissue improves following inotropic stimulation
(contractile reserve), whereas necrotic or scarred tissue does not. Criteria for viability include EDWT less
than or equal to 5.5 mm and dobutamine-induced
SWT greater than or equal to 2 mm. In patients with
an acute or recent MI, DS-MR has a sensitivity of
approximately 91% and a specificity of approximately
70% [5]. DS-MR is therefore a better and more
accurate predictor of left ventricle functional recovery
than is preserved EDWT [3,6]. For cardiac ischemia,
DS-MR uses dobutamine doses of 10 to 40 mg/kg/
min. Stress-induced wall motion abnormality is an
early and reliable sign of myocardial ischemia that
preceeds electrocardiographic (ECG) changes and
angina [7 10]. Quantitative analysis of SWT provides better results than does qualitative analysis of
the dobutamine response (overall sensitivity of up to
91%, with 100% for three-vessel disease; and specificity of 80%) [9,10].
In a large population (208 patients) DS-MR had
better sensitivity and specificity values (approximately 86%) than did dobutamine stress echocardiog-
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18
Fig. 1. Heterogeneity of contrast enhancement in an acute myocardial infarction in a 59-year-old man. The upper left image
shows an adequate nulling of the myocardial signal intensity at the beginning of the first-pass perfusion obtained with a
notched, interleaved, hybrid GRE EPI sequence. After 25 seconds (upper right), there is an extensive subendocardial
hypoenhancement in the territory of the left circumflex coronary artery (solid arrows), which corresponds to MO and reduces its
size at 56 seconds (lower left), due to gradual enhancement in the peripheral zone. In the image obtained at 20 minutes
postcontrast with a 3D, IR-prepared, fast GRE sequence (lower right), there is delayed enhancement around the hypointense area
of MO (arrowhead), corresponding to a transmurally extended myocardial infarction.
raphy (sensitivity 74%, specificity 70%) for significant coronary artery disease ( 50% stenosis) [7].
Currently, DS-MR is reserved mainly for patients
with inadequate stress echocardiograms due to a poor
acoustic window.
There are several limitations with DS-MR. First,
ECG changes due to ischemia cannot be detected
reliably in the high-field MR imaging environment.
Instead, visual and subjective detection of wall
motion abnormalities is performed to ensure patient
safety during stress testing. Also, wall thickening in
response to dobutamine is not entirely specific for
ischemia. This is due to through-plane motion of
the heart during the cardiac cycle, which leads to
images of different myocardial regions at end diastole versus end systole. These limitations of DS-MR
can be overcome by the use of MR imaging-tagged
cine sequences [11]. Two-dimensional (2D) tagged
MR imaging also correlates better with global
systolic ventricular function parameters than does
percentage wall thickening [12]. Clinical analysis of
tagged MR images is time consuming, however,
19
20
One of the earliest and most established indications of MRCA is the evaluation of anomalous
coronary arteries. This condition has a prevalence
of approximately 1.2%. Anomalous coronary arteries
may arise from an alternate aortic sinus of Valsalva,
from a branch of another coronary artery, or, rarely,
from the pulmonary artery [38]. These variant origins
are usually benign. If the artery travels between the
aorta and main pulmonary artery or right ventricular
outflow tract, however, there may be associated
myocardial ischemia and infarction or sudden death,
especially among adolescents and young adults [39].
X-ray coronary angiography is limited in the identification of anomalous vessels due to its projectional
nature and, therefore, is not used as a screening tool
in young adults. MRCA techniques have shown
excellent results for the identification and definition
(93% 100% of the cases) of anomalous coronary
arteries. Additionally, MRCA may classify cases that
could not be classified or were misclassified by x-ray
coronary angiography [40 42].
Differentiation between patent or occluded coronary artery bypass grafts was one of the initial
applications of MRCA. Venous bypass grafts often
have less motion, a larger lumen, and a straighter
course than do native coronary arteries. MR angiography that utilizes: black-blood and bright-blood 2D
techniques; breathholds; 3D contrast-enhancement;
and navigator gating have been shown to be useful
in demonstrating patency of bypass grafts (both
internal mammary arteries and saphenous veins)
[44,45]. Sensitivities range from 86% to 100% for
2D spin echo and GRE methods with specificities
from 59% to 96% and accuracies from 78% to 100%.
Studies with contrast-enhanced 3D MR angiography
reported greater than 93% for sensitivity, specificity,
and accuracy.
There has been limited experience using flow
measurements in bypass grafts. The determination of
the flow reserve ratio in bypass grafts may be useful for
identifying stenoses [46]. Previously, an important
limitation was the inability to evaluate all of the segments of multiple grafts within the duration of the
stress testing. Currently, however, a breath-hold,
hybrid, fast GRE echo planar imaging (EPI), phasecontrast (PC) sequence with a high temporal resolution
(23 milliseconds) now permits measurement of flow in
Kawasaki disease
MRCA has been proposed for noninvasive follow-up evaluation of children with coronary artery
Fig. 2. Large mass located ventrally of the heart with secondary compression of the right ventricular outflow tract and left
ventricle corresponding to a coronary artery aneurysm. Both black-blood (arrows, A) and cine bright-blood (arrowhead, B)
images show a small lumen.
21
(seen as a black jet). This is due to turbulent dephasing of spins either proximal or distal to the diseased
valve [57]. The extent of dephasing corresponds to
valvular dysfunction measured by color Doppler
echocardiography or cardiac catheterization [58
61]. The size of the MR signal void, however,
depends on acquisition parameters such as echo time
(TE), repetition time (TR), voxel size, and orientation
of the imaging plane relative to the flow jet [62,63].
Recently introduced steady-state free precession
(SSFP, commercially known as trueFISP, FIESTA, or
BalancedFFE) pulse sequences have shorter TEs and
TRs than do the conventional GRE sequences. Spin
dephasing is, therefore, much less pronounced making this an unreliable sequence for valve evaluation.
PC (velocity mapping) MR allows for quantification
and severity assessment of valve stenosis by calculating the valve orifice area and the transvalvular
pressure gradient. With this sequence, it is possible
to directly measure the peak jet velocity (Vmax, ie, in
the aorta up to 5 meters per second) at or just distal to
the valve. Emerging real-time techniques and
ongoing improvements in analysis software programs
with subsequent reduction in examination time and
data postprocessing may ease the use of MR in this
patient population, especially for pediatric patients.
Cardiomyopathies
Arrhythmogenic right ventricular dysplasia
One of the established indications for MR is the
assessment of arrhythmogenic right ventricular dysplasia (ARVD). ARVD is characterized by fatty or
fibrous infiltration with extreme thinning or thickening and wall motion abnormalities of the right
ventricle free wall [64]. These changes are the origin
for ventricular arrhythmias in adolescents or young
adults. Patients present with palpitations, syncope,
and, less commonly, sudden death. The clinical
diagnosis of ARVD is based on presence of criteria
that include structural and functional cardiac changes,
ECG abnormalities, and family history [64].
MR imaging is the most commonly used imaging
method for ARVD, due to its excellent soft tissue
contrast and the ability to depict morphology and
function (Fig. 3). To assess morphology, black-blood
double-IR FSE sequences are used. Alternatively,
gated spin echo axial images are obtained, beginning
above the pulmonary valve and extending inferiorly
down to the diaphragm. Saturation bands may be
placed over the anterior chest wall to reduce motion artifact.
22
Fig. 3. Thirty-five-year-old female athlete with positive diagnosis of ARVD. The double-IR, FSE, black-blood images without
(top) and with (bottom) spectrally selected fat suppression show high signal intensity areas within the right ventricle free wall
corresponding to fat (solid arrows), due to the signal loss with fat suppression. Note the depiction of the border between the right
ventricle myocardium and the epicardial fat (arrowheads), and the characteristic pattern of fat infiltration with irregular borders
starting from the epicardium toward the endocardium. On the cine bright-blood images (not shown), there are wall motion
abnormalities with dyskinesia in the corresponding areas of the middle and apical third of the right ventricle free wall. In
addition, there is an enlarged or dilatated right ventricle outflow tract (asterisk) in comparison with the left ventricle outflow tract
(in normal conditions both are of similar size).
raphy, however [5,69]. Cine GRE sequences demonstrate the degree and extension of left ventricular
hypertrophy [70]. In patients with obstructing septal
hypertrophy, cine GRE sequences have been used
for semiquantitative assessment of the degree of
dynamic left ventricle outflow tract obstruction and
associated mitral regurgitation [71] (Fig. 4).
Contrast-enhanced techniques have been applied
in patients with hypertrophic obstructive cardiomyopathy for which percutaneous transluminal septal
myocardial ablation is performed. With this technique, an alcohol-induced occlusion of the first septal
branch of the left anterior descending coronary artery
is performed, creating a controlled proximal septal
acute MI. Both first-pass perfusion and delayed
contrast-enhanced MR techniques combined with
cine sequences are used to document the extent and
location of the ablation [72].
Further insights into the left ventricle mechanics
of hypertrophic cardiomyopathy have been obtained
with tagged-MR techniques, but their clinical usefulness remains to be determined [73 75]. Absolute
coronary blood flow rate per gram of myocardial
mass and the vasodilator flow reserve have been
measured with MR imaging and are significantly
lower in this patient population when compared with
healthy subjects [76]. These findings could be used to
evaluate the functional severity of the disease and
determine the prognosis.
23
Fig. 4. Hypertrophic cardiomyopathy in a 45-year-old male. The black-blood image obtained with a double-IR FSE image (left)
shows the global thickening of the left ventricle myocardium, particularly in the septum. The images obtained postcontrast (right,
top and bottom) with an IR-prepared fast GRE sequence demonstrate an irregular, diffuse pattern of enhancement mainly in the
septum. The mechanism that explains the enhancement is not well known, but is thought to be due to fibrosis.
Dilated cardiomyopathy
Dilated cardiomyopathy is characterized by ventricular enlargement with depressed contractile and
diastolic left ventricle function. Cine MR sequences
have been used for diagnosing dilated cardiomyopathy and for evaluating response to drug therapy (ie,
angiotensin-converting enzyme) [77]. The use of
gadolinium-enhanced techniques has been advocated
for the diagnosis and follow-up of dilated cardiomyopathy secondary to acute viral myocarditis. This
method is preferred over the T2 sequences used for
edema visualization [78]. Contrast-enhanced images
can detect myocardial edema early in the course of
the disease (starting on the second day). In addition,
the degree of myocardial enhancement can be correlated to clinical status and left ventricle function.
Pericardial disease
Restrictive cardiomyopathy
Restrictive cardiomyopathy is characterized by
diastolic dysfunction (restricted ventricular filling
and reduction in diastolic volume) of one or both
ventricles, with normal to reduced left ventricle
systolic function [79]. The condition may be idiopathic or associated with systemic disorders such as
amyloidosis, hemochromatosis, and sarcoidosis. An
established indication for cardiac MR is differentiation of restrictive cardiomyopathy from constrictive pericarditis (Fig. 5). Pericardial thickening
24
Fig. 5. Constrictive pericarditis versus restrictive cardiomyopathy. The double-IR FSE sequence (top right) shows pericardial
thickening (5 mm, solid arrow) and diastolic filling impairment with contralateral bouncing of the septum in diastole, confirmed
with the cine GRE images obtained at end diastole and end systole (bottom left and bottom right, respectively). Additional signs
of right heart failure are the enlarged hepatic veins and hepatomegaly.
Cardiac masses
Metastases to the heart are much more common
(20-fold to 40-fold) than are primary cardiac tumors.
25
Summary
Vascular structures
Gadolinium-enhanced, 3D, MR angiography
techniques are particularly helpful for the evaluation
of the vascular structures [91]. Using this method,
anomalies of the aorta such as vascular rings (double
aortic arch, right aortic arch, aberrant left subclavian
artery, or coarctation with or without aortic hypoplasia) are well visualized and their size can be
measured accurately. Pulmonary branch arteries and
veins are also well visualized, even in the postoperative period. Cardiac catheterization in patients
with abnormal vascular structures potentially can be
avoided using MR imaging unless knowledge of the
coronary anatomy is required or an angioplasty
is planned.
Ventricular function
Myocardial tagging techniques have provided
insight into subtle changes in the normal heterogeneous cardiac regional function of both ventricles in
infants [92,93]. In patients with congenital heart
disease, studies on single right and left ventricles
have shown the importance of interactions between
both ventricles in the cardiac contraction sequence
[89,92]. Compared with echocardiography, the right
ventricle size and function can be assessed more
accurately by MR imaging. This is most relevant in
the management of patients with disorders such as
transposition of great vessels, interventricular and
interatrial shunts, or after repair of tetralogy of
Fallot. An emerging field for MR imaging is the
examination performed in the prenatal stage, which
has provided accurate diagnosis of congenital heart
disease [94].
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27
28
[71] Pattynama PM, Lamb HJ, Van DV, et al. Left ventricular measurements with cine and spin-echo MR imaging: a study of reproducibility with variance
component analysis. Radiology 1993;187:261.
[72] Schulz-Menger J, Strohm O, Waigand J, et al. The value of magnetic resonance imaging of the left ventricular
outflow tract in patients with hypertrophic obstructive
cardiomyopathy after septal artery embolization. Circulation 2000;101(15):1764 6.
[73] Dong SJ, MacGregor JH, Crawley AP, et al. Left ventricular wall thickness and regional systolic function in
patients with hypertrophic cardiomyopathy. A threedimensional tagged magnetic resonance imaging study.
Circulation 1994;90:1200.
[74] Kramer CM, Reichek N, Ferrari VA, et al. Regional
heterogeneity of function in hypertrophic cardiomyopathy. Circulation 1994;90:186.
[75] Maier SE, Fischer SE, McKinnon GC, et al. Evaluation
of left ventricular segmental wall motion in hypertrophic cardiomyopathy with myocardial tagging. Circulation 1992;86:1919.
[76] Kawada N, Sakuma H, Yamakado T, et al. Hypertrophic cardiomyopathy: MR measurement of coronary
blood flow and vasodilator flow reserve in patients
and healthy subjects. Radiology 1999;211:129.
[77] Doherty NE, Seelos KC, Suzuki J, et al. Application of
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[78] Friedrich MG, Strohm O, Schulz-Menger J, et al. Contrast media-enhanced magnetic resonance imaging visualizes myocardial changes in the course of viral
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[80] Masui T, Finck S, Higgins CB. Constrictive pericarditis and restrictive cardiomyopathy: evaluation with MR
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[82] Blankenberg F, Eisenberg S, Scheinman MN, et al. Use
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* Corresponding author.
E-mail address: florian.vogt@uni-essen.de (F.M. Vogt).
Technical considerations
Contrast-enhanced three-dimensional MRA of the
thoracic vasculature offers several advantages over
conventional MRA techniques, including shorter
acquisition times and high spatial resolution in conjunction with high signal- and contrast-to-noise. In
many centers, the availability of contrast-enhanced
three-dimensional MRA has profoundly impacted
diagnostic strategies for exploring the thoracic vascular system [4 6]. Requiring only a peripheral
intravenous catheter and administration of contrast
agents characterized by an excellent safety profile
[7,8], three-dimensional MRA techniques has vastly
lowered the threshold for assessing the arterial and
venous morphology of the thoracic vessels.
Paramagnetic contrast agents are pivotal for displaying the vascular system with fast three-dimensional gradient echo sequences. Without the presence
of paramagnetic contrast, these sequences, characterized by very short repetition and echo times, render
nondiagnostic images void of any intravascular signal.
The presence of paramagnetic contrast in the vascular
system over the length of the data acquisition period is
crucial for successful contrast-enhanced three-dimensional MRA.
Paramagnetic contrast shortens the T1 relaxation
time of blood. Gadolinium (Gd), the most commonly
used paramagnetic substance, has a high relaxivity
and a favorable safety profile when bound to a
chelate. During the short intravascular phase the
intravenously injected T1 shortening contrast agent
provides signal in the arterial and venous systems,
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Paramagnetic contrast
There are several paramagnetic contrast agents
available today. Currently, only extracellular nonbinding Gd chelates with a concentration of 0.5 mol/L
have regulatory approval for use in humans [16]. In
the United States, no agent is currently approved for
MRA by the Food and Drug Administration and any
such use constitutes off-label use of an approved drug.
Several paramagnetic intravascular Gd-based agents
and superparamagnetic compounds are currently
undergoing clinical and preclinical testing [17 20].
With higher infusion rates the local concentration
of the contrast in the vessel of interest is higher, but
because of a faster venous return there is a shorter
arterial-venous time window for imaging. Contrast
compounds with higher concentration formulations,
such as Gadovist 1 mol/L (Schering, Berlin, Germany), might be advantageous when slow infusion
protocols are used. Preliminary results comparing
a 0.5 mol/L contrast agent (Magnevist, Schering,
Berlin, Germany) with Gadovist 1 mol/L in pelvic
MRA are very promising with regard to arterial
enhancement [21].
Some newer agents, such as Multihance (Bracco,
Milan, Italy), have higher relaxivity because of a
transient binding to albumin and different routes of
excretion but are still distributed into the extracellular
space. Blood pool or intravascular contrast agents are
sufficiently large or bind to large molecules when
injected. This prevents them from leaking out of the
capillaries and confines them to the intravascular
compartment for extended periods of time. The major
disadvantage of intravascular contrast agents is the
early venous enhancement leaving a short window
for arterial imaging. This represents a particular
problem in the lower legs, where venous overlap
can seriously impair the ability to assess the arteries.
These agents are likely to play a dominant role in the
assessment of the coronary arteries [22,23].
In view of the rapid progress of MRA techniques
using extracellular agents, the future of intravascular
contrast agents for morphologic imaging of the arterial vascular tree (with the exception of the coronary
arteries) remains uncertain.
The paramagnetic agent is generally administered
by an intravenous catheter placed into an antecubital
vein. To achieve maximal image quality, the presence
of the intravenously administered contrast bolus in
the vascular territory under consideration must coincide with the data acquisition period. Several manual
and automated techniques are available to ensure
proper timing of the scan delay and are discussed
later. Maximal contrast concentration in the vessel of
31
32
Fig. 1. Normal contrast-enhanced MRA of the thoracic aorta in a 28-year-old healthy volunteer acquired in the coronal plane. (A)
Maximum intensity projection (MIP) reformation of a coronal three-dimensional MRA data set using a standard phased array
coil. (B) Coronal MIP image achieved with twofold simultaneous magnetization of spatial harmonics reduction using a new sixelement cardiac array. (C) Coronal MIP image with twofold sensitivity encoding reduction. A spatial resolution of 1.7 0.8
1.8 mm3 was achieved with decrease of scan time almost to 50% in Fig. 1B and C. Despite the intrinsic drawback in signal-tonoise ratio, the coronal MIP is of nearly identical diagnostic value.
Other techniques
The recently developed steady-state free precession (SSFP) gradient echo sequence (ie, TrueFISP,
FIESTA, balanced fast field echo) is characterized by
balanced gradients in all three directions, ensuring
maximum recovery of the transverse magnetization
[42,43]. At the end of the TR, the transverse magnetization is refocused, and the next excitation can be
started without further preparation. The image contrast with SSFP is determined by favorable T2*-T1
properties that are nearly independent from blood
flow [44]. The main advantage of this sequence
33
Fig. 2. A 57-year-old man with unknown right-sided chest pain and raised central venous pressure. Exclusion of suspected
central, chest tumor. (A) Coronal view of venous three-dimensional MRA data set delineating lack of contrast filling in the vena
cava superior. (B) Sagittal view of cine-mode TrueFISP sequence allowing differentiation between completely obstructed vena
cava superior and partially thrombosed right atrium and slow-flowing blood. (C) Coronal maximum intensity projection of the
thoracic vessels in venous phase missing the vena cava superior and delineating collateral flow in azygos and cervicothoracic
veins. (D) TrueFISP four-chamber view showing almost complete clotting of right atrium.
34
Image analysis
The high contrast between Gd-containing luminal
(bright) and extraluminal (dark) spins and the true
three-dimensional nature of the acquired data sets
provides the basis for using a variety of postprocessing algorithms. Analysis should never be limited to
maximum intensity projections or surface-shaded
display. The three-dimensionality inherent to the
technique can only be exploited fully if the data are
viewed interactively on a workstation using multiplanar reformations. Endoluminal, virtual angioscopic
images can also be obtained, but their clinical relevance is very limited.
Clinical applications
Contrast-enhanced three-dimensional MRA has
proved to be a versatile noninvasive imaging modality for analysis of thoracic arteries and veins. In
the following sections various imaging indications
involving the thoracic aorta, the pulmonary arteries
and pulmonary veins, and the thoracic systemic veins
are discussed.
Thoracic aorta
Although CT remains the modality of choice in all
acute, life-threatening conditions involving the thoracic aorta, contrast-enhanced three-dimensional
MRA has emerged as the imaging modality of choice
for assessing the thoracic aorta in the more stable
patient. The technique overcomes respiratory and
cardiac motion artifacts, which impair noncontrast
35
Fig. 3. A 64-year-old man with acute thoracic pain. (A) Maximum intensity projection reformats of coronal three-dimensional
MRA data set (oblique sagittal plane) demonstrate aortic dissection distal to the origin of the left subclavian artery. (B) Axial
multiplanar reformation. (C) Sagittal multiplanar reformation.
surgery is often a difficult clinical decision, however, particularly in asymptomatic patients or those
with comorbid conditions.
A recommendation of surgery represents a balance. Clinicians must weigh estimates of thoracic
aortic aneurysm natural history and rupture risk
against operative mortality and complication rate.
This risk is related to the site, etiology, size, and
expansion rate of the aneurysm. MR imaging of an
aortic aneurysm can demonstrate the site of aneurysm, its length, morphology, and relationship of the
aneurysm to branch vessels and the presence of mural
thrombus or a penetrating ulcer. All of these findings
can affect surgical decision making. Furthermore, the
aortic valve needs to be assessed for the presence of
valvular stenosis or insufficiency.
Complex underlying arterial morphology in
patients with thoracic aortic aneurysm may result in
an inadvertent exclusion of important portions of the
arterial anatomy from the three-dimensional imaging
volume. It is important to conduct the localizing process carefully using breathhold techniques
(Fig. 4). For imaging aortic aneurysms, which contain
slow flow, it is important to anticipate a long contrast
travel time to fill the entire aorta. As mentioned
previously, three-dimensional MRA contains little
information about the morphology of the aortic wall,
and should be complemented by T1-weighted postcontrast images in diagnosis of an aneurysm.
36
Fig. 4. Excessive aneurysm of the ascending aorta. (A) Sagittal maximum intensity projection projection demonstrates the
aneurysm originating immediately above the aortic valve and involving the supra-aortic vessels. (B) Axial half-Fourier singleshot turbo spin echo sequence delineating an extensive wall-adherent thrombus in the posterior part of descending aorta. No
dissection was observed.
Fig. 5. A 28-year-old man with coarctation of the aorta. Note the dilated proximal left subclavian artery. (A) Sagittal maximum
intensity projection projection. (B) Corresponding sagittal multiplanar reformation.
37
Fig. 6. A 29-year-old male conductor with left-sided arm weakness and known occlusion of subclavian and internal jugular vein
of the right side. Left-sided functional subclavian vein stenosis at the transition to brachiocephalic vein was suspected and
proofed using dynamic three-dimensional MRA. (A) Coronal maximum intensity projection (MIP), early phase. (B) Coronal
MIP, late phase.
38
Fig. 8. A 49-year-old man with suspected pulmonary arteriovenous malformation on chest radiograph in the right lower lobe.
The three-dimensional MRA data set revealed the feeding vessels and sharp delineated small nodules. The diagnosis was OslerWeber-Rendu disease. (A) Coronal maximum intensity projection reconstruction. (B) Shaded surface reconstruction
anteroposterior view of the arteriovenous malformation.
Summary
Using the described strategies all relevant disease
processes of the thoracic vessels can be fully
depicted using contrast-enhanced three-dimensional
MRA. The aorta and the major neck and arm vessels
are well visualized. Vascular pathologies, such as
aneurysms, dissections, and occlusions, are readily
recognized. With the implementation of high-performance gradients, three-dimensional MRA of the
pulmonary vasculature has become possible even in
dyspneic patients. Congenital lesions, such as coarctations, are particularly well suited for analysis with
these techniques.
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
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[1] Prince MR, Yucel EK, Kaufman JA, et al. Dynamic
gadolinium-enhanced three-dimensional abdominal
MR arteriography. J Magn Reson Imaging 1993;
3:877 81.
[2] Leung DA, McKinnon GC, Davis CP, et al. Breathhold, contrast-enhanced, three-dimensional MR angiography. Radiology 1996;200:569 71.
[3] Prince MR, Narasimham DL, Stanley JC, et al. Breathhold gadolinium-enhanced MR angiography of the abdominal aorta and its major branches. Radiology
1995;197:785 92.
[4] Hartnell GG, Finn JP, Zenni M, et al. MR imaging of
the thoracic aorta: comparison of spin-echo, angiographic, and breathhold techniques. Radiology 1994;
191:697 704.
[5] Krinsky GA, Rofsky NM, DeCorato DR, et al. Thoracic aorta: comparison of gadolinium-enhanced three-
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[22] Li D, Zheng J, Bae KT, et al. Contrast-enhanced magnetic resonance imaging of the coronary arteries: a review. Invest Radiol 1998;33:578 86.
[23] Zheng J, Li D, Cavagna FM, et al. Contrast-enhanced
coronary MR angiography: relationship between coronary artery delineation and blood T1. J Magn Reson
Imaging 2001;14:348 54.
[24] Carroll TJ, Korosec FR, Swan JS, et al. The effect
of injection rate on time-resolved contrast-enhanced
peripheral MRA. J Magn Reson Imaging 2001;14:
401 10.
[25] Svensson J, Petersson JS, Stahlberg F, et al. Image
artifacts due to a time-varying contrast medium concentration in 3D contrast-enhanced MRA. J Magn Reson Imaging 1999;10:919 28.
[26] Lee VS, Martin DJ, Krinsky GA, Rofsky NM. Gadolinium-enhanced MR angiography: artifacts and pitfalls. AJR Am J Roentgenol 2000;175:197 205.
[27] Prince MR, Narasimham DL, Jacoby WT, et al. Threedimensional gadolinium-enhanced MR angiography of
the thoracic aorta. AJR Am J Roentgenol 1996;
166:1387 97.
[28] Earls JP, Rofsky NM, DeCorato DR, et al. Breathhold single-dose gadolinium-enhanced three-dimensional MR aortography: usefulness of a timing examination and MR power injector. Radiology 1996;
201:705 10.
[29] Kreitner KF, Kunz RP, Kalden P, et al. Contrast-enhanced three-dimensional MR angiography of the
thoracic aorta: experiences after 118 examinations with
a standard dose contrast administration and different
injection protocols. Eur Radiol 2001;11:1355 63.
[30] Foo TK, Saranathan M, Prince MR, Chenevert TL.
Automated detection of bolus arrival and initiation of
data acquisition in fast, three-dimensional, gadolinium-enhanced MR angiography. Radiology 1997;
203:275 80.
[31] Fellner FA, Fellner C, Wutke R, et al. Fluoroscopically
triggered contrast-enhanced 3D MR DSA and 3D timeof-flight turbo MRA of the carotid arteries: first clinical
experiences in correlation with ultrasound, x-ray angiography, and endarterectomy findings. Magn Reson
Imaging 2000;18:575 85.
[32] Wilman AH, Riederer SJ, King BF, et al. Fluoroscopically triggered contrast-enhanced three-dimensional
MR angiography with elliptical centric view order: application to the renal arteries. Radiology 1997;205:
137 46.
[33] Goyen M, Laub G, Ladd ME, et al. Dynamic 3D MR
angiography of the pulmonary arteries in under four
seconds. J Magn Reson Imaging 2001;13:372 7.
[34] Hennig J, Scheffler K, Laubenberger J, Strecker R.
Time-resolved projection angiography after bolus injection of contrast agent. Magn Reson Med 1997;
37:341 5.
[35] Sodickson DK, McKenzie CA, Ohliger MA, et al. Recent advances in image reconstruction, coil sensitivity
calibration, and coil array design for SMASH and generalized parallel MRI. MAGMA 2002;13:158 63.
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[60] Goyen M, Barkhausen J, Kuehl H, et al. [Contrastenhanced 3D MR venography of central thoracic veins:
preliminary experience]. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2001;173:356 61.
[61] Spuentrup E, Buecker A, Stuber M, Gunther RW. MRvenography using high resolution True-FISP. Rofo
Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr
2001;173:686 90.
[62] Kauczor HU, Gamroth AH, Tuengerthal SJ, et al. [MR
angiography: its use in pulmonary and mediastinal
space-occupying lesions]. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 1992;157:15 20.
[63] Gupta A, Frazer CK, Ferguson JM, et al. Acute pulmonary embolism: diagnosis with MR angiography.
Radiology 1999;210:353 9.
[64] Kauczor HU, Heussel CP, Thelen M. Update on diagnostic strategies of pulmonary embolism. Eur Radiol
1999;9:262 75.
[65] Meaney JF, Johansson LO, Ahlstrom H, Prince MR.
Pulmonary magnetic resonance angiography. J Magn
Reson Imaging 1999;10:326 38.
[66] Wielopolski PA, Hicks SG, de Bruin HG, Oudkerk M.
Breath-hold three-dimensional lung perfusion imaging
and pulmonary angiography after contrast administration. In: Oudkerk M, Edelman RR, editors. Highpower gradient MR-imaging: advances in MRI. Oxford: Blackwell Science; 1997. p. 71.
[67] Goyen M, Ruehm SG, Jagenburg A, et al. Pulmonary
arteriovenous malformation: characterization with
time-resolved ultra-fast 3D MR angiography. J Magn
Reson Imaging 2001;13:458 60.
[68] Schoenberg SO, Knopp MV, Grau A, et al. [Ultrafast
MRI phlebography of the lungs]. Radiologe 1998;
38:597 605.
Breast MR imaging
Mitchell D. Schnall, MD, PhD
Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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45
46
Image interpretation
Interpretation of breast MR images is best performed on a computer workstation where reformatting, image processing, image subtraction, and image
quantitation is available. Film presentations are difficult, due to the number of images that comprise a
breast MR imaging examination. This makes it difficult for patients to have images available for second
opinions at other institutions. It is suggested that at
least one early phase postcontrast image set that
includes the entire breast be available on film at the
patients request. In addition, selected images including reformatting and subtraction through any
significant findings should be available. Associated
enhancement curves should also be available on film
or paper copy if they are felt to be relevant. This is the
minimum information needed by a colleague in
another institution to assist in the patients care.
The major task in interpreting breast MR imaging
is establishing the likelihood of malignancy for any
enhancement observed. There are two major classes
of image features that are available to the radiologist
Fig. 1. (A) Example of stippled regional enhancement from benign hyperplasia. (B) Lobulated focal mass, representing
a fibroadenoma.
47
Fig. 2. (A) Irregular-bordered enhancing mass secondary to invasive cancer. (B) Smooth-bordered enhancing mass, representing
a fibroadenoma.
48
49
50
Summary
Contrast-enhanced breast MR imaging has made
significant progress since its introduction into the
radiological literature in 1989. The techniques and
technology continue to be refined, and understanding
of the interpretation strategies has improved dramatically. Clinical applications in difficult diagnostic
cases and the evaluation of the extent of breast cancer
are now being practiced in many centers worldwide.
There is great excitement over the potential for breast
MR imaging to address the problem of screening
high-risk women. Despite all of the progress made
over the past years, however, there is still a significant amount of work ahead before a clear understanding of how this technique will affect the health
care of women is obtained.
References
[1] National Institutes of Health consensus development
conference statement: treatment of early breast cancer.
Bethesda, MD, June 18 21, 1990.
[2] Dash N, Lupetin AR, Daffner RH, et al. Magnetic
resonance imaging in the diagnosis of breast disease.
AJR Am J Roentgenol 1986;146:119 25.
[3] Stelling CB, Wang PC, Lieber A, et al. Prototype coil
for magnetic resonance imaging of the female breast.
Radiology 1985;154:457 62.
[4] Kaiser WA, Zeitler E. MR imaging of the breast: fast
imaging sequences with and without Gd-DTPA. Radiology 1989;170:681 6.
[5] Heywang SH, Wolf A, Pruss E, et al. MR imaging of
the breast with Gd-DTPA: use and limitations. Radiology 1989;171:95 103.
[6] Harms SE, Flamig DP, Hesley KL, et al. MR imaging
of the breast with rotating delivery of excitation off
resonance: clinical experience with pathologic correlation. Radiology 1993;187:493 501.
[7] Kuhl CK, Mielcareck P, Klaschik S, et al. Dynamic
breast MR imaging: are signal intensity time course
data useful for differential diagnosis of enhancing lesions? Radiology 1999;211(1):101 10.
[8] Orel SG, Schnall MD, LiVolsi VA, Troupin RH.
Suspicious breast lesions: MR imaging with radiologic pathologic correlation. Radiology 1994;190:
485 94.
The advantages of MR imaging in the investigation of liver disease are well documented. The lack of
ionizing radiation of MR imaging and the safety of
gadolinium chelates are important considerations.
Unlike iodinated contrast agents, gadolinium chelates
have negligible effects on renal function in patients
with renal failure and are much less likely to result in
major allergic reactions [1]. Moreover, recent developments in MR imaging, including fast scanning
techniques and new MR imaging contrast agents,
enable improved detection and characterization of
many liver lesions so that a definitive diagnosis can
be made noninvasively. Lesion characterization and
determination of the extent of disease often have
important prognostic and therapeutic implications.
Since the early 1990s, reports comparing current
MR imaging and CT approaches have shown that
MR imaging is more accurate than contrast-enhanced
CT for the detection and characterization of liver
lesions [2 8]. Earlier publications compared MR
imaging to dynamic contrast-enhanced CT, whereas
later studies compared MR imaging to CT arterial
portography or spiral CT. Comparisons to multidetector CT have not been published yet, but the
two modalities are probably nearly equivalent in the
evaluation of intrahepatic disease.
The aim of this article is to review the features
of liver masses using current state-of-the-art MR
imaging techniques, and to discuss the role of new
liver-specific contrast agents in the detection and
characterization of liver masses.
* Corresponding author.
E-mail address: ikamel@jhmi.edu (I.R. Kamel).
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52
allows for a greater dynamic range of signal intensities to be displayed in the images. This can cause
increased conspicuity of focal lesions in the liver.
Because of local field inhomogeneities, however, it is
necessary to perform manual tuning of the fat suppression pulse on most systems. In addition, fat
suppression away from the isocenter of the magnet
may not be effective.
Half-Fourier acquisition single-shot turbo spin
echo (HASTE) or single-shot FSE sequence provides
breath-hold T2-weighted imaging of the liver. The
technique is acquired just over half of the k-space
in single echo train. The symmetry of the k-space
allows for mathematical reconstruction of the image
[21 23]. HASTE is helpful in patients who are
unable to breath hold because it can be acquired in
less than 1 second. Effectively the TR is infinite (or
undefined), whereas the TE can be manipulated to
achieve different contrasts. HASTE has been shown
to be effective for characterizing cysts and hemangiomas with long T2 times. HASTE is not effective
for tumor detection due to poor contrast resolution for
lesions with moderate T2 times. It should not be used
as the primary sequence for liver tumor detection.
Contrast-enhanced sequences
Intravenous contrast agents have been used in
evaluating the liver since the late 1980s. The use of
contrast agents can potentially increase the sensitivity
and specificity of liver MR imaging in detection and
characterization of liver lesions.
The first category of contrast agents to be used in
clinical practice was extracellular gadolinium chelates. Two other classes of contrast agents, reticuloendothelial system (RES) specific and hepatocyte
selective, recently have been developed and employed
for liver studies. In addition, contrast agents that have
combined perfusional and hepatocyte selective functions recently have been introduced, and their utility is
discussed below.
Extracellular gadolinium chelates
There are two physiological principles that allow
targeting contrast enhancement: the dual blood supply
of the liver and the hemodynamics of hepatic tumors.
The liver is unique among abdominal organs in having
a dual blood supply, with the portal vein supplying
75% to 80% of flow and the hepatic artery supplying
the remaining 20% to 25%. Liver tumors, however,
receive nearly all their blood supply from the hepatic
artery. Hepatic tumors are divided into hypovascular
or hypervascular, relative to the vascularity of the
liver. Most benign and malignant hepatic masses are
53
been valuable in generating high-quality MR angiograms, allowing for accurate depiction of the vascular
anatomy of the liver.
RES contrast agents
Ion oxide particulate agentsformerly termed
superparamagnetic iron oxide (SPIO)are currently
identified as ferumoxides. Ferumoxides (marketed in
the United States under the tradename Feridex, Berlex
Laboratories Inc., Wayne, NJ) are taken up by cells of
the reticuloendothelial system in the liver, spleen, and
bone marrow. Ferumoxide is administered IV in
100 mL D5W over approximately 30 minutes. The
agent is distributed relatively rapidly to the liver,
spleen, and bone marrow. The agent is contraindicated
in patients with hemochromatosis or hypersensitivity
to iron. Other than idiosyncratic reactions, the other
possible side effect is back pain, although this is
infrequent (4% of patients) [26]. This side effect
begins 5 7 minutes after contrast agent administration, is probably related to the particulate agents, and
is not specific to ferumoxides. If the patient complains
of back pain, the infusion should be stopped immediately. The pain will gradually resolve over 10 to
15 minutes. In our experience, we have been able to
restart and finish administration of the ferumoxide,
and acquire the necessary sequences.
Ferumoxides are T2* contrast agents, so the largest signal change is on T2-weighted and T2*weighted images. The liver shows decreased signal
intensity, as does the spleen and marrow. The normal
liver takes up the agent, resulting in increased contrast-to-noise ratio between tumor and normal liver
[6,7,26]. On T1 images, there is typically some
circulating contrast agent and blood vessels show
increased signal intensity. Our current protocol
includes T1-weighted breath-hold GRE images of
the liver, and FSE T2-weighted images, which require
about 15 minutes. The patient is then removed from
the scanner, and the contrast agent is administered.
After contrast administration, the same pulse sequences are repeated again. Hepatocellular lesions, such as
adenoma or focal nodular hyperplasia (FNH), contain
reticuloendothelial cells, so they will behave similar
to the liver, with decreased signal on T2-weighted
images [27]. Focal lesions that do not contain reticuloendothelial cells maintain nearly the same signal
intensity before and after the administration of contrast material, but are rendered relatively higher in
signal due to a loss of signal in background liver.
Moderate or poorly differentiated HCC do not change
signal after ferumoxide; thus, they are easily detected
(Fig. 1). Well-differentiated HCC, however, may
contain reticuloendothelial cells and may show signal
54
Fig. 1. Patient with cirrhosis and poorly differentiated HCC. (A) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds)
shows slightly hyperintense tumor in the right lobe (arrow). (B) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds)
30 minutes after ferumoxide injection shows drop in signal intensity of the liver and spleen, but no enhancement of the tumor.
This results in increased tumor conspicuity.
Smaller particulate agents are known as ultrasmall particles iron oxide (USPIO) [26], and these
have a more prolonged intravascular half-life than
do the larger particle agents. In a dilute intravascular
phase, USPIO possess T1 effects that are similar to
the vascular phase effects of T1 agents. Therefore,
they can provide additional characterization information. Additionally, USPIO can be administered as a
rapid IV bolus in a very small volume, making them
more convenient to use and minimizing potential
back pain.
Hepatocyte-selective contrast agents
An agent commonly utilized is marketed currently
under the name Teslascan (Nycomed Inc., Princeton,
Fig. 2. Patient with FNH. (A) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds) showing subtle lesion (arrow) that
is minimally hyperintense to liver. (B) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds) 30 minutes after
ferumoxide injection showing homogenous tumor enhancement. FNH frequently shows significant signal intensity loss after
ferumoxide, usually more than do other primary liver tumors. This is due to the presence of reticuloendothelial cells within the
tumor, resulting in increased contrast uptake.
55
Fig. 3. Patient with colon cancer and liver metastasis. (A) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds,
70 flip angle) shows a subtle slightly hypointense lesion in segment 4b (arrow). (B) Axial, FSE, T2-weighted image (TR/TE
3500/100 milliseconds) shows the lesion as hyperintense related to liver parenchyma. (C) Axial, T1-weighted, FMPSPGR image
(TR/TE 110/4.4 milliseconds, 70 flip angle) 3 minutes after Teslasan injection showing increased lesion conspicuity. Metastases
do not contain hepatocytes, and therefore do not enhance following Teslascan administration.
56
Fig. 4. Patient with exophytic fibrolamellar HCC. (A) Axial, T1-weighted FMPSPGR image (TR/TE 110/4.4 milliseconds, 70
flip angle) shows large exophytic mass connected to segment 2 of the left lobe (arrow). (B) Axial, T1-weighted, FMPSPGR
image (TR/TE 110/4.4 milliseconds, 70 flip angle) 3 minutes after Teslasan injection shows mass enhancing similar to the same
degree as the liver. This confirms that the mass is hepatic in origin, and not a gastrointestinal stromal tumor.
Fig. 5. Patient with two large adenomas. (A) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip angle)
shows a large hemorrhagic adenoma (arrow). A subtle nonhemorrhagic lesion is identified in the right lobe (curved arrow). (B)
Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip angle) 3 minutes after Teslasan injection shows
homogenous enhancement of the nonhemorrhagic mass, likely due to the presence of hepatocytes.
57
Fig. 6. Patient with metastatic colorectal cancer. (A) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70
flip angle) shows an ill-defined hypointense lesion in segment 4b (arrow). (B) Axial, T1-weighted, FMPSPGR image (TR/TE
110/4.4 milliseconds, 70 flip angle) 60 seconds after Eovist injection (Diagnostic Imaging Berlex Laboratories Inc., Wayne, NJ)
shows minimal heterogeneous enhancement of the same lesion. (C) Axial, T1-weighted, FMPSPGR image (TR/TE 110/
4.4 milliseconds, 70 flip angle) 20 minutes after Eovist injection shows better definition of tumor contour and increased lesion
conspicuity. Metastases do not enhance on delayed images, and therefore can be differentiated from other hepatic tumors.
Hepatic cysts
Simple cysts are derived from biliary endothelium. They contain thin serous fluid, not bile, and
are lined by a single layer of epithelium. They occur
in 5% to 14% of the population and are more
prevalent in women [34]. Simple cysts are usually
solitary to few in number, but innumerable cysts
may occur in autosomal-dominant or recessive polycystic disease.
Like other cysts, the criteria for diagnosis of
hepatic cyst include sharp margins with no definable
walls. On MR, cysts show internal signals on T1 and
T2 sequences that follow cerebrospinal fluid (CSF).
After contrast administration, cysts do not show
58
Fig. 7. Patient with FNH. (A) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip angle) 25 seconds
after Eovist injection shows two hyperenhancing liver lesions (arrows). (B) Axial, T1-weighted, FMPSPGR image (TR/TE 110/
4.4 milliseconds, 70 flip angle) 20 minutes after Eovist injection shows some enhancement of both lesions, probably related to
impaired excretion of the contrast agent.
Hemangioma
Hemangioma is the most common benign hepatic
neoplasm, occurring in 5% to 20% of the population
[34]. Women are affected more than are men and the
lesions are commonly found in a subcapsular location
in the right lobe of the liver. Most lesions grow
slowly and are uncommonly diagnosed in children.
Even large and exophytic hemangiomas are usually
asymptomatic, and spontaneous hemorrhage or other
complications are extremely rare. Hemangiomas consist of large endothelial-lined vascular spaces separated by fibrous septa. They can range in size from a
few millimeters to more than 20 cm. Although
usually solitary, multiple hemangiomas are commonly encountered.
On MR, hemangiomas have a characteristic
appearance of a 1-cm to 3-cm lesion that is extremely bright (light bulb) on T2 images (Fig. 8)
[12,35,36]. Lesions larger than about 3 cm tend to
be less homogeneously bright, due to internal fibrous
septa or scarring. The tumor margin is well defined,
and may be somewhat lobulated. No peritumoral
edema is present. Long TE images (TE 120
180 milliseconds) will demonstrate that hemangiomas have a signal similar to CSF, whereas most
malignant tumors will not be as bright as CSF. There
are two differential diagnostic considerations for
hemangioma: a cyst and a hypervascular hepatic
metastasis. Differentiation of hemangioma from a
cyst is unimportant because both are benign. The
signal characteristics of some malignant tumors,
however, will overlap with that of hemangioma [37]
because of similar T2 values (most hemangiomas
have calculated T2 values greater than 88 milliseconds at 1.5 T). For example, metastatic leiomyo-
59
Fig. 8. Patient with large hepatic hemagioma. (A) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds) shows a large
hyperintense mass in the left lobe (arrow). (B) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip
angle) 60 seconds after gadolinium injection shows peripheral nodular enhancement, that continues to fill in on delayed
(3 minutes) images (C). These features are characteristic of hemangioma.
nant potential and is unlikely to hemorrhage; adenomas are often resected because of the potential for
hemorrhage and malignant degeneration.
On MR images, FNH is typically isointense to liver
on T1 images, and slightly hyperintense on T2 images.
On T1 images, an internal low signal area that corresponds to a central scar is present in more than 50% of
cases [39,40]. The scar is usually hyperintense to liver
on T2 images, but may be hypointense. A central scar,
best seen on T1 images, is highly suggestive of the
diagnosis. Other than the central scar, the lesions are
homogeneous on both T1 and T2 images.
FNH lesions are highly vascular. Unlike the
central scars in hemangioma, the central scar in
FNH is vascular and is surrounded by collagenous
fibers. Following contrast administration, because of
their prominent vascularity, FNH lesions tend to
enhance early, and may be isointense to liver as early
as 1 to 2 minutes after contrast injection, except for
the central scar (Figs. 2, 7, 9). After administration of
60
Fig. 9. Patient with FNH. (A) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds) shows a slightly hyperintense
lesion in the right lobe (arrow). (B) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip angle)
20 seconds after gadolinium injection shows homogenous hyperenhancement of the lesion. (C) Axial, T1-weighted, FMPSPGR
image (TR/TE 110/4.4 milliseconds, 70 flip angle) 60 seconds after gadolinium injection shows minimal residual tumor
enhancement. Imaging in this phase only may miss hypervascular liver lesions.
Biliary cystadenoma
This tumor presents typically as a symptomatic
large hepatic mass characterized by large cystic spaces
surrounded and separated by thickened, nodular,
enhancing walls. Although imaging features might
overlap with a pyogenic or parasitic abscess, this is
usually not a clinical dilemma. MR imaging studies
clearly demonstrate cystadenoma as an aggressive
and complex neoplasm (Fig. 10) [42]. These are
known to undergo malignant transformation and there
is no imaging technique capable of distinguishing
between benign and malignant cystadenomas.
Malignant liver lesions
Hepatic metastasis
Metatstatic disease to the liver is approximately
20 times more common than is primary hepatic neoplasms. The presence of metastatic disease to the liver
is a prime determinant of survival. Prognosis is inver-
61
Fig. 10. Patient with biliary cystadenoma. (A) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds) shows a large
hyperintense cyst (arrow), with associated ductal dilatation in both lobes, particularly the left lobe (curved arrow). (B) Axial,
T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip angle) 60 seconds after gadolinium injection shows cystic
mass with enhancement of a mural nodule (arrow).
sely proportional not only to the presence of metastases, but also to the number and volume of metastases. The most common primary tumors to
metastasize to the liver are colon, breast, lung, pancreas, melanoma and sarcoma. Metastases in the liver
usually appear as focal, discrete lesions, but diffuse
infiltrative involvement of the liver may be seen in
breast cancer or lymphoma, and rarely with colon or
lung primaries.
For small lesions that are less than or equal to
15 mm in size, benign tumors (hemangioma, cyst)
must be considered in the differential diagnosis of
metastatic disease, even if multiple lesions are found.
In one series of 209 patients with a known primary
Fig. 11. Patient with metastatic carcinoid. (A) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip
angle) 20 seconds after gadolinium injection shows innumerable rim-enhancing lesions. (B) Axial, T1-weighted, FMPSPGR
image (TR/TE 110/4.4 milliseconds, 70 flip angle) 60 seconds after gadolinium injection. The lesions are less conspicuous on
this portal venous phase of enhancement.
62
Fig. 12. Patient with HCC. (A) Axial, FSE, T2-weighted image (TR/TE 3500/100 milliseconds) shows a slightly hyperintense
heterogeneous mass in segment 4 (arrow). (B) Axial, T1-weighted, FMPSPGR image (TR/TE 110/4.4 milliseconds, 70 flip
angle) 60 seconds after gadolinium injection shows hypoenhancing mass abutting, but not invading, left portal vein (arrow).
63
Summary
The article reviews the current MR imaging
techniques commonly utilized for imaging liver
tumors. Breath-hold T1-weighted GRE sequences,
FSE T2-weighted sequences, and properly timed
contrast-enhanced 3D SGE are important for lesion
characterization. New liver-specific contrast agents
improve lesion detection and are useful in lesion characterization.
References
[1] Rofsky NM, Weinreb JC, Bosniak MA, et al. Renal
lesion characterization with gadolinium-enhanced MR
imaging: efficacy and safety in patients with renal insufficiency. Radiology 1991;180(1):85 9.
[2] Bluemke DA, Paulson EK, Choti MA, et al. Detection
of hepatic lesions in candidates for surgery: comparison
of ferumoxides-enhanced MR imaging and dual phase
helical CT. AJR Am J Roentgenol 2000;175(6):
1653 8.
[3] de Lang EE, Mugler 3rd JP, Gay SB, et al. Focal liver
disease: comparison of breath-hold T1 weighted MPGRE MR imaging and contrast-enhanced CTlesion
detection, localization, and characterization. Radiology
1996;200:465 73.
[4] Semelka RC, Willms AB, Brown MA, et al. Comparison of breath-hold T1-weighted MR sequences for
imaging of the liver. J Magn Reson Imaging 1994;
4(6):759 65.
[5] Semelka RC, Worawattanakul S, Kelekis NL, et al.
Liver lesion detection, characterization, and effect on
patient management: comparison of single-phase spiral
CT and current MR techniques. J Magn Reson Imaging
1997;7(6):1040 7.
[6] Seneterre E, Taourel P, Bouvier Y, et al. Detection of
hepatic metastases: ferumoxides-enhanced MR imaging versus unenhanced MR imaging and CT during
arterial portography. Radiology 1996;200(3):785 92.
64
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
65
The recent development of rapid-acquisition techniques with excellent image quality and tissue-specific contrast agents has rendered MR imaging the
most accurate imaging modality for the evaluation of
liver disease. In many instances, with the appropriate
combination of sequences, MR imaging can diagnose
and characterize diffuse liver disease accurately so
that the need for invasive procedures is obviated. MR
imaging plays an important role in the evaluation of
complications and follow-up of diffuse hepatic disease and may have prognostic and therapeutic implications. Diffuse liver disease by definition refers to
any destructive or infiltrative process that involves
the liver parenchyma, the biliary ducts, or the vascular structures leading to liver dysfunction. Diffuse
liver disease includes a variety of conditions, such as
infectious and inflammatory diseases, storage and
metabolic disorders, neoplastic diseases, and vascular
diseases. Cirrhosis, a complex and slowly destructive
process of various etiologies, is considered as a
distinct entity. This article discusses abdominal MR
imaging techniques and findings on the most common causes of diffuse liver disease with an emphasis
on MR imaging patterns and pathologic correlation.
MR imaging technique
The current standard MR imaging examination
of the liver includes a combination of T1- and
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insensitive to motion artifacts. On T1-weighted images, high fluid content lesions, such as cysts or
hemangiomas, hypovascular lesions, or lesions with
a high fibrotic content are moderately low in signal
intensity [6]. Hemorrhagic lesions, lesions with high
protein content, or lesions containing melanin are of
high signal intensity.
The most commonly performed T2-weighted
sequences are breathing-averaged conventional spin
echo or faster sequences, such as echo-train spin echo
sequences or a modified turbo spin echo sequence
termed half Fourier single-shot turbo spin echo
(HASTE). The combination of T2-weighted images
with fat suppression improves the detection of focal
liver lesions within a fatty infiltrated liver and the
detection of lymphadenopathy in the porta hepatis.
Moreover, fat-suppressed T2-weighted images diminish phase artifacts from respiration. On T2-weighted
images, lesions with increased fluid content are of
high signal intensity, whereas the presence of fibrotic
tissue or increased iron content is low in signal
intensity [6]. T2-weighted echo train spin echo
sequences, such as the HASTE sequence, provide an
excellent anatomic display of the common bile duct on
coronal plane images.
The development of phased-array or multiarray
torso coils has improved the signal-to-noise ratio
permitting faster acquisition of thinner sections with
improved spatial resolution.
The current standard protocol as used in the
authors center includes fat-suppressed T2-weighted
HASTE, turbo short tau inversion recovery, precontrast T1-weighted SGE, opposed-phase SGE, and
postgadolinium dynamic imaging in the arterial-dominant phase, the portal phase, and the interstitial phase.
Cirrhosis
Cirrhosis is a slowly progressive condition in
which irreversible damage to liver parenchyma
caused by inflammation and necrosis is followed by
fibrous scarring and development of regenerative
nodules. Although a variety of hepatic disorders
may lead to cirrhosis, in North America the most
common causes include alcoholism and viral hepatitis
[7]. MR imaging can evaluate the morphologic
changes of cirrhotic livers, characterize focal hepatic
masses, and provide a noninvasive evaluation of
intrahepatic and extrahepatic vessels. In the authors
center, MR imaging is used routinely for the followup of patients with cirrhosis and for the evaluation of
liver transplant candidates.
69
Fig. 1. Cirrhosis. T2-weighted single shot-echotrain spin echo (A), spoiled gradient echo (SGE) (B), out-of-phase (C), immediate
postgadolinium SGE (D), 45-second postgadolinium SGE (E), and 90-second postgadolinium fat-suppressed SGE (F) images.
The liver is diminutive in size and demonstrates nodular and irregular contour with distorted anatomy. The hepatic parenchyma is
heterogeneous in appearance with extensive linear fibrosis. The fibrous stroma is best shown on out-of-phase image (C) as lowsignal reticular strands and on the late postgadolinium fat-suppressed SGE (F) as enhancing tissue.
70
sion ratio from the micronodular form to the macronodular form has been found in 90% of cases in
10 years [14].
MR imaging can demonstrate regenerative nodules
with greater sensitivity than any other imaging modality. Regenerative nodules are hypointense to hyper-
Fig. 2. Cirrhosis with regenerative nodules. Spoiled gradient echo (SGE) (A), out-of-phase SGE (B), immediate postgadolinium
SGE (C), 45-second postgadolinium SGE (D), and 90-second postgadolinium fat-suppressed SGE (E) images. The liver is
diminutive in size and shows irregular nodular contours consistent with cirrhosis. Multiple-sized siderotic nodules are
appreciated throughout the liver and exhibit low signal on T1-weighted (A) images and negligible enhancement after
administration of contrast (C E) compatible with regenerative nodules.
71
Fig. 3. Cirrhosis with high-grade dysplastic nodule and early hepatocellular carcinoma. Echo-train short tau inversion recovery (A),
spoiled gradient echo (SGE) (B), immediate postgadolinium SGE (C), 45-second postgadolinium SGE (D), and 90-second
postgadolinium fat-suppressed SGE (E). There is 1-cm lesion in the anterior part of the right lobe that is not evident on T2-weighted
(A) image, demonstrates a slightly high signal on T1-weighted (B) image, and displays an intense enhancement on the immediate
postcontrast image (C) that persists on late image (E), consistent with severe dysplastic nodule.
72
T2-weighted appearance between regenerative, dysplastic, and early HCC, however, their differentiation
on the basis of these sequences is limited (Fig. 3). As
the degree of malignancy increases in the pathway of
hepatocarcinogenesis, portal blood supply is expected
to decrease, whereas the arterial blood supply increases [18].
Fig. 4. Hepatocellular carcinoma. Echo-train short tau inversion recovery (A), spoiled gradient echo (SGE) (B), immediate
postgadolinium SGE (C), 45-second postgadolinium SGE (D), and 90-second postgadolinium fat-suppressed SGE (E) images.
There is a lesion in the left hepatic lobe that demonstrates slightly heterogeneous high signal on T2-weighted images (A), slightly
low signal on T1-weighted images (B), intense uniform enhancement on the immediate postgadolinium image (C), and fades to
hypointensity by 45 (D) and 90 (E) seconds. Note the enhancement of a pseudocapsule, more pronounced on late image (E). This
lesion is compatible with hepatocellular carcinoma.
Although enhancement in the early arterial-dominant phase may be present in dysplastic nodules,
intense early enhancement is a distinctive feature of
HCC. The presence of early arterial enhancement
with rapid washout during the portal phase should
be regarded as highly suspicious for the presence of
a small HCC (Fig. 4). As HCC develops in the
dysplastic nodule, hyperintensity on T2-weighted
images becomes apparent. The nodule within a nodule sign has been described for a hypointense
dysplastic nodule harboring a small hyperintense
HCC on T2-weighted images [19]. Imaging features
that suggest the presence of HCC are (1) lesion size
greater than 3 cm, (2) hyperintensity on T2-weighted
images, (3) intense enhancement in the arterial-dominant phase, (4) late tumor washout, (5) the presence
of a capsule, and (6) a rapid rate of growth on followup studies. The presence of a capsule is relatively
common in HCC, whereas it is seldom found in
other malignant liver lesions. MR imaging is the
73
Fig. 5. Acute or chronic hepatitis. Echo-train short tau inversion recovery (A), spoiled gradient echo (SGE) (B), immediate
postgadolinium SGE (C), and 90-second postgadolinium fat-suppressed SGE (D) images in a patient with a chronic hepatitis.
The left lobe and part of the right lobe demonstrate a well-delimitated region with slightly high signal on T2- (A) and T1(B) weighted images, increased enhancement on immediate postcontrast (D) images, and persistence of the signal on late image
consistent with acute or chronic hepatitis.
74
Fig. 6. Cirrhosis and peritoneal enhancement. Transverse 90-second postgadolinium fat-suppressed spoiled gradient echo (A,B)
images in a patient with history of cirrhosis. A mild linear peritoneal enhancement (arrow) consistent with microvarices in the
peritoneal lining caused by portal hypertension is demonstrated.
75
Fig. 7. Cirrhosis and omental hypertrophy. Echo-train short tau inversion recovery (A), spoiled gradient echo (SGE) (B),
immediate postgadolinium SGE (C), and 90-second postgadolinium fat-suppressed SGE (D) images. The liver is small, nodular
in contour, and demonstrates a reticular heterogeneous enhancement pattern consistent with cirrhosis. Note also the omental
hypertrophy (arrow), recanalization of umbilical vein, and ascites.
76
Fig. 8. Primary sclerosing cholangitis. T2-weighted SS-ETSE fat-suppressed (A), spoiled gradient echo (SGE) (B), immediate
postgadolinium SGE (C), 45-second postgadolinium SGE (D), and 90-second postgadolinium fat-suppressed SGE (E) images.
The liver shows distorted anatomy with massive enlargement of caudate lobe and atrophy of the peripheral liver. The signal
intensity is heterogeneous on T2- and T1-weighted images with multiple macronodules and fibrotic bands. Note also, that there is
ductal dilatation in the peripheral liver because of the central hypertrophy that contributes to periportal compression or
obstruction of bile ducts. These findings are consistent with cirrhosis caused by primary sclerosing cholangitis.
77
Fig. 9. Acute hepatitis postchemotherapy. Spoiled gradient echo (SGE) (A), immediate postgadolinium SGE (B), 45-second
postgadolinium SGE (C), and 90-second postgadolinium fat-suppressed SGE (D) images in a patient in chemotherapy treatment.
The liver is enlarged and demonstrates a patchy heterogeneous transient enhancement after administration of contrast consistent
with acute hepatitis.
78
signals from fat and water cancel each other and there
is loss of signal intensity on out-of-phase images by
comparison with in-phase images [30]. The maximal
signal loss is observed when fat content approaches
50% of the voxel in liver. The spleen can be used as the
organ of reference for the signal loss, and when the fat
and water are present in equal proportion in the voxel
Fig. 10. Fatty infiltration with focal sparing. Echo-train short tau inversion recovery (A), spoiled gradient echo (SGE) (B), out-ofphase SGE (C), immediate postgadolinium SGE (D), and 90-second postgadolinium fat-suppressed SGE (E) images.
Homogeneous signal of the liver is present on the T1-weighted image (B). On the out-of-phase image (C) the liver drops in signal
but a persistent focus of higher signal is still appreciated in segment 8/5. Note that in 90-second image (E) the same region is
identified as higher signal. This reflects a fat-suppression effect of the remainder of the liver rather than a gadolinium-enhanced
effect of the regions of normal liver.
79
Fig. 11. Primary hemochromatosis. Echo-train short tau inversion recovery (A), in-phase spoiled gradient echo (SGE) (B), and
out-of-phase SGE (C) images. The liver and pancreas are low signal intensity on T2- (A) and T1-weighted (B) images consistent
with iron deposition. The spleen is relatively normal in signal intensity.
80
Fig. 12. Storage disease. T2-weighted SS-ETSE (A) and spoiled gradient echo (B) images in a patient with a history of
mucopolysacharidosis demonstrate an enlargement of the liver. No other abnormalities are observed.
81
82
Fig. 13. Liver metastases. Coronal T2-weighted SS-ETSE (A), spoiled gradient echo (SGE) (B), out-of-phase SGE (C),
immediate postgadolinium SGE (D), and 90-second postgadolinium fat-suppressed SGE (E) images. There are multiple small
lesions scattered throughout hepatic parenchyma. These lesions are slightly high signal on T2-weighted (A) image, low signal on
T1-weighed (B) image, and demonstrate a uniform ring enhancement on immediate postgadolinium image (D) that fades over
time (E) with negligible central enhancement consistent with metastases.
83
Fig. 14. Subacute Budd-Chiari syndrome. T2-weighted SS-ETSE fat-suppressed (A), spoiled gradient echo (SGE) (B),
immediate postgadolinium SGE (C), 45-second postgadolinium SGE (D), and 90-second postgadolinium fat-suppressed SGE (E)
images. The liver is enlarged, irregular in contour, and with hypertrophy of caudate lobe. The signal of the peripheral liver is
slightly high on T2-weighted (A) images and slightly low on T1-weighted (B) images. Postadministration of contrast there is an
increased heterogeneous enhancement in the peripheral liver in comparison with central liver. Over time the central area becomes
more homogeneous with the remainder of the liver.
84
Fig. 15. Congestive liver. Spoiled gradient echo (SGE) (A), immediate postgadolinium SGE (B), 45-second postgadolinium SGE
(C), and 90-second postgadolinium SGE (C) images. The liver is enlarged with a dilated inferior vena cava. A mosaic pattern of
enhancement is demonstrated in 45-second images (C) and became less evident in 90-second images (D).
85
Summary
MR imaging is able to demonstrate and distinguish the full variety of benign and malignant diffuse
liver diseases.
References
[1] Semelka RC, Balci NC, Op de Beeck B, Reinhold C.
Evaluation of a 10-minute comprehensive MR imaging
examination of the upper abdomen. Radiology 1999;
211:189 95.
[2] Semelka RC, Helmberger TK. Contrast agents for MR
imaging of the liver. Radiology 2000;218: 27 38.
[3] Semelka RC, Worawattanakul S, Kelekis NL, et al.
Liver lesion detection, characterisation and effect on
patient management: comparison of single-phase spiral
CT and current MRI techniques. J Magn Reson Imaging 1977;7:1040 7.
[4] Semelka RC, Willms AB, Brown MA, et al. Comparison of breathhold T1-weighted MR sequences for
imaging of the liver. J Magn Reson Imaging 1994;
212:876 84.
[5] Rofsky NM, Lee VS, Laub G, Pollack MA, Krinsky
86
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
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[38]
87
MR cholangiopancreatography
Tomofumi Motohara, MDa, Richard C. Semelka, MDa,*, Till R. Bader, MDb
a
Department of Radiology, University of North Carolina, 2006 Old Clinic Building, CB #7510,
Chapel Hill, NC 27599 7510, USA
b
Department of Radiology, University of Vienna, Austria
* Corresponding author.
E-mail address: richsem@med.unc.edu (R.C. Semelka).
MRCP techniques
MR cholangiopancreatography uses heavily
T2-weighted images to visualize stationary or slowmoving fluids in the biliary system and pancreatic
duct with high signal intensity. For this purpose,
single-shot echo-train spin echo technique is used
most commonly. Echo-train spin echo technique uses
a single 90-degree pulse followed by multiple refo-
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Usually, to obtain ERCP-like MRCP images, single-shot echo-train spin echo sequence is performed
by using a very long effective TE value (eg, 1000 milliseconds) without fat-suppression technique or a long
effective TE value (eg, 250 to 400 milliseconds) with
fat-suppression technique. With these images, however, it is not possible to evaluate periductal structures, such as tumors, which may cause narrowing or
obstruction of the ducts. Also, fluids with relatively
short TE, such as concentrated bile or mucinous
fluid, may produce very little signal with long
effective TE sequences, and that may obscure small
bile ducts or mucinous lesions. To overcome those
drawbacks of MRCP with long effective TE, an
intermediate effective TE (80 to 100 milliseconds)
can be used. This produces images where not only
all fluid including concentrated bile and mucinous
fluid is bright, but also periductal structures are well
depicted. The combination of images with intermediate effective TE and ERCP-like MRCP images gives
detailed evaluation of both intraductal and periductal structures.
Disease processes
Benign disease
Cystic diseases of the bile duct
Congenital cystic lesions of the bile duct can be
classified according to Todanis classification system
[12]: type I, choledochal cyst; type II, diverticulum of
extrahepatic ducts; type III choledochocele; type IV,
multiple segmental cysts; and type V, Carolis dis-
Fig. 1. Comparison of thick-slab MRCP and three-dimensional maximum intensity projection (MIP) reconstruction MRCP in a
patient with a pancreatic head carcinoma. (A) Coronal thick-slab single-shot echo-train spin echo MRCP. (B) Three-dimensional
MIP reconstruction obtained from thin-slice collimation source images. Dilatation of the biliary tree and pancreatic duct and
definition of the level of obstruction are demonstrated on both images. The three-dimensional MIP reconstructed image,
however, demonstrates more details of the biliary tree and the pancreatic duct. (From Bader TR, Semelka RC. Gallbladder and
biliary system. In: Abdominal-pelvic MRI. New York: Wiley Liss; 2002. p. 319 71; with permission.)
91
Fig. 2. Gallstone disease. (A) Coronal thin-slice single-shot echo-train spin echo MRCP in a patient with gallstones and common
bile duct (CBD) stones. Multiple gallstones and CBD stones are clearly demonstrated (arrows). (B) Coronal thin-slice single-shot
echo-train spin echo MRCP in a patient with a CBD stone after liver transplantation. A CBD stone is demonstrated in the dilated
graft CBD. (From Bader TR, Semelka RC. Gallbladder and biliary system. In: Abdominal-pelvic MRI. New York: Wiley Liss;
2002. p. 319 71; with permission.)
92
93
Neoplastic diseases
Cholangiocarcinoma
Cholangiocarcinoma can be classified into three
types according to the anatomic location: (1) peripheral type, originating from peripheral bile ducts in
the liver; (2) hilar type (Klatskins tumor), originating from the confluence of the right and left
hepatic ducts; and (3) extrahepatic type, originating
from the main hepatic ducts, common hepatic duct,
or CBD [37,38]. Ductal obstruction is observed in
all cases of Klatskins tumor and extrahepatic cholangiocarcinoma. Evaluation of the level of obstruction is important for treatment planning. In a study
evaluating malignant perihilar biliary obstruction in
40 patients including 26 Klatskins tumors, it was
reported that MRCP was as effective as ERCP at
detecting the presence and the level of biliary
obstruction (40 of 40 cases on MRCP and 38 of
38 cases on ERCP) [39]. The disadvantage of ERCP
is that it may result in sepsis caused by overdistention of an obstructed biliary duct with stagnant bile
colonized by bacteria, and additionally ERCP may
be unable to provide sufficient biliary opacification
to evaluate adequately the region of narrowing.
MRCP, however, can demonstrate the bile duct
proximal to the obstructing site safely and efficiently
(Fig. 5).
The authors routine procedure is to evaluate
patients with possible cholangiocarcinoma with tissue
imaging sequences in addition to MRCP. Special
emphasis is made on T1-weighted fat-suppressed
spoiled gradient echo acquired 2 to 5 minutes following gadolinium administration because it is the
most consistent technique to demonstrate cholangio-
Fig. 5. Cholangiocarcinoma. (A) Coronal single-shot echo-train spin echo thin section MRCP source image shows an irregular
stricture of the common bile duct (CBD) caused by cholangiocarcinoma (arrow). (B) Transverse 2-minute postgadolinium fatsuppressed spoiled gradient echo image shows circumferential thickening and moderate enhancement of the extrahepatic CBD
caused by cholangiocarcinoma (arrow).
94
Future directions
Using current techniques, MRCP does not provide
dynamic information about pancreatic exocrine function; however, research is ongoing to obtain such
information using secretin stimulation, and results
seem promising [43]. In a study evaluating 31
patients with chronic pancreatitis and 84 patients with
suspicion of pancreatic disease, MRCP after secretin
stimulation showed reduced duodenal filling in
patients with severe chronic pancreatitis [43].
Another advance in MRCP is the use of contrast
agents that are hepatocyte-selective and eliminated, at
least in part, by the biliary system. With these agents
and faster acquisition with thin-section three-dimensional T1-weighted images of the biliary system,
Fig. 6. Pancreatic head adenocarcinoma. (A) Coronal T2-weighted single-shot echo-train spin echo image shows the dilated
common bile duct (CBD) and the pancreatic head adenocarcinoma adjacent to the ampulla of Vater. (B,C) Coronal T2-weighted
fat-suppressed thin-section MRCP shows obstruction of the CBD and main pancreatic duct with the dilatation of the ducts
proximal to the obstructed sites. (D) Transverse immediate postgadolinium spoiled gradient echo image shows low signal
intensity mass of the pancreatic head.
Summary
Although MRCP is still an evolving technique, it
has established itself as clinically useful and comparable with ERCP for the evaluation of various biliary
or pancreatic ductal diseases. MRCP is not only
comparable with ERCP in its diagnostic ability, but
it has the tremendous advantage of being noninvasive. Furthermore, MR imaging is useful in patients
with incomplete or failed ERCP, and in patients with
certain biliary or gastrointestinal surgical procedures
it is the imaging modality of choice. ERCP will
remain an extremely important modality because of
the great clinical importance for interventional biliary
procedures with this technique. Nonetheless, MRCP
may in the near future replace most of the diagnostic
imaging of the biliary tree, with diagnostic results
even more improved with further developments of
hardware and technique.
References
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KM. Half-Fourier RARE MR cholangiopancreatography: experience in 300 subjects. Radiology 1998;207:
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95
96
[36]
[37]
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[42]
[43]
[44]
MR cholangiopancreatography:
evaluation of common pancreatic diseases
Laura M. Fayad, MDa,*, Thomas Kowalski, MDb, Donald G. Mitchell, MDa
a
Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 North Wolfe Street,
Baltimore, MD 21287, USA
b
Gastrointestinal Endoscopy, Division of Gastroenterology and Hepatology, 132 South 10th Street,
480 Main Building, Philadelphia, PA 19107, USA
Technique
The normal pancreatic duct is a small structure,
with a diameter of 3 mm or less, and is challenging
to visualize completely by MR imaging. Because
pancreatic ductal fluid has a long T2 relaxation time,
a heavily T2-weighted sequence will result in high
signal within the pancreatic duct, whereas background tissue, which has a shorter T2 relaxation
* Corresponding author.
E-mail address: lfayad1@jhmi.edu (L.M. Fayad).
0033-8389/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 6 6 - 0
98
Fig. 1. Thick-section MRCP. (A) Coronal, oblique, thick-section SSFSE image showing a normal pancreatic duct ( P) with a loop
configuration (L). Also shown are the common bile duct (B), common hepatic duct (H ), and the cystic duct (C ). (B) Coronal,
oblique, thick-section SSFSE image of the patient in Fig. 1, acquired at a different obliquity, showing unfolding of the pancreatic
duct loop configuration (L).
99
Fig. 3. MRCP with overlap of fluid-containing structures. (A) Coronal, oblique, thick-section SSFSE image in a patient with
autosomal-dominant polycystic kidney disease and multiple small liver cysts (small arrows) and renal cysts (R) depicted on the
thick-section MRCP. These fluid-containing structures obscure view of the pancreatic duct ( P) in the pancreatic tail. (B) Axial,
thin-section SSFSE image of the same patient shows delineation of the pancreatic duct ( P) in the pancreatic tail. Enlarged
kidneys containing multiple cysts (R) are noted bilaterally.
100
Fig. 4. Duodenal diverticulum. Coronal, oblique, thicksection SSFSE image showing a duodenal diverticulum with
an air-fluid level (long arrow) lateral to a normal common bile
duct (B). The pancreatic duct ( P) also appears normal. A
duodenal diverticulum is a common cause for ERCP failure.
101
102
Fig. 7. Acute pancreatitis secondary to stones. (A) Coronal, oblique, thick-section SSFSE image showing gallstones (short
arrows) and common bile duct stones (long arrows) in the setting of acute pancreatitis. (B) Axial, thin-section SSFSE image
showing gallstones (short arrow) and common bile duct stones (long arrow). The pancreas ( P) is enlarged and heterogeneous in
this patient with acute pancreatitis.
Fig. 8. Chronic pancreatitis. (A) Coronal, oblique, thick-section SSFSE image showing a markedly dilated pancreatic duct (large
arrow) with markedly dilated side-branches (small arrows) in a patient with chronic alcoholic pancreatitis. (B) Axial, thinsection, fat-suppressed, 2D FSE image showing small hypointense filling defects in the pancreatic duct and its side branches,
representing pancreatic duct stones (arrows) in a patient with chronic alcoholic calcific pancreatitis.
103
Fig. 9. Chronic pancreatitis. (A) Coronal, oblique, thick-section SSFSE image showing changes of chronic pancreatitis, including
a dilated pancreatic duct (large arrow) with filling defects representing mucus (small arrows), and two pseudocysts (C ). (B)
Coronal, thin-section SSFSE image showing the findings in Fig. 9A in greater detail. (C) Coronal, thin-section SSFSE image
acquired more anteriorly. C, pseudocysts. (D) Axial, nonenhanced, T1-weighted, gradient echo image showing decreased signal
in the pancreas ( P) from fibrosis. The dilated pancreatic duct (arrow) and two pseudocysts (C ) are again noted.
104
Fig. 10. Focal obstructive pancreatitis due to adenocarcinoma of the pancreas. (A) Coronal, thick-section SSFSE image showing
a dilated pancreatic duct (thick arrows) in the body and tail of the pancreas with termination (thin arrow) of the duct in the body.
(B) Axial, T1-weighted, 3D, gradient echo image of the pancreas obtained in the arterial phase following the administration of
intravenous gadolinium shows a hypoenhancing mass (arrow) that is responsible for obstruction of the pancreatic duct with
resultant obstructive pancreatitis distally.
105
Fig. 11. Pancreatic adenocarcinoma. (A) Coronal, thick-section SSFSE image showing the classic double-duct sign of
pancreatic carcinoma; both the pancreatic duct ( P) and common bile duct (C ) are dilated and abruptly terminate (large arrow) in
the head of the pancreas. In this case, the intrahepatic biliary ducts are also dilated. (B) Axial, nonenhanced, T1-weighted,
gradient echo image showing an ill-defined hypointense mass (arrow) in the head of the pancreas. A biopsy of this mass revealed
pancreatic adenocarcinoma.
ductal structures not seen with ERCP [84]. Comprehensive MR imaging is also useful to accurately
determine resectability [85].
106
Fig. 12. Communicating pseudocyst. Axial, thin-section SSFSE image showing an uncomplicated pseudocyst (C) with
communication to the pancreatic duct (arrow) in a patient with pancreatitis.
changes that suggest pancreatitis, making their differentiation from pancreatic neoplasms possible in most
cases. Pseudocysts resolve spontaneously in 60% of
cases [87].
Treatment options for persistent pseudocysts
include endoscopic, radiologic, and surgical drainage.
These must be considered cautiously, in the event that
a cystic neoplasm is misdiagnosed as a pseudocyst
[88]. Misdiagnosis, usually by CT, has been reported
as high as one third of the time [89 91]. The traditional approach for treating pseudocysts that require
drainage has been surgical. Treatment is considered
when the patient is symptomatic, if the pseudocyst
Fig. 13. Hemorrhage pseudocyst. (A) Axial, thin-section SSFSE image showing a large complex cystic collection with a fluid
fluid level (arrow) representing a hemorrhagic pseudocyst in a patient with pancreatitis. The head of the pancreas ( P) is denoted.
(B) Axial, T1-weighted, gradient echo image showing hyperintensity (arrows) at the posterior aspect of the pseudocyst,
representing hemorrhage. The head of the pancreas (P) is again denoted.
Parenchymal cystic lesions include serous and mucinous cystic neoplasms. Intraductal neoplasms are
referred to as intraductal papillary mucinous tumors
(IPMTs). Cystic neoplasms can easily be detected on
MRCP because of their high fluid content, but full
examination requires T1-weighted, T2-weighted, and
postgadolinium sequences.
Serous microcystic adenomas are benign pancreatic parenchymal lesions with a relatively equal
distribution throughout the pancreas. Although typically appearing solid on CT or US, a serous adenoma
is cystic with more than six internal cysts, each
measuring less than 2 cm in diameter. Approximately
40% of these tumors have calcifications and 15%
have a central stellate scar (Fig. 14). Their soft tissue
component is typically hypervascular and aspirated
contents contain glycogen [94]. A small serous
tumor adjacent to the main pancreatic duct or a
branch duct may be difficult to distinguish from an
intraductal neoplasm.
Mucinous cystic neoplasms are also parenchymal
lesions. In the past, this neoplasm was subcategorized
107
Fig. 14. Serous tumor. (A) Coronal, thick-section SSFSE image showing a round, well-defined, cystic mass (large arrow) in the
head of the pancreas with a conglomerate of small cysts measuring less than 2 cm each. The common bile duct (B), pancreatic
duct ( P), and cystic duct (C) are denoted on this image. (B) Axial, thin-section SSFSE image showing the cystic mass (thick
arrow) with a suggestion of a central scar (thin arrow), characteristic of a serous tumor.
108
Fig. 15. Mucinous tumor. (A) Coronal, thick-section SSFSE image depicting a cystic mass (thick arrow) in the tail of the
pancreas, without associated dilation of the pancreatic duct (thin arrow). (B) Axial, thin-section SSFSE image showing the cystic
mass (thick arrow) with internal complex signal. The pancreatic duct (thin arrows) is not dilated. Resection of this mass yielded a
benign mucinous cystic tumor.
Fig. 16. IPMT. (A) Coronal, thick-section SSFSE image showing a cystic mass (large arrow) associated with a dilated pancreatic
duct ( P) with dilated side branches. Incidental note is made of a cystic duct remnant (C ). (B) Coronal, thin-section SSFSE image
showing the cystic mass (large arrow) in communication with a dilated draining pancreatic duct ( P), a finding that is highly
suggestive of an intraductal papillary mucinous tumor.
109
Fig. 17. IPMT. (A) Coronal, thick-section SSFSE image showing an IPMT (thick arrow) with a dilated draining pancreatic duct
( P) and bulging papilla (thin arrow). The latter finding is pathognomonic of IPMTs. (B) Coronal, thick-section SSFSE image
obtained in a different projection showing the dilated main pancreatic duct (thin arrows) in association with this IPMT (thick
arrow). (C) Coronal, thin-section SSFSE image again demonstrating a cystic mass representing an IPMT (thick arrow) with a
dilated draining pancreatic duct and bulging papilla (thin arrow). On thin-section MRCP images, a bulging papilla is seen as a
filling defect in the duodenum. In this case, possible papillary projections are noted within the cystic mass.
110
Summary
In the evaluation of common pancreatic diseases,
MRCP is a noninvasive alternative to ERCP. Ductal
anatomy can be ascertained without risk of complications. MRCP is valuable in defining common
anatomic variants, determining the state of the pancreatic duct in pancreatitis, and characterizing neoplasms, especially combined with other MR imaging
sequences. With the advent of MRCP, techniques
requiring endoscopy and percutaneous access are
largely reserved for histologic diagnosis and treatment, or for cases in which MRCP fails to establish
a diagnosis.
References
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cholangiography with a heavily T2-weighted contrast-enhanced fast-sequence. Radiology 1991;181:
805 8.
[2] Morimoto K, Shimoi M, Shirakawa T, et al. Biliary
obstruction: evaluation with three-dimensional MR
cholangiography. Radiology 1992;183:578 80.
[3] Ishizaki Y, Wakayama T, Okada Y, Kobayashi T.
Magnetic resonance cholangiography for evaluation
of obstructive jaundice. Am J Gastroenterol 1993;12:
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spin-echo multicoil magnetic resonance cholangiog-
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a pictorial essay. Radiographics 1999;19:1447 63.
[98] Procacci C, Graziani R, Bicego E, et al. Intraductal
mucin-producing tumors of the pancreas: imaging
findings. Radiology 1996;198:249 57.
[99] Megibow AJ, Lombardo FP, Guarise A, et al. Cystic
pancreatic masses: cross-sectional imaging observations and serial follow-up. Abdom Imaging 2001;
26:640 7.
[100] Agostini S, Choux R, Payan MJ, Sastre B, Sahel J,
Clement JP. Mucinous pancreatic duct ectasia in the
body of the pancreas. Radiology 1989;170:815 6.
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papillary mucinous tumours of the pancreas: clinical
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NE, Haber GB. Mucinous ductal ectasia: cholangiopancreatographic and endoscopic findings. Endoscopy 1994;26:303 7.
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Department of Radiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda,
MD 20814, USA
b
MR Imaging, Doylestown Hospital, 595 West State Street, Doylestown, PA 18901, USA
0338-3890/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
PII: S 0 3 3 8 - 3 8 9 0 ( 0 2 ) 0 0 0 6 2 - 3
116
Fig. 1. A 77-year-old man with hypertension. On standard coronal maximum intensity projection (MIP) (A) from a Gd-enhanced
three-dimensional MRA, the proximal renal arteries are noted to be normal and patent. On oblique coronal MIP (B) and axial
subvolume MIP (C), however, the occluded left upper pole segmental renal artery (large arrow) and the moderate stenosis (small
arrow) of the left lower pole segmental renal artery are better visualized.
117
Fig. 2. A 49-year-old man with rectal cancer. Gd-enhanced three-dimensional MRA of the aortoiliac vessels was performed as a
preprocedural road map for intra-arterial chemotherapy planning. The arterial anatomy is well seen on volume-rendered projection of the three-dimensional data set. (A) Coronal maximum intensity projection (MIP). (B) Sagittal MIP.
118
are all that are typically needed for routine interpretation [13].
Gadolinium-enhanced three-dimensional MRA
has consistently been shown to be accurate and
preferable to traditional noncontrast MRA techniques
for evaluation of not only the aorta but also the
lower extremity arteries [1 3]. In many institutions,
Gd-enhanced three-dimensional MRA is steadily
emerging as the preferred method for evaluation
of the abdominal aorta, and the peripheral run-off
vessels. The growing popularity of Gd-enhanced
three-dimensional MRA has been facilitated by MR
scanner and equipment manufacturers who have
designed new pulse sequences, interactive timing
algorithms, improved user-interfaces, and coil products specifically for the performance of Gd-enhanced
three-dimensional MRA. In addition, a large variety
of vendor and third-party products are now available
for soft-copy interpretation and viewing of the threedimensional data sets. In the ensuing sections, the
theory and technical considerations associated with
Gd-enhanced three-dimensional MRA are discussed
followed by a brief clinical discussion of interpretative issues for several common clinical indications
for MRA of the abdominal aorta, its branches, and
peripheral vessels.
119
[18] 10 to 20 seconds per three-dimensional acquisition). This has enabled the performance of breathhold
image acquisition, which minimizes respiratory
motion artifacts and significantly improves arterial
visualization of abdominal aortic branch vessels
[19 22]. Faster imaging, however, has necessitated
more accurate timing of data acquisition.
Timing
There are several methods for achieving proper
timing of a Gd-enhanced three-dimensional MRA
[15,19,20,23 26]. The simplest is using a fixed
timing delay (eg, 15 seconds). This can often be
unreliable, however, because circulatory times are
highly variable, especially if the patient has a poor
ejection fraction or large capacious aortic aneurysm.
The arrival of a contrast bolus in the abdominal aorta
can take from 10 to 60 seconds [19]. The preferred
methods are the use of a timing bolus injection
[19,20], a triggering algorithm [23,24,26], or a fast
multiphase technique [25]. The timing bolus strategy
entails the administration of a small 1- to 2-mL test
bolus at the same rate as the actual bolus (eg, 2 mL/
Fig. 5. Diagram of vascular signal intensity as it relates to bolus injection rate. Fast bolus injection results in higher arterial
contrast media concentrations and higher signal intensity. With faster injection rates, however, the duration of preferential arterial
enhancement is diminished because of earlier and more significant venous enhancement than seen with slower injection rates.
Slow injection rates prolong the arterial phase; however, the maximum arterial concentration of contrast media is lower. Very
slow injection rates may result in insufficient signal for adequate arterial visualization. (From Ho VB, Choyke PL, Foo TKF, et al.
Automated bolus chase peripheral MR angiography: initial practical experiences and future directions of this work-in-progress.
J Magn Reson Imaging 1999;10:376 88; with permission.)
120
Fig. 6. Proper alignment of preferential arterial-phase enhancement for a variety of k-space schemes used for Gd-enhanced threedimensional MRA. The critical issue for all the schemes is for the central k-space data (ie, low spatial frequency data) to be
acquired during the plateau phase of arterial enhancement. In the conventional sequential k-space scheme, the central k-space
data are acquired during the middle of the data acquisition period. In both the conventional centric and elliptical centric
acquisition schemes, the central k-space data are obtained at the beginning of imaging. Note that with conventional centric
acquisitions, k-space is only centric in ky and that the high spatial frequency encodings in kz are also acquired during each linear
pass and the central k-space encodings in ky and kz are gathered more efficiently (ie, acquired more quickly) in the elliptical
centric acquisition scheme. Partial Fourier imaging with reverse sequential acquisition ordering can also provide a compact
acquisition of low spatial frequency data during the beginning of image acquisition. Note that low spatial frequency data are best
obtained during the plateau period of arterial enhancement. Acquisition of central k-space data prematurely during the rapid rise
in arterial signal (open arrow) can result in significant ringing artifacts (see Fig. 7). (Adapted from Ho VB, Foo TKF, Czum JM,
et al. Contrast-enhanced magnetic resonance angiography: technical considerations for optimized clinical implementation. Top
Magn Reson Imaging 2001;12:283 99; with permission.)
enables the operator to trigger the MRA data acquisition manually on contrast bolus arrival [26].
The final timing method is simply to perform
multiple fast MRA acquisitions in succession [25].
This tact, also known as multiphase or time-resolved
imaging, assumes that at least one of the MRA
acquisitions is performed properly during the arterial
phase of the bolus. The typical compromise for high
temporal resolution (5 to 8 seconds per three-dimensional acquisition) is lower spatial resolution of any
individual acquisition. This method may have little
use in patients with a poor breathholding capacity
because the limitations in breathholding may preclude the acquisition of sufficient data sets during a
single breathhold to ensure arterial-phase imaging.
Furthermore, respiratory motion during these acquisitions significantly degrades what are already lower
spatial resolution data sets.
Pulse sequence
Gadolinium-enhanced MRA is traditionally performed with a T1-weighted fast three-dimensional
spoiled gradient echo pulse sequence using the shortest possible repetition time (TR) and echo time (TE)
to ensure the fastest possible imaging speed. The use
of a three-dimensional acquisition provides high
121
spatial resolution and improves background suppression. Radiofrequency spoiling and the use of a higher
flip angle improve the T1 weighting of the acquisition
and the arterial signal following contrast administration. The imaging parameters should be tailored to
afford the highest possible spatial resolution for the
allotted time period, which for a breathhold acquisition is generally 20 to 30 seconds. Prescription of a
volume with a matrix of 256 224 to 256, partition
thickness of 1.5 to 2.5 mm, and 40 to 60 partitions is
usually sufficient for imaging the abdominal aorta
during a 20- to 30-second breathhold Gd-enhanced
three-dimensional MRA of the abdominal aorta.
Knowledge of the k-space trajectory of the threedimensional pulse sequence is also critical for proper
timing [15]. Historically, Gd-enhanced three-dimensional MRA had only been implemented using a
traditional sequential k-space scheme in which the
k-space is filled linearly in a sequential fashion from
top to bottom with the low spatial frequency data
(center of k-space) being acquired during the middle
of the imaging period. Because the central k-space
data are responsible for most image contrast, its
acquisition should be timed for peak arterial enhancement, and preferably before significant venous
enhancement occurs (Fig. 6). With the development
of real-time triggering methods, however, a variety of
Fig. 7. Ringing artifact on breathhold renal Gd-enhanced three-dimensional MRA in a 36-year-old man with left renal artery
stenosis. This artifact is recognized by the presence of bright and dark lines ([A] coronal maximum intensity projection, [B]
coronal source image) that parallel the edge of the enhancing abdominal aorta (small arrows) and results from the premature
acquisition of low spatial frequency data during leading edge of the contrast bolus when arterial signal is rapidly rising. This
artifact is more common with centric acquisition ordering, which acquires central k-space data early. Ringing artifact can be
avoided by timing for the low spatial frequency to be obtained during the plateau phase of the arterial enhancement (see Fig. 6).
Note that despite the artifacts, the patients left renal artery stenosis (large arrow) was well delineated. (Adapted from Ho VB,
Foo TKF, Czum JM, et al. Contrast-enhanced magnetic resonance angiography: technical considerations for optimized clinical
implementation. Top Magn Reson Imaging 2001;12:283 99; with permission.)
122
Fig. 8. A 72-year-old man with a 9-cm abdominal aortic aneurysm. The extent of this large aortic aneurysm is displayed on the
arterial-phase Gd-enhanced three-dimensional MRA ([A] coronal maximum intensity projection [MIP], [B] sagittal MIP) and
delayed-phase Gd-enhanced three-dimensional MRA ([C] coronal MIP). Note the improvement in visualization of the infrarenal
aorta on the later delayed-phase acquisition (C) compared with the arterial-phase images (A,B). This is secondary to the slow
aortic flow within the large abdominal aortic aneurysm. Performing two acquisitions (arterial phase and delayed phase) after the
administration of contrast agent is prudent because it is hard to know a priori whether the patient has slow blood flow.
Furthermore, the delayed-phase images can often provide diagnostic quality angiographic images should there be inadequate
patient breathholding or motion during the arterial-phase acquisition. An axial image (D) from a late delayed-phase axial twodimensional spoiled gradient echo acquisition (ie, traditional axial two-dimensional time-of-flight MRA) taken through the
abdominal aorta delineates the circumferential mural thrombus (T) within the aneurysm and provides a better assessment of
actual aortic wall-to-wall diameter (arrows). (Adapted from Ho VB, Prince MR, Dong Q. Magnetic resonance imaging of the
aorta and branch vessels. Coron Artery Dis 1999;10:141 9; with permission.)
123
Bolus delivery
Faster pulse sequences have enabled the achievement of high-quality Gd-enhanced three-dimensional MRA more efficiently using smaller doses
Fig. 9. A 66-year-old man with a small infrarenal abdominal aortic aneurysm (AAA). On the coronal maximum intensity
projection (MIP) (A), a small AAA can be seen (arrow) well below the renal arteries, which are noted to be solitary for each
kidney and to have a normal caliber. On sagittal subvolume MIP (B), the ventral origins of the celiac artery (thick arrow) and the
superior mesenteric artery (thin arrow) are noted to also have a normal caliber. The contour and shape of the lumen of the small
infrarenal AAA (arrow) is particularly well seen on a volume-rendered projection (C).
124
Fig. 10. A 75-year-old woman with hypertension and an infrarenal AAA. On coronal maximum intensity projection (MIP) (A) a
long, fusiform infrarenal AAA that extends to the aortic bifurcation. High-grade stenoses are also noted at the origins of both
common iliac arteries. On an oblique coronal subvolume MIP (B), a high-grade stenosis of the left renal artery is noted (arrow).
A high-grade stenosis (arrow) was also noted in the right renal artery at its origin; however, this was best seen on an oblique axial
subvolume MIP (C) from below.
branch vessel stenosis (especially renal artery stenosis). As discussed in the ensuing sections, breathhold Gd-enhanced three-dimensional MRA can
adequately answer the clinical questions related to
these aortic diseases. Gd-enhanced MRA of the
abdominal aorta is best performed in the coronal or
oblique coronal three-dimensional prescription. On
occasion, a sagittal acquisition may be preferable for
imaging arterial branches that originate ventrally,
such as the superior and inferior mesenteric arteries,
125
Fig. 11. A 78-year-old man with chronic type B aortic dissection. On oblique sagittal maximum intensity projection (A), the
patient is noted to have a very tortuous thoracic aorta with only a hint of the dissection, which begins in the distal arch beyond the
subclavian artery (not shown). On oblique sagittal multiplanar reformation (MPR) (B), however, spiral extension of the intimal
tear into the abdominal aorta is clearly seen. Oblique axial MPRs at the levels of the celiac artery (C), superior mesenteric artery
(D), and renal arteries (E) demonstrate that all four arteries originate from the true lumen (T ) and not the false channel (F ).
126
Fig. 12. A 60-year-old woman with chronic type B aortic dissection but worsening vague abdominal pain. Sagittal maximum
intensity projection (MIP) (A) from a sagittal Gd-enhanced three-dimensional MRA demonstrates a narrowing of the celiac
artery (arrow) at its origin. On an oblique axial subvolume MIP (B), the extension of the dissection into the proximal celiac
artery is better visualized. Note that the true lumen is bright but the false channel was thrombosed and only apparent by its mass
effect on the true lumen (arrows) on Gd-enhanced three-dimensional MRA.
larger dose of 30 mL (or 0.2 mmol/kg) is recommended in patients with a large abdominal aortic
aneurysm (AAA), an aortic dissection, or aortic
occlusion because this ensures a sufficiently high
arterial Gd concentration for adequate visualization
of the arterial structures.
Clinical considerations
Abdominal aortic aneurysm
Aneurysms are defined as enlargement of the
arterial diameter by 50% or more from its normal
caliber, which for the abdominal aorta is generally
greater than or equal to 3 cm [31]. AAAs are common
especially in men above the age of 55 and in women
above the age of 70 [32]. The urgency of this
diagnosis relates to its risk of rupture, which is fatal
in most cases (81% to 94% [33]). AAAs are frequently asymptomatic, however, until they rupture.
Large AAAs (greater than 5 cm) have a 25% to
41% likelihood of rupture within 5 years [34,35] and
generally are repaired surgically. The risk of rupture
of small AAAs (aortic diameter less than 4 cm), on
the other hand, is low (0% to 2% [34,35]). Because
the 30-day operative mortality risk for elective AAA
repair is 5% to 6% [36], AAAs with diameters less
than 4 cm are typically followed with periodic
surveillance to check for interval expansion, which
is typically 0.2 to 0.4 cm per year [34,35]. Of course,
rapid expansion of an AAA (eg, greater than 1 cm per
year), widening of the pulse pressure, or the mani-
127
Fig. 13. A 56-year-old man with Leriches syndrome who presented with hypertension and buttock claudication. Preoperative
Gd-enhanced three-dimensional MRA ([A] coronal maximum intensity projection [MIP]) demonstrates the characteristic
occlusion of the distal abdominal aorta below the renal arteries. A high-grade stenosis was also noted in the proximal left renal
artery (arrow). The postoperative Gd-enhanced three-dimensional MRA ([B] coronal MIP) demonstrates the aortobifemoral graft
that included revascularization of the left renal artery at the proximal anastomosis. (Courtesy of Qian Dong, MD, and Martin
Prince, MD, PhD, Ann Arbor, MI.)
128
rupture, complications of the aortic wall, supernumerary renal arteries, obstructive disease of renal, celiac,
or mesenteric vessels, or an anomaly, such as a
horseshoe kidney, can significantly alter the surgical
plan [43]. Gd-enhanced three-dimensional MRA
(Figs. 9, 10) can illustrate these features accurately
and reliably and has been shown to be sufficient for
preoperative planning for AAA interventions
[22,44 47]. For example, Gd-enhanced three-dimensional MRA has been shown to predict correctly the
proximal anastomotic site for AAA repair in 95% of
patients, which was comparable with that of conven-
Fig. 14. A 50-year-old woman with hypertension. On Gd-enhanced three-dimensional MRA ([A] oblique coronal subvolume
maximum intensity projection (MIP), [B] axial subvolume MIP, [C] coronal volume-rendered projection, [D] coronal transparent
volume-rendered projection), the string of beads appearance (arrows) characteristic for fibromuscular dysplasia is noted in the
right renal artery, which looks comparable with that of conventional x-ray angiography (E). Note that the beaded appearance was
well seen in the right renal artery on Gd-enhanced three-dimensional MRA, especially on the volume-rendered projections (C,D).
(F) Mild fibromuscular dysplasia was also noted on conventional x-ray angiography in the proximal left renal artery (arrow).
This was suggested on Gd-enhanced three-dimensional MRA (G) but less clearly seen, most probably secondary to the inherent
lower spatial resolution of MRA.
129
of the three-dimensional data sets enables the selective viewing of individual aortic branch vessels and
the identification of their blood supply (ie, from true
versus false channel). The extension of an intimal
tear into the abdominal aorta typically spirals posterior laterally about the arch with the false channel
coursing to the left of the aorta potentially to involve
the left renal artery and possibly the celiac and
superior mesenteric arteries. Delayed-phase imaging
is recommended (ie, at least two postcontrast MRA
acquisitions) because flow within the false channel
may be slow and not adequately fill with contrast
media during the initial acquisition.
Aortic occlusion (Leriches syndrome)
Occlusion of the abdominal aorta is uncommon
but worth mentioning because MRA can be very
useful in this condition [43,52]. Abdominal aortic
occlusion may occur as a result of a variety of
Fig. 14 (continued )
130
131
Fig. 15. A 71-year-old man with a history of hypertension and diabetes mellitus. Gd-enhanced three-dimensional MRA ([A]
coronal maximum intensity projection) shows severe renal artery stenosis bilaterally (arrows). On phase-contrast threedimensional MRA (B), signal loss distal to the renal artery stenoses (arrows) is seen. This suggests that both arterial narrowings
are hemodynamically significant. Bilateral high-grade stenoses (75% on right and 80% on left) are noted on conventional x-ray
angiography (C). (Adapted from Hood MN, Ho VB, Corse WR. Three-dimensional phase contrast MR angiography: a useful
clinical adjunct to gadolinium-enhanced three-dimensional renal MRA? Mil Med 2002;167:343 9; with permission.)
angiography [72,73]. The critical issue for the preoperative evaluation of potential donors is to determine the most suitable kidney for expedient and safe
removal [74,75]. Imaging is performed to identify the
number of renal arteries, the presence of early branching arteries, unsuspected renovascular disease, or any
parenchymal disease (eg, renal cell carcinoma) that
132
Fig. 16. A 48-year-old man with autosomal-dominant polycystic kidney disease. On Gd-enhanced three-dimensional MRA ([A]
coronal maximum intensity projection [MIP], [B] oblique coronal subvolume MIP, [C] coronal multiplanar reformation [MPR])
a normal and patent arterial anastomosis (arrow) of the transplant kidney (t) with the external right iliac artery (a) is noted. On
MPR (C), overlapping signal from the right external iliac artery could be removed, enabling improved visualization of the
anastomosis (arrow).
133
Fig. 17. Arterial-phase renal Gd-enhanced three-dimensional MRA using an automated bolus detection scheme that was
prescribed to monitor signal in a 3 3 3 cm volume within the mid-abdominal aorta at the level of the renal artery origins.
The breathheld renal Gd-enhanced three-dimensional MRA ([A] coronal maximum intensity projection [MIP], [B] oblique
subvolume MIP) in this 46-year-old male renal donor demonstrates supernumerary renal arteries (two right and three left renal
arteries). (Adapted from Ho VB, Foo TKF, Czum JM, et al. Contrast-enhanced magnetic resonance angiography: technical
considerations for optimized clinical implementation. Top Magn Reson Imaging 2001;12:283 99; with permission.)
134
Fig. 18. Schematic of multistation peripheral bolus chase three-dimensional MRA. Imaging of the peripheral vasculature requires
the imaging of three contiguous anatomic regions: the aortoiliac segment (station 1); the femoropopliteal segment (station 2); and
the tibioperoneal or trifurcation segment (station 3). (From Ho VB, Choyke PL, Foo TKF, et al. Automated bolus chase
peripheral MR angiography: initial practical experiences and future directions of this work-in-progress. J Magn Reson Imaging
1999;10:376 88; with permission.)
135
Fig. 19. Schematic of arterial-phase imaging of the contrast bolus at stations 1 through 3. The relative timing of the data
acquisition of the half-Fourier three-dimensional gradient echo sequences is diagrammed as A (station 1), B (station 2), and C
(station 3) with the center lines of k-space for each marked by diagonal lines. Note that the use of sequential view ordering for
station 1 and reverse sequential view ordering for station 3 results in a shortened duration required for central k-space coverage
during the arterial phase (ie, shortened critical arterial imaging period). (From Ho VB, Choyke PL, Foo TKF, et al. Automated
bolus chase peripheral MR angiography: initial practical experiences and future directions of this work-in-progress. J Magn
Reson Imaging 1999;10:376 88; with permission.)
136
Future directions
In addition to the use of higher field strength MR
scanners (eg, 3 T) and high performance gradients,
there are a variety of new techniques that may
significantly improve the speed of MRA data acquisition. New parallel imaging techniques, such as simultaneous acquisition of spatial harmonics [105] and
sensitivity encoding [18], use the spatial-encoding
properties of multiple phased-array coil elements to
reduce the number of requisite spatial-encoding
views. These can result in a significant reduction
(twofold or threefold) in scan time but at the cost of
signal-to-noise (approximately equal to the square
root of the scan time reduction factor). This is
especially promising for MRA of the abdominal aorta
137
138
139
injection. Blood pool agents like conventional extracellular Gd-chelates rely on their T1-shortening effects
for improved signal on contrast-enhanced MRA. The
prolonged window of arterial signal improvement
affords a large temporal window for high spatial
resolution scanning. The main limitation of this technique is the significant venous enhancement that is
typically present after the initial 1 to 2 minutes. Given
the systemic nature of atherosclerosis, however, the
use of blood pool agents may be beneficial for wholebody screening. A hybrid contrast agent called
gadobenate dimeglumine (MultiHance, Bracco Diagnostics, Milan, Italy) has been approved for use in
Europe and has some protein binding, which has been
shown to improve arterial signal-to-noise significantly
when compared with traditional Gd-chelate contrast at
a comparable Gd dose of 0.1 mmol/kg [111]. Recently,
Ruehm et al [99] demonstrated the feasibility of
performing a five-station bolus-chase MRA using a
0.3-mmol/kg dose of gadobenate dimeglumine.
Any of the aforementioned improvements may
significantly expand the current role and diagnostic
accuracy of aortic and peripheral MRA. Specifically,
they may improve the reliability of infrapopliteal
imaging and even renal imaging during a boluschase MRA. A high percentage of patients with
peripheral vascular disease have renal artery stenosis, yet most of the current bolus-chase techniques
fail to produce diagnostic-quality images of the renal
arteries reliably. Although this may be secondary to
the height of the patient (insufficient superior anatomic coverage of overlapping stations), more commonly time considerations often result in the use of
140
References
Summary
Contrast-enhanced MRA can be an accurate and
reliable method for the arterial evaluation of the
abdominal aorta and peripheral vessels. This technique can be adapted for a variety of anatomic
regions. The basic issues relate to proper synchronization of imaging with peak arterial enhancement
and to optimization of voxel dimensions for adequate
depiction of the arterial structures.
Acknowledgments
The authors thank Michael Schweikert, RT(R),
(MR), lead MR technologist at Doylestown Hospital,
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
141
142
[46]
[47]
[48]
[49]
[50]
[51]
[52]
[53]
[54]
[55]
[56]
[57]
[58]
[59]
[60]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
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144
Technique
With the evolution of MR imaging technology, the
protocols used to evaluate the kidneys and adrenal
glands have also evolved. At the authors institution,
all abdominal MR imaging examinations are performed with a torso phased-array coil. Phased-array
coils increase signal to noise by a factor of two to
three, which allows for the use of smaller fields of
view with concomitant increased spatial resolution.
* Corresponding author.
E-mail address: gary.israel@med.nyu.edu (G.M. Israel).
Breath-hold sequences are used exclusively to minimize artifacts secondary to respiratory motion. Studies are performed during end expiration to optimize
image co-registration for subtraction algorithms. For
those patients in whom the sequences are longer than
their breath-hold capability, the authors administer
2 L/minute of oxygen by nasal cannula. Finally,
before starting the MR imaging examination, cushions are used to elevate the patients arms anterior to
the level of the kidneys and out of the imaging plane
of a coronal acquisition. This minimizes wraparound
artifact (in the phase-encoding direction) when performing three-dimensional coronal acquisitions and
allows the use of smaller fields of view with improved resolution.
Comprehensive examination of the kidneys entails
evaluating the renal vasculature, parenchyma, and
collecting system. Precontrast imaging includes an
axial breath-hold T1-weighted gradient echo (GRE)
sequence performed in and out of phase. This
sequence provides an excellent anatomic overview
of the abdomen and is useful to evaluate for adenopathy and characterize an incidental adrenal lesion.
Used in conjunction with a frequency-selective fatsuppressed T1-weighted sequence, this also allows
differentiation of fat from hemorrhage, both of which
may occur in a renal or adrenal mass.
A coronal breath-hold T2-weighted half-Fourier
single-shot turbo spin echo sequence is performed to
help characterize cystic lesions of the kidney, to
assess for hydronephrosis, and to determine if an
adrenal mass is present. The coronal plane is advantageous in evaluating exophytic lesions that occur at
the poles of the kidneys. These may not be optimally
demonstrated in the axial plane. In addition, coronal
plane images are more helpful in establishing the
association of the lesion to its surrounding organs.
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Fig. 1. (A) Unenhanced sagittal fat-suppressed T1-weighted GRE image shows a 2-cm hyperintense mass in the upper pole of the
kidney (arrow). (B) Nephrogenic phase of enhancement shows the mass (arrow) is now isointense to the renal parenchyma. It is
difficult to determine subjectively the presence or absence of enhancement. (C) An image obtained by subtracting the precontrast
(A) from the postcontrast image (B) shows the mass (arrow) as markedly hypointense, without internal enhancement, consistent
with a hemorrhagic cyst. Also notice the simple cyst (c) anteriorly and the enhancing renal neoplasm (N ) at the posterior inferior
aspect of the kidney.
onstrate any signal intensity depending on their content of hemorrhagic material. The diagnosis of renal
cell carcinoma rests on demonstrating enhancement
within a renal mass. Unlike CT, in which Hounsfield
units are standardized, MR intensity units are arbitrary
and vary from sequence to sequence. It is difficult
to accurately quantify enhancement. Qualitative
enhancement by means of a subjective comparison
of the precontrast and postcontrast acquisitions or
more accurately by means of subtraction algorithms
needs to be performed. This is most important for
hypovascular lesions or those that are hyperintense on
the precontrast T1-weighted images.
148
149
Fig. 4. (A) Coronal gadolinium-enhanced fat-suppressed T1-weighted image obtained during the excretory phase demonstrates a
complex enhancing mass (straight arrow), which abuts the lower pole calyx (curved arrow). (B) Following partial nephrectomy,
maximum-intensity-projection image from a coronal-subtracted gadolinium-enhanced MR urogram demonstrates a urinary leak
(arrows) into the postoperative bed.
sequences and may be diagnosed erroneously as containing fat. Some angiomyolipomas contain only a tiny
amount of macroscopic fat and a concerted effort
should be made to identify even small amounts of
fat. In rare instances these lesions may not contain any
fat. In such cases, the diagnosis of angiomyolipoma
cannot be made and the lesion is indistinguishable
from a renal cell carcinoma.
Angiomyolipoma may also be diagnosed with the
use of chemical-shift imaging techniques. Exploiting
the precessional frequency differences of fat and
water, this technique provides images when fat and
water signal are in phase (additive) or out of phase
(destructive). This produces the characteristic India
ink artifact on the T1-weighted out-of-phase images,
manifested as a low signal intensity rim at any soft
tissue (water) and fat interface. Both hemorrhagic
cysts and angiomyolipomas are hyperintense on
150
Fig. 5. (A) Axial T1-weighted GRE image (in phase) shows a 1.5-cm hyperintense left renal mass (arrow). This is nonspecific,
and may represent a hemorrhagic cyst, angiomyolipoma, or, less likely, a renal neoplasm. (B) Axial T1-weighted GRE image
obtained with frequency-selective fat suppression demonstrates near complete signal loss, diagnostic of an angiomyolipoma.
T1-weighted in-phase images and may be indistinguishable from each other. They are readily differentiated, however, on the T1-weighted out-of-phase
images. For angiomyolipomas, the India ink artifact
appears at the interface of the tumor (fat) with the
kidney (water) (Fig. 6). For hemorrhagic cysts, the
India ink artifact occurs at the interface of the cyst
(fluid) and the perirenal fat (fat) (Fig. 7), not at the
interface of the cyst and the kidney.
Caution should be used in diagnosing a renal mass
as an angiomyolipoma if it loses signal on out-ofphase imaging, because clear cell carcinoma of the
kidney may show identical findings [14]. Clear cell
carcinoma does not contain bulk fat, however, and
does not lose signal on frequency-selective fat-suppressed T1-weighted images.
Metastases
The most common tumor to metastasize to the
kidney is carcinoma of the lung. Renal metastases
tend to be multiple and bilateral, and frequently are
associated with metastases to other organs. Although
they have nonspecific MR imaging features, renal
metastases may demonstrate infiltrative growth patterns. With the proper clinical history, the diagnosis
Lymphoma
Lymphoma may involve the kidneys by hematogenous spread, in which a single mass or multiple
bilateral masses are present, or by direct extension of
retroperitoneal lymphoma. Generally, most patients
with renal lymphoma have systemic involvement and
the diagnosis should not be difficult, given the
appropriate clinical history. The MR imaging appearance of lymphoma is nonspecific; however, the most
common appearance is that of multiple homogeneous
solid masses that may be well defined, but tend to
have infiltrative margins with the kidney. When
lymphoma diffusely infiltrates a kidney, the kidney
enlarges, but maintains its reniform shape [15].
151
Fig. 7. (A) Axial T1-weighted GRE image (in phase) demonstrates a hyperintense mass (arrow) in the left kidney. (B) Opposedphase axial T1-weighted GRE image demonstrates the India ink artifact (arrows) at the interface of the mass and the perirenal fat.
Although this may represent a hemorrhagic cyst or neoplasm, this excludes an angiomyolipoma. Subtracted images (not shown)
did not demonstrate enhancement in this lesion, consistent with a hemorrhagic cyst.
152
Fig. 9. Axial gadolinium-enhanced fat-suppressed threedimensional T1-weighted GRE image demonstrates a 3.5-cm
mass in the right posterior aspect of a horseshoe kidney. The
mass has a thick enhancing wall (straight arrow) and septum
(curved arrow) consistent with a category III cyst. At
pathology, this represented a renal cell carcinoma.
153
values could characterize these lesions [25,26]. Sufficient overlap exists, however, to render this cumbersome technique unreliable. Some authors advocate
using gadolinium chelates to help characterize adenomas. Krestin et al [27] showed that adenomas tend to
washout faster when compared with metastasis.
Although some overlap between benign and malignant lesions occurs, it is time consuming to quantify
enhancement on MR, and can be done quickly
with CT. Other authors have reported that adenomas
have a capillary blush seen on arterial-phase imaging,
whereas metastases do not [28]. The easiest, fastest,
and most reliable way to diagnosis an adrenal adenoma, however, rests on demonstrating intracellular
lipid within the mass (lipid-rich adenoma) [29].
By using chemical-shift techniques (breath-hold T1weighted GRE images in phase and out of phase) it is
possible to characterize lipid-rich adenomas. These
adenomas contain intracellular lipid and water protons within the same imaging voxel. On out-of-phase
images, the signal from these protons cancel each
other out and result in signal loss when compared
with the in-phase images (Fig. 10).
Frequently, signal loss on opposed-phase imaging
is obvious. There are cases, however, in which the
signal loss is subtle and not readily apparent. In these
cases, it is necessary to compare the adrenal mass
with an internal standard. In general, the liver is not a
reliable standard secondary to the possibility of
coexisting steatosis. The authors prefer to use spleen
as an internal standard for subjective analysis of
signal loss [29,30]. It is important to remember that
the echo time of the out-of-phase image should be
shorter than the in-phase image to eliminate T2 decay
as a confounding variable of signal loss.
Fig. 10. (A) Axial T1-weighted (in phase) GRE image demonstrates a 2.5-cm right adrenal mass (arrow), which is isointense in
signal when compared with the spleen. (B) Opposed-phase axial T1-weighted GRE image shows the adrenal mass (arrow) is
now hypointense in signal when compared with the spleen, diagnostic of an adrenal adenoma.
154
Fig. 11. Two left adrenal masses in a patient with a history of lung cancer. (A) Axial T1-weighted (in phase) GRE image
demonstrates two masses (arrows) in the left adrenal gland, both of which are isointense in signal when compared with the
spleen. (B) Opposed-phase axial T1-weighted GRE image demonstrates that the posterior mass (curved arrow) is slightly
hypointense in signal when compared with the spleen, consistent with an adenoma. The anterior mass (straight arrow) remains
isointense to the spleen, and may represent a lipid-poor adenoma or, in this case, a metastasis.
155
Fig. 12. (A) Sagittal gadolinium-enhanced fat-suppressed T1-weighted GRE image demonstrates a large heterogeneous
enhancing adrenal neoplasm (arrows) displacing the kidney inferiorly. Note the simple cyst (c) in the kidney. (B) Coronal
gadolinium-enhanced fat-suppressed T1-weighted GRE image shows enhancing tumor thrombus growing into the left adrenal
vein (long straight arrow) and inferior vena cava (short straight arrow) with extension into the right atrium (long curved arrow).
Note the bland thrombus proximal to the tumor thrombus (short curved arrow).
156
157
Fig. 14. Coronal T2-weighted (HASTE) image demonstrates a large simple cystic suprarenal mass (c) consistent with a
congenital adrenal cyst. The adrenal gland is stretched along the periphery of the mass (straight arrow). Note how the cyst
deviates the left kidney (curved arrow) inferiorly, and exerts mass effect on the pancreas ( P) and spleen (S ).
Summary
By performing a comprehensive MR imaging
examination, it is not only possible accurately to
characterize and stage cystic and solid lesions of the
kidney, but also to provide important preoperative
information to the surgeon. In addition, MR imaging
can characterize many adrenal lesions and frequently
can obviate the need to obtain biopsies. The continued development and growth of MR technology
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sequences, the muscle has a slightly higher signal intensity than does urine and a slightly lower signal intensity than does perivesical fat. On T2W sequences,
it is contrasted between the high-signal urine and fat
[13]. Wall contrast improves on a T2W sequence,
with longer TE at the cost of signal to noise though.
The bright mucosa and lamina propria may be
obscured against the urine, however. Although not a
consistent finding, Maeda et al [14] have documented the three muscle layers on T2W sequences.
The superficial muscle layer has intermediate signal
intensity. The deep muscle layer has lower signal
intensity and is distinguishable using a T2W
sequence of detrusor hypertrophy [15]. The fetal
bladder can be imaged, in utero, using SSFSE
sequences in multiple planes.
Although the thin serosa is not perceptible as a
single layer, the outer aspect of the bladder wall is
defined against the high-signal perivesical fat on
T1W and T2W sequences. The ureterovesical junctions are best defined by the high-signal urine-filled
ureters on T2W or SSFSE sequences. Fascial planes
and lymph nodes are usually low signal on a T1W
sequence and are defined by their boundaries with
high-signal pelvic fat. The adjacent pelvic viscera
have internal signal characteristics that are well
described but, in general, are best depicted on non
fat-saturated T2. Normal vessels have signal voids on
spin echo sequences and the fatty marrow of pelvic
bones is defined by the surrounding low-signal cortex, which is best seen on a T1W sequence [1].
and pheochromocytoma. The single greatest risk factor for bladder cancer is cigarette smoking, causing a
sixfold increase in risk [20]. Other factors include
exposure to aniline dye, aromatic amine, diesel fume,
and phenacetin. A genetic predisposition has been
identified [21] and some chromosomal findings have
been linked to aggressiveness of the tumor [22].
Squamous tumors are linked to chronic cystitis and
schistosomiasis. Adenocarcinomas may invade from a
persistent urachus in the bladder wall supravesically,
or may occur in the trigone region [23,24].
Bladder cancer prognosis is predicated on depth
of invasion (T), nodal involvement (N), the presence
of metastatic foci (M), and histologic type and grade
(see Table 1) [20]. The TNM staging system has been
updated a number of times, the last time being in
1997 [20]. Deeply invading tumors are associated
with increased lymphatic spread and poorer prognosis
[25 28]. The various stages of bladder cancer affecting the bladder wall have been much discussed, but
have less impact on preoperative decision-making.
The main surgical demarcation is between organconfined and non organ-confined disease.
Table 1
The TNM classification for bladder cancer
Stage
Organ-confined
Ta
Tis
T1
Characteristic
disease
Noninvasive papillary carcinoma
Carcinoma in situ
Tumor invades subepithelial
connective tissue
T2 Tumor invades muscle)
T2a
Tumor invades superficial muscle
T2b
Tumor invades deep muscle
Non organ-confined disease
T3 Tumor invades perivesical tissue
T3a
Tumor invades perivesical
tissue microscopically
T3b
Tumor invades perivesical
tissue macroscopically (mass)
T4 Tumor invades adjacent viscera or body wall
T4a
Tumor invades prostate, uterus, or vagina
T4b
Tumor invades pelvic side wall or
abdominal wall
N0
No regional lymph node metastases
N1
Metastases to a single lymph node
V to 2 cm
N2
Metastases to a single lymph node > 2 cm
but V 5 cm, or multiple lymph nodes
No lymph nodes > 5 cm
N3
Metastasis in a lymph node > 5 cm
MO
No distant metastasis
M1
Distant metastasis
163
164
165
166
Fig. 10. (A) Coronal T2W image (FSE, TR 3500/msec, TE 102/msec). Normal high-signal seminal vesicles (arrows) are seen
entering the prostate ( P). (B) Sagittal T2W image (FSE, TR 3500/msec, TE 102/msec). The normal high-signal fat plane (arrow) is
seen separating the seminal vesicles (S) from the low-signal posterior bladder wall (arrowheads). B, bladder; R, rectum. Loss of this
plane or the high signal within the seminal vesicle in the setting of posterior bladder tumor should arouse suspicion for extravesical
spread and seminal vesicle involvement.
167
Fig. 11. (A) Axial T2W image (FSE, TR 4167/msec, TE 77/msec). Low-signal tumor of the posterior bladder wall (arrows)
extends posteriorly around the seminal vesicles (arrowheads), obscures the high-signal fat plane normally present here, and
extends toward the rectum (R). B, bladder. (B) Axial, fat-saturated, T2W image (FSE, TR 3500/msec, TE 99/msec). The bilateral
hydronephrosis (arrowheads) with loss of renal cortex on the right (short arrow), although preserved on the right (long arrow), is
due to the posterior bladder tumor involvement of the ureteral orifices.
168
Fig. 13. (A) Coronal, postcontrast, fat-saturated, T1W image (FSPGR/70, TR 295/msec, TE 4.2/msec). A lobulated intermediate
signal transitional cell carcinoma (short arrow) hangs from the dome of the bladder (B). (B) Coronal, postcontrast, fat-saturated,
T1W image (FSPGR/70, TR 295/msec, TE 4.2/msec). On dynamic imaging, the mass (M) is noted to enhance briskly along with
thickening of the adjacent bladder dome (long arrow). The nonenhancing end of the tumor represents clot (arrowhead). The thin
normal bladder wall (short arrow) is noted. (C) Coronal, postcontrast, fat-saturated, subtraction, T1W image (FSPGR/70,
TR 295/msec, TE 4.2/msec). Subtraction increases the conspicuity of the enhancing tumor (long arrow) and confirms the lack of
enhancement of the clot (short arrow).
169
170
171
172
173
Cystocele
The pelvic floor serves to support the pelvic organs
and aid their normal functions of controlled continence, urination, and defecation. This support may be
compromised through physical insult such as childbirth and the loss of the estrogenic support of the tissue
integrity. Pelvic floor weakness and organ prolapse is
common in women and can lead to pain, pressure, and
174
Fig. 26. (A) Sagittal T2W image (SSFSE, TR 2195/msec, TE 69/msec). On this resting image, urine is in the bladder (long
arrow) and there is high-signal contrast in the vagina (arrowhead) and rectum (short arrow). (B) Sagittal single-shot fast spin
echo image (SSFSE, TR 30711/msec,TE 69/msec) during straining. The bladder is seen to prolapse posteroinferiorly (long
arrow) behind the pubic bone ( P). An anterior rectocele (short arrow) and contrast from the vagina (arrowhead) are also noted.
(C) Axial single-shot fast spin echo image (SSFSE, TR 23311/msec,TE 68/msec). This inferior view demonstrates the cystocele
during straining as it protrudes through the introitus (arrow).
175
Summary
References
MR imaging features of cystocele
The normal bladder neck at MR imaging should be
close to the symphysis, with an H-shaped vaginal
lumen and horizontal urethropelvic ligaments [74].
On MR imaging, the posterior bladder wall forms a
smooth bulge that extends posteroinferiorly. Its apex is
directed toward the introitus, whereas the relatively
fixed anterior bladder remains undisturbed. The exact
configuration of the bulge will depend somewhat on
the site and character of any pubocervical fascia defect.
Associated descent of the cervix and remaining pelvic
floor may alter the configuration of the cystocele. The
imaging definition of cystocele has been variably
described as bladder below the symphysis, below the
pubococcygeal line, and 1 cm below the pubococcygeal line. Loss of muscle bulk and increased T1W
signal may help to document predisposing fatty
atrophy, and follow-up studies may help to monitor
any trophic effects of estrogenic therapy (Figs. 26, 27).
Cystocele treatment
Conservative therapies are aimed at restoring the
firmness of the pelvic floor and include hormonal
therapy, pessaries, and pelvic floor muscle exercises
176
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MR imaging is becoming an increasingly important tool in the diagnosis of benign and malignant
disease of the female pelvis. Although ultrasound
(US) and hysterosalpingography (HSG) remain the
primary forms of imaging, MR imaging is now
routinely used in the diagnostic work-up of infertility,
including mullerian anomalies, and chronic pelvic
pain. Both CT and MR imaging can be used to
determine the origin of and to characterize a pelvic
mass. Staging of gynecologic malignancies can also
be performed with both modalities. In obstetrics, MR
imaging is used to assess maternal complications of
pregnancy and to identify or confirm fetal anomalies.
MR imaging technique
Before imaging, the patient should fast for 6 hours
to diminish bowel peristalsis. Alternatively, 0.5 to
1 mg of glucagon can be administered intramuscularly
at the beginning of the examination. It is also advisable to have the patient void before the examination to
limit deformation of adjacent organs by an enlarged
bladder. Although imaging using the body coil is
certainly adequate for most diagnoses, the highest
resolution images are obtained using a multicoil array.
All major vendors have such an array in which several
surface coils are enclosed within a band that encircles
the pelvis. Information from the surface coils is
summed to form the final images. Saturation bands
placed along the anterior and posterior body wall fat
are useful to diminish near field artifact.
Coronal, rapid T2-weighted scout images encompassing the entirety of the abdomen and pelvis serve
Normal anatomy
Because of the unique contrast differences among
the viscera, T2-weighted MR images are often superior
to CT and US in assessing the female pelvis. The uterus
has three distinct zones: (1) the high T2 signal endometrium, (2) the low T2 signal junctional zone, and (3)
0033-8389/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 6 3 - 5
180
Fig. 1. Sagittal (A) and axial (B,C) T2-weighted images of the normal female pelvis. On the sagittal image (A), the three zones of the
uterus are demarcated: (1) the myometrium (black arrows); (2) the junctional zone (white arrowheads); and (3) the bright
endometrium (e). Incidental note is made of a bladder fold. (B) The normal convex fundal contour (short arrows) and the normal
appearance of the ovaries (long arrows). Bright T2 signal follicles make the ovaries identifiable in 90% of women of menstrual age.
(C) The normal H or butterfly shape of the vagina (short arrows) and the puborecatalis component of the levator ani (long arrows).
Benign conditions
Mullerian anomalies
The mullerian ducts are paired structures that fuse
between weeks 6 and 11 of gestation. They form the
uterus, cervix, fallopian tubes, and upper two thirds
of the vagina. The lower one third of the vagina arises
from the urogenital sinus. Anomalies occur in less
than 5% of the general population but are present in
approximately 20% of those patients who present
with multiple spontaneous first-trimester abortions
[4]. Anomalies occur because of failure of development or fusion of the mullerian ducts and failure of
septal resorption once fusion has occurred. Although
often initially diagnosed using HSG, MR imaging
should be performed when surgical therapy is considered to characterize more accurately the anomaly.
It is particularly important to differentiate a septate
from a bicornuate uterus, each of which requires
different therapy.
The most common mullerian anomalies are caused
by in utero exposure to diethylstilbestrol. This medication, intended to thwart premature labor, was last
given in 1970. It is estimated that 60% of exposed
individuals have an abnormal HSG. Abnormal findings include a squared off uterine contour (caused by
myometrial hypertrophy), uterine hypoplasia, and
fallopian tube diverticula [5,6]. The diagnosis of
181
Fig. 2. Coronal T2-weighted MR image (A,B) of a didelphys uterus. The anterior image (A) shows the two widely separated
uterine horns, each with its own myometrium, junctional zone, and endometrial canal (arrows). The posterior image (B) shows
two cervices (curved arrow) extending inferiorly to the level of the vaginal fornices.
182
Fig. 3. Axial (A) and coronal (B) T2-weighted MR image of a septate uterus. Axial image (A) shows the characteristic flat
external uterine contour (arrowheads) of the septate uterus. The septum is demarcated with an open arrow. Coronal image (B)
shows a black, fibrous septum extending through the cervices (open arrows) and into the proximal vaginas. The vaginal fornices
are marked with long arrows.
Fibroids
Fibroids, or leiomyomata, are present in an estimated 40% of women over 40 years of age and are
particularly common in the black population [7].
Symptoms associated with fibroids include bleeding,
pain, and urinary incontinence. Their presence can
also contribute to infertility. US, either transabdominal or transvaginal, in combination with physical examination, is most often used to diagnose
the presence and monitor the growth of fibroids.
MR imaging is of value in the symptomatic patient
when uterine salvage therapy is considered [8,9].
Techniques include myomectomy, focal endometrial
curettage, hormone administration, and uterine artery embolization.
Using axial and sagittal T2-weighted imaging,
most fibroids, including pedunculated ones, can be
identified with confidence. They should be described
in terms of size, location, and signal intensity. Any
fibroid that impresses on the endometrial canal is
considered to have a submucosal component and can
be a source of bleeding.
Based on T2 signal, fibroids can be classified
further into groups depending on their degree of
cellularity (Fig. 5) [10]. The most common group is
the ordinary fibroids, of relatively homogeneous low
T2 signal and composed of collagenous material.
Cellular fibroids contain less collagen and are of
intermediate T2 signal intensity. These fibroids
respond well to hormonal therapy. Degenerating fibroids are of very bright T2 signal intensity but often
183
Fig. 4. (A) Sagittal and (B) axial T2-weighted MR image of a woman with an enlarged fibroid uterus. A cellular fibroid (black
arrowhead ) of intermediate signal intensity distorts the uterine canal (open arrow).
Adenomyosis
Adenomyosis is a common cause of pelvic pain in
women of menstrual age. It is defined as extension of
endometrial glandular tissue more than one third of the
depth of the myometrium with adjacent muscular
hypertrophy. Adenomyosis cannot be diagnosed
using CT. With meticulous US technique, it appears
as heterogeneous and cystic areas [12,13]. Because
of its accuracy and ease, MR imaging remains
the diagnostic test of choice (Fig. 6) [14,15]. On T2weighted MR imaging, adenomyosis appears as
poorly defined low T2 signal intensity confluent with
and widening the junctional zone ( > 11 mm) [42].
High T2 signal intensity glands are often seen within
the diseased area. Occasionally, focal adenomyosis
forms a cavity with a very low T2 signal intensity
Laparoscopy remains the test of choice for diagnosing and staging endometriosis. Transvaginal US
and MR imaging are useful only when the diagnosis
of an endometrioma is suspected. Endometriomas
may be unilocular or multilocular and are predominantly high signal on T1- and low or mixed signal
on T2-weighted images [17]. On T2-weighted
images, intermediate signal shading, caused by T2
shortening of blood products, is often seen within the
mass [18]. Recurrent bleeding may lead to a very low
signal hemosiderin rim. Adjacent bowel loops may be
distorted and tethered to the mass. Confident diagnosis can be difficult when some of the previously
mentioned MR imaging features are absent [19].
Differential diagnosis includes dermoid and hemorrhagic cyst.
184
Fig. 5. Sagittal and axial (A,B) T2-weighted MR image of a woman with abdominal pain and an enlarged uterus caused by
adenomyosis. On the sagittal image (A), the abnormal low T2 signal is confluent with and widens the junctional zone nearly to
the edge of the myometrium (arrowheads). The distorted endometrial canal is marked with a star. On the axial image (B), a
dilated endometrial gland (white arrow) extends into the adenomyoma.
Fig. 6. Axial T1- (A) and T2-weighted (B) MR images of a woman with chronic pelvic pain caused by endometriosis. The
encapsulated structure in the cul-de-sac is of mixed low and high signal on both T1- and T2-weighted images indicating the
presence of blood products of variable age and diagnostic of an endometrioma (arrows).
185
Fig. 8. Axial contrast-enhanced CT (A) and T2-weighted MR images (B) of a woman with a left adnexal dermoid. (A) A large
pelvic mass composed of fat and soft tissue elements (arrows). (B) Obtained at the same level, image shows chemical shift
artifact in the frequency-encoding direction (arrowheads) and the Rokitansky nodule (star) with speckling artifact caused by
myriad sites of chemical shift.
186
Fig. 9. Axial contrast-enhanced CT (A) and T1-weighted, fat-suppressed, contrast-enhanced MR images (B) of a woman with a
right lower quadrant mass. Both images show a primarily cystic mass with a thick enhancing wall and septum (arrow). Two
smaller cystic masses are seen in the left lower quadrant (arrowheads) (A). The differential diagnosis includes ovarian
cystadenocarcinoma. In this case the patient had a long history of pelvic inflammatory disease and sepsis and surgical exploration
revealed bilateral tubo-ovarian abscesses.
ential diagnosis includes torsion, diverticulitis, appendicitis, and ovarian neoplasm; however, the presence
of fever, cervical motion tenderness, and appropriate
history usually points to the correct diagnosis. Primary treatment is antibiotic therapy for 48 to
72 hours. If this regimen fails, percutaneous or
surgical drainage is usually performed.
Gynecologic neoplasms
Most gynecologic oncologists stage pelvic neoplasms according to the FIGO system (International
Federation of Gynecology and Obstetrics). This form
of clinical staging relies on a high-quality physical
examination performed under general anesthesia.
Numerous radiologic tests are then performed including chest radiograph, barium enema, and intravenous
pyelogram. It has been reported by two groups of
investigators that performing a single MR exam of
the pelvis can replace all of the ancillary examinations with the exception of the chest radiograph at a
slightly lower cost [23,24].
Some gynecologic oncologists argue that preoperative imaging is of little value because once a
significant gynecologic mass is detected, it must be
removed using an extensive oncologic-type resection
that is both diagnostic and therapeutic. There is
agreement that CT or MR imaging is of particular
value in the case of very advanced disease, where the
primary therapy should be chemotherapy and not
187
Endometrial cancer
Endometrial cancer is the most common of the
gynecologic malignancies. It also has the best prognosis. Of the 38,000 new cases diagnosed each year,
75% of patients present with stage I disease confined
to the endometrial canal and curable by hysterectomy
[25]. Presentation is usually painless vaginal bleeding
in a postmenopausal woman and detection is usually
done by a combination of US and pipette biopsy. Risk
factors include increased age and prolonged exposure
to unopposed estrogens.
The endometrial thickness of postmenopausal
women should not exceed 5 mm. Women with
thickened endometrial linings on US examination
merit biopsy. Even in the presence of vaginal
bleeding, however, endometrial thickness of less
than 5 mm on US excludes endometrial cancer.
Women taking hormone replacement therapy or
tamoxifen may have slightly thicker endometrial
linings (8 mm); however, 5 mm should still be
taken as the upper limits of normal because these
women are at a higher risk for endometrial carcinoma [27 29].
Most women with endometrial carcinoma do not
require imaging. Treatment is predicated on physical
Fig. 10. Sagittal (A) and axial (B) T2-weighted MR images of a woman with a large cervical cancer. On the sagittal image (A)
the tumor bulk is delineated by arrows. The anterior aspect of the tumor invades the bladder wall. (B) A markedly enlarged
cervix with tumor replacing the entirety of the normal low T2 signal stroma (arrowheads). This finding alone has an 85%
positive predictive value for extension of tumor beyond the confines of the cervix and into the parametria.
188
Fig. 11. Contrast-enhanced axial CT images of the abdomen and pelvis of a woman with advanced cervical cancer. (A) The
cervix is enlarged and contains a large amount of gas, likely caused by tumor necrosis (short arrows). A large lymph node abuts
the right pelvic sidewall (long arrow). (B) There is right hydronephrosis (arrowhead) and hydroureter, likely caused by invasion
and occlusion of the ureterovesical junction.
189
Fig. 12. Sagittal and axial T2-weighted (A,B) and axial contrast-enhanced T1-weighted (C) MR images of the uterus of a woman
with painless vaginal bleeding. (A,B) An intermediate signal mass within and widening the endometrial canal (arrowheads). (B)
A suggestion of endometrial invasion of the anterior aspect of the myometrium. This finding is confirmed on the contrastenhanced image (C). The endometrial cancer extends less than 50% of myometrial thickness indicating a good long-term
prognosis (arrow).
Pregnancy
Imaging of the pregnant mother or fetus is done
only in certain circumstances and following a clear
discussion among the patient, referring physician, and
radiologist of possible risks and benefits. In the case of
significant maternal trauma, contrast-enhanced CT
scan is the test of choice. It can be done quickly and
is extremely reliable in the detection of hemoperito-
190
Fetal anomalies
With the advent of ultrafast T2-weighted pulse
sequences, such as half Fourier single-shot turbo spin
echo and SSFSE, it has become possible to image the
fetus without the blurring associated with motion. An
MR image is first obtained parallel to the fetal spine.
Each set of images then serves as the scout for the
next, including fetal axial and coronal planes [41].
Although US remains the mainstay in the detection of
fetal anomalies, MR imaging has proved of value in
confirming visceral and musculoskeletal anomalies
and identifying cranial anomalies. Imaging is usually
done as part of a complete clinical work-up in a parent
known to carry a second-trimester fetus with an
abnormal karyotype or US. The most common indication is myelomeningocele. Findings can be used to
Fig. 13. Transabdominal ultrasound (A) and sagittal T2-weighted MR images (B) of a pregnant woman with pelvic pain
following cerclage. (A) The fetal head is demarcated by a white arrow. A fluid collection is seen within the cul-de-sac. (B) The
fluid collection is marked with a star and the gravid uterus with long arrows. Both ovaries were identified on other MR images
(not shown) eliminating the possibility of a hydrosalpinx or cystadenoma. Percutaneous drainage was curative and demonstrated
abundant white blood cells indicative of abscess.
Summary
MR imaging has become a valuable modality in
the evaluation of the female pelvis. In many cases, it
follows the performance of HSG or US. These cases
include infertility and pelvic pain. In some cases, it
should serve as the test of choice. This is true in the
local staging of cervical cancer and the evaluation of
pain or disability in the pregnant patient. Finally, in
the evaluation of advanced gynecologic cancers, it is
usually a secondary choice with CT preferred.
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[20]
[21]
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192
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[42]
Index
Note: Page numbers of article titles are in boldface type.
B
Bicornuate uterus, MR imaging of, 181 182
Biliary complications, postoperative, MR cholangiopancreatography of, 92 93
Biliary cystadenomas, MR imaging of, 60
Biliary cysts, MR cholangiopancreatography of,
90 91
Bladder, MR imaging of, 161 177
anatomy in, 162
for cystoceles, 173 175
for diverticula, 171 172
for endometriosis, 172 173
for lymphomas, 170
for mesenchymal tumors, 170 171
for tumors, 162 170
contrast-enhanced, 167 168
direct spread, 165 167
epidemiology of, 162 163
management and follow-up, 169 170
metastatic to bones, 168 169
metastatic to lymph nodes, 169
primary mass, 163 165
for vesical congestion and inflammation, 172
patient preparation for, 161
planes in, 161 162
pulse sequences in, 161 162
Blood pool agents, in MR angiography, 140
0033-8389/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 3 ) 0 0 0 0 3 - 4
194
Cholecystolithiasis, MR cholangiopancreatography
of, 91
Choledocholithiasis, MR cholangiopancreatography
of, 91 92
D
Dermoids, MR imaging of, 185
Diffuse hepatic disease, MR imaging of, 67 87
arterial obstruction, 85
Budd-Chiari syndrome, 84 85
cirrhosis, 68 74
congestive heart failure, 85
fatty liver, 77 79
hemochromatosis, 23, 79 80
hepatitis, 74 75, 77
hepatocellular carcinoma, 62, 81
lymphomas, 81
metastatic disease, 81
mucopolysaccharidoses, 80 81
portal vein thrombosis, 81, 84
technique for, 67 68
vascular disorders, 81
Dilated cardiomyopathy, MR imaging of, 23
Diverticula, bladder, MR imaging of, 171 172
Dobutamine stress imaging, of cardiovascular
disease, 17 18
Double-duct sign, in MR cholangiopancreatography, 105
E
Echo planar MR imaging, physics of, 9 12
Endometrial cancer, MR imaging of, 187 188
Endometriosis, MR imaging of, 172 173, 183
Endoscopic retrograde cholangiopancreatography,
versus MR cholangiopancreatography, 89,
99 100
F
Fast spin echo MR imaging, physics of, 6 7, 9
Fatty liver, MR imaging of, 77 79
Female pelvis, MR imaging of, 179 192
anatomy in, 179 181
for adenomyosis, 183
for cervical cancer, 186 187
for dermoids, 185
for endometrial cancer, 187 188
for endometriosis, 183
for fetal anomalies, 1990 191
for fibroids, 182 183
for mullerian anomalies, 181 182
for ovarian cancer, 188
for pelvic floor relaxation, 188 189
for polycystic ovarian disease, 184 185
for tubo-ovarian complex, 185 186
in pregnancy, 189 190
technique for, 179
I
Intraductal papillary mucinous tumors, MR cholangiopancreatography of, 107 110
Iron deposition, hepatic, MR imaging of, 79 80
Ischemic heart disease, MR imaging of.
See Cardiovascular system.
Ferumoxides, in MR imaging, 53 54
H
Half-Fourier acquisition single-shot turbo spin echo
sequence, in MR imaging, 52, 68
195
L
Leiomyomas, bladder, MR imaging of, 170
uterine, MR imaging of, 182 183
196
M
Magnetic resonance imaging, of adrenal glands.
See Adrenal glands.
of bladder. See Bladder.
of breasts. See Breasts.
of cardiovascular system.
See Cardiovascular system.
of diffuse hepatic disease. See Diffuse
hepatic disease.
of female pelvis. See Female pelvis.
of hepatic tumors. See Hepatic tumors.
of kidneys. See Kidneys.
physics of, 1 15
conventional image acquisition, 3
image data, 2 3
motion artifacts, 3
motion compensation approaches to,
35
pulse sequences, 5 7, 9 12, 161 162
echo planar imaging, 9 12
fast spin echo imaging, 6 7, 9
spiral imaging, 9 12
reduction of data collection in, 12 14
requirements and challenges of, 1
Mangafodipir, in MR imaging, 54 55
Mesenchymal tumors, bladder, MR imaging of,
170 171
Metastatic disease, to bones, MR imaging of,
168 169
to kidneys, MR imaging of, 150 151
to liver, MR imaging of, 60 62, 81
MR angiography, contrast-enhanced, 116, 118 124
bolus delivery in, 123 124
pulse sequences in, 121 123
timing of, 119 121
future directions in, 138 140
of abdominal aorta. See Abdominal aorta.
of chest. See Chest.
of coronary arteries, 19 21
N
Neurofibromas, bladder, MR imaging of, 170
O
Ovarian cancer, MR imaging of, 188
P
Pancreas divisum, MR cholangiopancreatography of,
91, 101
Pancreatic diseases, MR cholangiopancreatography
of, 89 96, 97 114
anatomy in, 100 101
biliary congenital variants, 91
biliary cystic diseases, 90 91
cancer, 94
cholangiocarcinoma, 93 94
cholecystolithiasis, 91
choledocholithiasis, 91 92
cysts, 105 110
future directions in, 94 95
pancreas divisum, 91, 101
pancreatitis, 93, 101 104
versus pancreatic cancer, 104 105
postoperative biliary complications, 92 93
primary sclerosing cholangitis, 92
santoriniceles, 101
technique for, 89 90, 97 99
versus endoscopic retrograde cholangiopancreatography, 89, 99 100
Pancreatitis, MR cholangiopancreatography of, 93,
101 104
197
Santoriniceles, MR cholangiopancreatography
of, 101
T
Teratomas, MR imaging of, 185
Teslascan, in MR imaging, 54 55
Thoracic aorta, MR angiography of, 34
Thoracic veins, central, MR angiography of, 37
Time-of-flight MR angiography, technique for,
115 116
Time-resolved two- and three-dimensional digital
subtraction angiography, technique for, 139