THAI J

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Liver MRI Makes Easy
Corner
Liver MRI Makes Easy

Pantongrag-Brown L

Introduction T1 in-phase/out phase (Figure 1)

MRI is a good imaging modality to detect and
characterize solid organs within the abdomen. Liver,
biliary system, pancreas, spleen, kidneys, and pelvic
organs are good targets for MRI study. The most com-
mon indication for abdominal MRI is to characterize
liver mass. Therefore, liver will be the organ discussed
and emphasized in this article. There is several MRI
pulse sequences used in the abdominal MRI. How-
ever, for non-radiologists, the following pulse se-
quences are the gist of the study.
Key liver MRI pulse sequences
1. T1 in-phase/out-phase
2. T2/heavy T2 fat saturation
3. T1 dynamic gadolinium
4. 20 min delayed hepatobiliary phase (if
primovist is used.)
This sequence is to determine fat content. If the
image voxel contains both water and fat, the signal will
enhance in the T1 in-phase and loss in the T1 out-phase.
Fatty liver, focal fatty infiltration, and fatty sparing will
be able to diagnose with these pulse sequences.
T2/heavy T2 fat saturation (Figure 2)
T2 fat saturation (T2 FS) is a pulse sequence to
determine if the lesion is true or pseudolesion. Most
of true lesions will exhibit high signal intensity, ex-
cept for a few conditions, such as early hepatocellular
carcinoma or focal nodular hyperplasis, which may
show low signal intensity. Heavy T2 is used to distin-
guished solid from cystic lesion and hemangioma. Cyst
and hemangioma will show very bright signal inten-
sity, similar to spinal fluid, whereas solid lesion will
show not-so-bright signal intensity, just higher signal

Figure 1. T1 in-phase/out-phase
Fatty liver shows signal dropping at T1 out-phase (B), comparing to T1 in-phase (A), except for an area of focal
fatty sparing (arrow in B).

AIMC, Ramathibodi Hospital, Bangkok, Thailand.

Address for Correspondence: Linda Pantongrag-Brown, AIMC, Ramathibodi Hospital, Bangkok 10400, Thailand.
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Figure 2. T2/heavy T2 fat saturation

Liver hemangioma (A), and liver cyst (B) show very bright signal intensity at T2, whereas hepatoma (C) and
metastasis (D) show not-so-bright signal intensity, just higher signal than the liver parenchyma.

Figure 3. T1 dynamic primovist with 20 min delayed hepatobiliary (HB) phase of a small hepatocellular carcinoma
A: Pre-contrast shows a low-signal intensity nodule
B: Arterial phase shows rapid enhancement of the nodule
C: Venous phase shows rapid washout of the nodule
D: 20 min HB phase shows no uptake of primovist by the nodule. Note that the liver parenchyma shows high
signal intensity secondary to uptake of primovist by normal hepatocytes.
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than the liver parenchyma. overlapping may occur.

T1 dynamic gadolinium (Figure 3A-C) 20 min delayed hepatobiliary phase primovist

This is a must to do pulse sequence. Vascular
enhancement pattern is the key to characterize liver
mass. Dynamic arterial, venous, equilibrium, and 3
min delayed phases are used to evaluate arterial en-
hancement and venous washout. Each tumor will have
its own character of vascular enhancement, although
(Figure 3D)
If primovist, the hepatobiliary specific contrast
agent, is used, 20 min delayed phase has to be evalu-
ated after dynamic phases. The liver parenchyma needs
about 10-20 min to uptake contrast media to exhibit
high signal intensity. Most tumors show no uptake of

Figure 4. Focal fatty infiltration in an asymptomatic female

A, B: T1 in-phase (A), and out-phase (B) shows a lobulated mass at right hepatic lobe with signal loss, indicative
of fatty mass.
C: T2 FS shows the lesion to be low signal intensity suggestive of pseudolesion.
D-F: Arterial (D), venous (E), and delayed phases (F) show no enhancement within the lesion. Note the vessel
coursing through this pseudolesion, which is focal fatty infiltration.
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primovist, except for focal nodular hyperplasia (FNH), 2. Hemangioma (Figure 5)

and dysplastic nodule. MRI signal Interpretation
T1 in-phase/out-phase No signal loss =
Case examples
no fat
Each liver nodule, mass, and pseudolesion exhib- T2 FS High SI = true
its different MRI pattern(1-7). A few examples of le- lesion, very bright
sions and MRI pattern are shown, as following. signal similar to
1. Focal fatty infiltration (Figure 4) spinal fluid
MRI signal Interpretation T1 dynamic gadolinium Peripheral nodular
T1 in-phase/out-phase Signal loss = fat and 3 min delayed enhancement,
T2 FS Low SI = pseudo- central filling in,
lesion and persistent en-
T1 dynamic gadolinium No enhancement, hancement
normal vessels throughout de-
coursing through layed phase

Figure 5. Hemangioma in a woman with breast cancer

A, B: T1 in-phase/out-phase shows a low signal intensity nodule at right hepatic lobe.
C: T2 FS shows the nodule to be high signal intensity, similar to spinal fluid.
D-F: The nodule shows peripheral nodular enhancement at arterial phase (D), central filling-in at venous phase
(E), and persistent enhancement throughout delayed phase (F). MRI pattern is characteristic for a benign
hemangioma.
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3. Focal nodular hyperplasia (Figure 6) 4. Hepatocellular carcinoma (Figure 7)

MRI signal Interpretation MRI signal Interpretation
T1 in-phase/out-phase No signal loss = T1 in-phase/out-phase No signal loss =
no fat no fat
T2 FS High SI = true le- T2 FS High SI = true le-
sion, bright cen- sion
tral scar T1 dynamic gadolinium Rapid arterial en-
T1 dynamic gadolinium Rapid arterial en- and 20 min HB phase hancement, rapid
and 20 min HB phase hancement, iso- primovist venous washout,
primovist venous washout, and no uptake of
and uptake of primovist
primovist

Figure 6. Focal nodular hyperplasia (FNH) in an asymptomatic woman

A, B: T1 in-phase/out-phase shows fatty liver as shown by signal loss at out-phase (B), compared to in-phase (A).
The lobulated mass at right hepatic lobe is noted.
C: T2 FS shows the nodule to be high signal intensity with a very bright small central scar.
D-F: The nodule shows rapid arterial enhancement (D), iso-venous washout (E), and uptake of primovist except
for a central scar (F). MRI pattern is characteristic for a benign FNH.
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Figure 7. HCC in a man with chronic hepatitis B

A, B: T1 in-phase/out-phase shows a small mass at left hepatic lobe.
C: T2 FS shows the mass to be high signal intensity, but not as bright as fluid. .
D-F: The mass shows rapid arterial enhancement (D), rapid venous washout (E), and no uptake of primovist (F).
MRI pattern is characteristic for HCC in this clinical setting.

CONCLUSIONS
1. Liver is the most common organ studied in ab-
dominal MRI.
2. Key MRI pulse sequences are T1 in-phase/out-
phase, T2/heavy T2 FS, T1 dynamic gadolinium, and
20 min HB phase (if primovist is used).
3. T1 in-phase/out-phase is to determine fat con-
tent.
4. T2 is to determine if the lesion is true or
pseudolesion.
5. T1 dynamic enhancement is to determine vas-
cular enhancement pattern. This is the most important
pulse sequence.
6. 20 min HB phase of primovist is to confirm
diagnosis of FNH and to distinguish dysplastic nodule
from HCC.
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