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Section of Abdominal Imaging

Magnetic Resonance Imaging

Body Imaging

Protocols

October 2009

Cleveland Clinic

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Joseph C. Veniero M.D. Ph.D.

Cleveland Clinic

Division of Radiology

Section of Abdominal Imaging

Cleveland OH, 44195

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Table of Contents

Introduction........................................................................................................................................................... 5

The MR Mantra ................................................................................................................................................... 5

General Information............................................................................................................................................. 6

Contraindications................................................................................................................................................. 6

Contrast................................................................................................................................................................ 6

Breathholding ...................................................................................................................................................... 7

SAR Problems ..................................................................................................................................................... 8

Contrast Injection Timing.................................................................................................................................... 8

Miscellaneous points ........................................................................................................................................... 9

Liver / Pancreatic Imaging................................................................................................................................. 10

Positioning Liver and MRCP Sequences........................................................................................................... 11

Routine Liver (AMRLIV) 7/09 ........................................................................................................................ 14

Non-Breath-hold Liver (AMRNBHLIV) 7/09 ................................................................................................. 15

LIVER DONOR PROTOCOL 7/09 ................................................................................................................. 16

Routine Pancreas & Biliary MR (AMRPANCBIL) 7/09................................................................................. 17

Routine MRCP (without contrast) (AMRMRCP) 7/09..................................................................................... 18

Functional Pancreas (Secretin) PLUS Pancreas & Biliary MR 7/09 (AMRFUNPANBIL) ............................. 19

Functional Pancreas ONLY (AMRFUNPANC) 7/09 ....................................................................................... 20

(only use if previous Panc/Bil with in 1 month)................................................................................................ 20

Renal/Adrenal Imaging ...................................................................................................................................... 21

Routine Renal Mass (AMRRENALMS) 7/09................................................................................................... 22

Partial Nephrectomy Pre-surgical Planning (AMRRENPNX) 7/09.................................................................. 23

Post-Ablation Renal Mass (AMRPOSTABL) 7/09........................................................................................... 24

Urogram (AMRUROGRAM) 7/09 ................................................................................................................... 25

THESE PATIENTS NEED TO ARRIVE 45 MINUTES EARLY TO DRINK WATER................................ 25

Kidney Donor (AMRRENDON) 7/09............................................................................................................... 26

Routine Adrenal (AMRADRENAL) 7/09......................................................................................................... 27

Pelvic Imaging ..................................................................................................................................................... 28

Routine Prostate w/o Endorectal Coil (AMRPROST) 7/09 .............................................................................. 29

Routine Female Pelvis without contrast (AMRFPELWO) 7/09 ....................................................................... 30

Routine Female Pelvis with contrast (AMRFPELW) 7/09 ............................................................................... 31

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Pelvis with contrast (AMRPELW) 7/09............................................................................................................ 32

Pelvis without contrast (AMRPELWO) 7/09.................................................................................................... 33

Dynamic Pelvis (AMRDYNPEL) 7/09 ............................................................................................................. 34

Pre-Uterine Artery Embolization (AMRPREUAE) 7/09 .................................................................................. 35

Routine Urethra (AMRURETH) 7/09 ............................................................................................................... 36

Rectal Carcinoma Staging (AMRRECTM)....................................................................................................... 37

Perineal Fistula (AMRFISTULA) 7/09............................................................................................................. 38

Abdomen/Pelvis Studies ..................................................................................................................................... 39

Routine Abdomen & Pelvis Screen (AMRABDPEL) 7/09............................................................................... 40

MR Enterography (AMRENTERO) 7/09......................................................................................................... 41

Appendix.............................................................................................................................................................. 42

Cleveland Clinic NSF Policy............................................................................................................................. 43

Dynamic MR Evaluation of the Pelvis: Technologist Guidelines..................................................................... 48

SYNGO Abdominal MRI Protocol Codes ........................................................................................................ 50

Research Protocols ............................................................................................................................................ 52

Database............................................................................................................................................................. 52

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Introduction The demand for body MRI studies is increasing. It is imperative that all MRI staff involved in patient imaging and interpretation thoroughly familiarize themselves with these protocols. Liver and kidney imaging should become common in ways similar to “routine brain and spine.” Patients should be directed to complete the proper questionnaire/survey. Technologists should be familiar with the anatomy to be covered, image quality needed, and filming/processing needed. Film copies should be checked for quality before being sent out. If the senior technologist is unable to answer questions about the above procedures, the appropriate abdominal imaging fellow or staff member should be consulted directly. Hopefully, this presentation of protocols will guide the user to perform the most optimal body imaging today. The MR Mantra

Scan through the entire lesion. Place the region of interest in center of coil and field! History and clinical information is everything! (which you will rarely have when doing protocols ) MR Summary Invest the time up front, so you don’t get burned.

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General Information Contraindications � 1st semester pregnancy (Relative) � Pacemaker � Tissue expanders � Aneurysm clips, etc. (Check specific device)

Contrast Most body cases are performed with Gadolinium (we use Magnevist or Eovist), the dose varies: � Check creatinine to estimate GFR. Patients with eGFR <30 need consent and possibly

hydration/dialysis/renal consultation. See the CCF NSF policy in the appendix of this manual for further details.

� No Gd:

o MRCP for stones only (not pancreas or cirrhosis) o Female pelvis (unless for malignancy or urethra) o Prostate

� Weight based Gadiolinium routinely

o Routine liver, liver and pancreas or kidney studies o Female pelvis for malignancy or urethra o Soft tissue mass

� Non-weight-based Gd (at least 20cc Gd):

o Any time an angiogram is needed (for example: pre-operative planning cases, potential organ donors, etc.)

Wraparound problems These problems occur when there is signal originating outside the FOV in the phase-encode direction. For example arms located outside a coronal FOV. In order to deal with these problems you could: � Do nothing. This is ok if the wrap does not interfere with the clinically relevant anatomy. � Increase field of view to directly decrease the wrap. � For renal studies, prop the patient’s arms up anterior to coil to position them outside of the plane of the

FOV. � Try saturation bands over arms to eliminate signal. � Try to use phase-oversampling (large cost in time!)

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Breathholding

Technologists should assess each patient’s breath holding capacity as they are setting up the patient and coaching them on instructions. Take a deep breath in. (give them time to do it) Breathe all the way out (give them more time) Take a second deep breath in (more time) Breathe all the way out and hold it out … don’t breathe. REMEMBER TO TRY NASAL CANNULA 02 if patients seem borderline (especially if over age 70 and if they’re inpatients). All studies (except prostate and some pelvic) are best done breath-hold. If patients cannot breath-hold, most BH sequences can be replaced by NBH sequences- but remember, this is sub-optimal. In poor breath-holders, try the following steps: � First, give oxygen. � Then, shorten breath hold without too much resolution sacrifice. (i.e. minimal changes) � Next, try to run the normal sequences on inspiration. Note: If you need to do this or any of the

following steps, you should contact the fellow. � Next, try to run shorter sequences on inspiration. � Next, try to run very short breath-hold sequences on inspiration. You may need to make significant

sacrifices in resolution. � Finally, if all else fails, run non-breath-hold sequences

Shortening acquisition times can be achieved by:

� Decreasing the number of slices on some 2D sequences, which allows you to decrease the TR. � On 3D sequences, minimize slab thickness in order to reduce the number of partitions while maintaining

a reasonable effective thickness. � Enlarge the field of view and increase the rectangular FOV (resolution decreases in the read direction). � Try to use an alternative plane (sagital may allow better use of rectangular FOV) � Decrease matrix size (number of phase-encoding steps) but remember the resolution will decrease. � Try sequence increasing the bandwidth this will also allow a shorter TR but will decrease the signal-to-

noise ratio. Remember that some patients can’t breath-hold because they can’t understand or can’t hear the instructions. Make use of family members and friends to translate or relay instructions if needed. Also, in deaf patients, the room lights can be used to signal breath-holding instructions to the patient.

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SAR Problems These problems occur when the computer calculates that the sequence you are trying to run will deposit too much RF energy into the patient. RF energy deposition can be reduced by: � Switch to “First Level” SAR limits (remember to go back to NORMAL level after each acquisition) � Decrease flip angle. � Increase TR. � Decrease number of slices. � In HASTE sequences, do not lower the flip angle below 130. Instead, raise the TD (which increases the

acquisition time). Contrast Injection Timing A timing run should be done for all studies that need arterial phase imaging, including liver, pancreas, kidney and all MRAs. With regard to the timing run: � Before the study, check/advance the injector to get rid of air bubbles. � Typically run using 1cc Gd plus 20cc saline flush at 2cc/sec � With Eovist is important to never use more than 1cc plus 20cc flush for timing run � Simultaneously start the power injector (no delay) and the timing run sequence. � If no contrast is seen on the timing run,

o Check with patient to see if the arm is wet or painful (indicating a leak or extravasation). o Run it again (sometimes air bubbles in Gd syringe prevent contrast from getting into the line).

� Evaluate the timing run images in order to obtain the time to peak contrast enhancement in the vessel of interest (Typically the aorta, but sometimes the femoral or carotid arteries).

In order to obtain an angiographic phase use the standard timing formula:

Scan delay = time-to-peak + ½(injection time) – time-to-center of k-space. For symmetric k-space filling, the time-to-center of k-space is ½(scan time).

Example: time-to-peak = 18 sec Injection time = 10 sec (20 ml at 2/ml/sec) Scan time = 20 sec (symmetric k-space filling) Scan delay = 18 + 5 – 10 = 13 sec

Enter a 13 second scan delay into the power injector and use the remaining 19cc of Gd and 20 ml saline at 2/sec.

Other phases may be obtained by using different formulas, as described in specific protocols.

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Miscellaneous points � Check the patient’s order

o If there is any difference between it and the protocol, check with the fellow or staff. o The protocol may need to be changed to accommodate the referring physician’s order.

� Try to optimize MRA and VIBE slabs o Minimize slab thickness o Keep FOV as small as possible o Choose slab orientation to get best coverage in smallest slab o This is usually chosen ahead of time o Remember in-plane resolution is usually best o Try to get close to isotropic voxels

� Saturation bands should be applied over the anterior abdominal wall for pelvis to minimize phase artifacts from fat.

� Scout images should be done on end expiration for abdominal imaging in order to best guide placement of 3D volumes, etc.

� NEMA convention for slice position numbering: o Remember LAD numbers increase when imaging: Right to Left, Post to Anterior, and Cranial to

Caudal. o However, on the Syngo platform, the user can select a different convention.

� Phased array coils are used for most chest, abdomen, and pelvis applications. o Remember if you are imaging something small and close to the surface, consider a surface coil

since you can worry less about wrap around artifacts. o Multiple coils can be coupled on the Symphony.

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Liver / Pancreatic Imaging

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Positioning Liver and MRCP Sequences Remember, when scanning on expiration, the liver will be higher than expected in the chest and you may need to adjust the body array or move the patient so that the liver is in the isocenter after the first scout is obtained. Axial sequences including the STIR, in- and out-of-phase T1 and HASTE should all be arranged with the FOV as small as possible using as much rectangular FOV as possible without cutting off intra-abdominal structures. You want to get as much coverage as you can in a single expiratory breath hold (maximum of about 23-24 sec). Ideally we would like to cover from the top of the liver to the bottom of the kidneys. But, this is typically not possible in a breath hold. We need to cover at least to the bottom of the pancreas. In order to do this with thin enough slices on some of the sequences, two packages need to be run.

T1 weighted in- and out-of-phase images are obtained in a single acquisition. 3D sequences (i.e. VIBE) have wrap artifact at the top and bottom of the field so the slab should be about 2cm larger than needed for coverage.

Axial scans are done with Anterior-Posterior phase encoding so you don’t need to sacrifice significant in-plane resolution and you gain time because you can do fewer phase encode steps. Also wrap artifact is not generally a problem.

Remember the goal is small isotropic voxels. That means keep length, width and height about the same.

STIR and HASTE images are acquired as two interleaved scans to allow more coverage with no gaps. The data is later combined for easier viewing. (4mm * 40 slices = 160mm of coverage)

Scan 1 Scan 2

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The time-of-flight sat-up sequence can be easily planned from the coronal HASTE. Use an image where the portal vein can be seen and orient the slices perpendicular to the portal vein but be sure the slice will include the IVC and aorta.

The superior sat band nulls the signal from spins entering slices from above (i.e. blood in the aorta will be black and blood in the IVC will be bright). This allows identification of the direction of blood flow in the portal vein.

The longer TE of this sequence (10 ms) also makes it sensitive to iron in the liver. Even very small amounts of iron deposition can be detected as signal drop out.

Thick Slab #1: Oblique coronal slab (-30�) with parallel sat bands and a 3rd oblique sat band to cover the CSF, stomach and left kidney. Position off the axial HASTE images.

Coronal HASTE images are done as two sequential packages. Plan images off an axial scout or T1. You can get 4mm slices with no gap if you use an interleaved acquisition. Try to get the whole biliary tree in the anterior package and slightly overlap the packages.

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When doing post contrast imaging, whenever possible, history everything and add measurements rather than repositioning a new sequence. This will give the best registration of pre and post contrast images and allow for image subtraction to identify contrast enhancement.

Thick Slab #3: Straight coronal slab (0�) with parallel sat bands and a 3rd oblique sat band to cover the CSF, stomach and left kidney. Position off the axial HASTE images.

Thick Slab #2: Oblique coronal slab (-30�) with parallel sat bands and a 3rd oblique sat band to cover the CSF, stomach and left kidney. Position off the axial HASTE images.

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Routine Liver (AMRLIV) 7/09 � Phased array coil centered over the liver. � EOVIST CONTRAST for ALL Liver Studies � Weight based Gd may be used. (remember Eovist is ½ volume of normal Magnevist) � Power injector needed. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film #

STIR Ax Run 2 concatenated packages. (Physio- Pace- Breath hold if needed) If bad ghosting, run Ax HASTE with fat sat (7mm 0.2 gap)

1

DIXON Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0

Sat up TOF Ax Run perpendicular to portal vein. 0

VIBE pre Ax Try to get effective thickness 2mm or less. Use FOV as small as possible. If >375 needed call MD.

VIBE

Timing Run Ax Thru top of kidneys – 1cc ONLY EOVIST at 2cc/sec followed by 20 cc saline at 2cc/sec (check for renal enhancement if can’t see aorta enhance)

0

VIBE Ax 3 measures (0, 45, 120 sec) Start scanning at time to peak.

0,1,0

HASTE Cor No fat sat. 4mm slices. Run 2 or 3 concatentated packages to get skin to skin coverage. (Use Physio-PACE-Breath hold if needed)

HASTE Ax No fat sat. 4 mm slices. (Use Physio-PACE-Breath hold if needed)

Diffusion Ax Through liver (6-8mm).

BLADE T2 Ax Through liver (4-5mm) 0

VIBE Ax As a delay for Hepatocyte Phase. History to prior. Must be minimum of 20 minutes post injection.

0

Do Subtraction Each post-contrast phase – pre-contrast

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Non-Breath-hold Liver (AMRNBHLIV) 7/09 ONLY USE THIS PROTOCOL IN PATIENTS WHO ARE UNABLE TO BREATH-HOLD (VENTILATED) OR WHO ARE UNABLE TO FOLLOW BREATHING INSTRUCTIONS (UNCONSCIOUS). � Phased array coil centered over the liver. � Weight based Gd � Power injector needed. � Run sequences in the order listed.

Sequence Plane Comment Film # STIR Ax Run concatenated. (Physio- Pace- Breath hold if needed)

If bad quality, run Ax HASTE with fat sat (7mm 0.2 gap) 1

HASTE Ax Respiratory triggered. Fat sat. (6 mm; no gap). Dixon Ax Run with respiratory trigger if available otherwise do Turbo FLASH below Turbo FLASH Out-of-phase

Ax 7 mm slices 0

Turbo FLASH In-phase

Ax 7 mm slices 1

HASTE Cor Respiratory triggered. No fat sat. 4mm slices. 1 Sat up Ax 0 Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 Turbo FLASH In-phase

Ax 3 measures (0, 45, 120 sec) Start scanning at time to peak. Consider a 4th delayed measure.

0,1,0

VIBE Ax Delayed phase run with respiratory trigger

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LIVER DONOR PROTOCOL 7/09 MAIN CAMPUS ONLY – DELAYED SCANS ON 3T ONLY

� The patients should fast at least 4-6 hours prior to the study. � Phased array coil centered over liver. � EOVIST CONTRAST USED (1/2 NORMAL DOSE OF MAGNEVIST) � Power injector needed. � Assess the patient’s breath holding capability. If poor, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film # HASTE Cor No fat sat. 4 mm slices. Run concatenated packages, skin to skin coverage

(Physio- Pace- Breath hold if needed). 1

HASTE Ax Run concatenated. No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed)

0

HASTE Sag No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed) 0 3D T2 w/ Rest or Space when

available

Ax FOV to include biliary tree and pancreas If scan is poor quality, perform thick slab scans.

0

STIR Ax Run concatenated. (Physio- Pace- Breath hold if needed). If bad ghosting, run Ax HASTE with fat sat (7mm 0.2 gap)

1

DIXON Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 VIBE Ax Try to get effective thickness 2mm.

Include pancreas in FOV. Use FOV as small as possible. If >375 needed call MD.

0

Timing Run Ax Thru top of kidneys – 1cc at 2cc/sec followed by 20cc saline at 2cc/sec Check enhancement of kidneys if no enhancement seen in the aorta.

0

VIBE Ax 3 measures (0, 45, 120 sec) Start scanning at time to peak.

0,1,0

Diffusion Ax Through pancreas (include adjacent masses, if any). 5mm slices. 0 VIBE Ax As a delay for Hepatocyte Phase. History to prior. Must be minimum of 20

minutes post injection. 0

Subtraction Each phase – pre-contrast 0 Get patient off table, return in for 1 hour delay, not to

exceed 2hr

Next four scans need to primarily cover bifurcation of bile duct, entire liver coverage is not needed. Do on 3T system

Flash Cor 1mm- on inspiration FLIP 45º - No subtraction 0 Flash Ax 1mm- on inspiration FLIP 45º - No subtraction 0 Vibe Cor 1mm- on inspiration FLIP 45º - No subtraction 0 Vibe Ax 1mm- on inspiration FLIP 45º - No subtraction 0 SEND and Bill Send 3D T2 data set to 3D image processing lab. 0

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Routine Pancreas & Biliary MR (AMRPANCBIL) 7/09 � The patients should fast at least 4-6 hours prior to the study. � Phased array coil centered over liver. � Weight based Gd � Power injector needed. � Assess the patient’s breath holding capability. If poor, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film # HASTE Cor No fat sat. 4 mm slices. Run concatenated packages, skin to skin coverage


HASTE Ax Run concatenated. No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed)

0

HASTE Sag No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed) 0 If available, run NBH triggered 3D T2 with restore (i.e. Trio, Avanto, Espree) instead of Thick Slabs

It is NOT necessary to run Thick Slabs if 3D T2 comes out well. Make sure to review for quality 3D T2 w/ Rest or Space when

available

Ax FOV to include biliary tree and pancreas If scan is poor quality, perform thick slab scans.

0

Thick Slab Cor Straight (Try to get FOV ~ 250) These need run on all Symphonys only 0 Thick Slab Obl 30� to the right (Try to get FOV ~ 250) These need run on all Symphonys 0 Thick Slab Obl 30� to the left (Try to get FOV ~ 250) These need run on all Symphonys 0 STIR Ax Run concatenated. (Physio- Pace- Breath hold if needed).

If bad ghosting, run Ax HASTE with fat sat (7mm 0.2 gap) 1

DIXON Ax 3-4 mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 VIBE Ax Try to get effective thickness 2mm.


0

Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 VIBE Ax 3 measures (0, 45, 120 sec)

Use formula: SD = TP + 10. 0,1,0

Diffusion Ax Through pancreas (include adjacent masses, if any). 5mm slices. 0 VIBE Ax Repeat as a delayed phase. History to prior. 0 Do Subtraction Each phase – pre-contrast 0 SEND and Bill Send 3D T2 data set to 3D image processing lab. 0

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Routine MRCP (without contrast) (AMRMRCP) 7/09 � The patients should fast at least 4-6 hours prior to the study. � Phased array coil centered over liver. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film # HASTE Cor No fat sat. 4 mm slices. Run concatenated packages, skin to skin coverage.


HASTE Ax Run concatenated. No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed).

0

HASTE Sag No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed). 0 If available, run NBH triggered 3D T2 with restore (i.e. Avanto, Espree) instead of Thick Slabs:

It is NOT necessary to run Thick Slabs if 3D T2 comes out well. Make sure to review for quality

3D T2 w/ Rest or Space if available

Ax FOV to include biliary tree and pancreas 0

Otherwise, run 3 Thick Slabs: Thick Slab Cor Straight These need run on all Symphonys

Use 2 posterior sat bands for all thick slabs. (Try to get FOV ~ 250)

0

Thick Slab Obl 30� to the right (Try to get FOV ~ 250) These need run on all Symphonys 0 Thick Slab Obl 30� to the left (Try to get FOV ~ 250) These need run on all Symphonys 0 STIR Ax Run concatenated. (Physio- Pace- Breath hold if needed).


DIXON

Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0

Diffusion Ax Through pancreas (include adjacent masses, if any). 5mm slices. 0 VIBE Ax Use 3mm thickness.


0

SEND and Bill Send 3D T2 to 3D image processing lab. 0

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Functional Pancreas (Secretin) PLUS Pancreas & Biliary MR 7/09 (AMRFUNPANBIL)

� All functional pancreas studies are done on the main campus in L10. � The patients should fast at least 4-6 hours prior to the study. � The patient should be scheduled in a sedation slot and assessed by the nurse who will

administer a test bolus of secretin. If that goes well, proceed with test. � Oral contrast (Gastromark) administered before study.

� Phased array coil centered over liver. � Power injector needed. � Assess the patient’s breath holding capability. If poor, give oxygen. � Run sequences in the order listed.




0

HASTE Sag No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed). 0 Thick Slab Cor Straight (Try to get FOV ~ 250) 0 Thick Slab Obl 30� to the right (Try to get FOV ~ 250) 0 Thick Slab Obl 30� to the left (Try to get FOV ~ 250) 0

Optimize slab for secretin (include pancreas and duodenum) HASTE Obl Pre-secretin administration

Nurse injects secretin over 1 minute then signals you to begin. HASTE Obl 1 measure every 30 sec for 10 min HASTE Cor No fat sat. 4 mm slices. Run sequential packages, skin to skin coverage. 1 HASTE Ax Run concatenated. No fat sat. 4 mm slices. 0 STIR Ax Run concatenated.


Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 VIBE Ax Try to get effective thickness 2mm.


0

Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 VIBE Ax 3 measures (0, 45, 120 sec)

Use formula: SD = TP + 10. 0,1,0

Diffusion Ax Through pancreas (include adjacent masses, if any). 5mm slices. 0 Do Subtraction Each phase – pre-contrast 0 Do MIPS Rotational MIP of 3D T2 data set. 360° every 15° 1

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Functional Pancreas ONLY (AMRFUNPANC) 7/09 (only use if previous Panc/Bil with in 1 month)

� All functional pancreas studies are done on the main campus in L10. � The patients should fast at least 4-6 hours prior to the study. � The patient should be scheduled in a sedation slot and assessed by the nurse who will

administer a test bolus of secretin. If that goes well, proceed with test. � Oral contrast (Gastromark) administered before study.

� Phased array coil centered over liver. � Assess the patient’s breath holding capability. If poor, give oxygen. � Run sequences in the order listed.




0

HASTE Sag No fat sat. 4 mm slices. (Physio- Pace- Breath hold if needed). 0 Thick Slab Cor Straight (Try to get FOV ~ 250) 0 Thick Slab Obl 30� to the right (Try to get FOV ~ 250) 0 Thick Slab Obl 30� to the left (Try to get FOV ~ 250) 0

Optimize slab for secretin (include pancreas and duodenum) HASTE Obl Pre-secretin administration

Nurse injects secretin over 1 minute then signals you to begin. HASTE Obl 1 measure every 30 sec for 10 min HASTE Cor No fat sat. 4 mm slices. Run sequential packages, skin to skin coverage. 1 HASTE Ax Run concatenated. No fat sat. 4 mm slices. 0 STIR Ax Run concatenated.


Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 Diffusion Ax Through pancreas (include adjacent masses, if any). 5mm slices. 0 VIBE Ax Try to get effective thickness 2mm.


0

Do MIPS Rotational MIP of 3D T2 data set. 360° every 15° 1

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Renal/Adrenal Imaging

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Routine Renal Mass (AMRRENALMS) 7/09 � Phased array coil centered over kidneys. � Arms propped up anterior to kidney (Use rolled up sheets). � Weight Based Gadolinium � Power injector needed. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film # Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Ax No fat sat. 4-5 mm slices (Physio- Pace- Breath hold if needed). 1 HASTE Cor No fat sat. 4 mm slices (Physio- Pace- Breath hold if needed). 1 Diffusion Cor Through kidneys 0 VIBE Ax Slab thickness to include kidneys and entire mass.

Try to get 2 mm effective thickness. 0

VIBE Cor Slab thickness to include kidneys and entire mass. Use 2 mm effective thickness.

0

3D FLASH Cor Obl Try to get effective thickness 1.5 mm. 0 Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 3D FLASH Cor Obl 1 measure (0 sec)

Use standard timing formula. (SD = TP + 5 – time-to-center) 0

VIBE Cor History prior. 1 measure. 70 sec post contrast. 1 VIBE Ax History prior. 2 measures. 2 and 3 min post contrast. 1 Do Subtraction Arterial phase FLASH – pre-contrast 0 Do Subtraction Axial and coronal VIBE post contrast – pre-contrast 0

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Partial Nephrectomy Pre-surgical Planning (AMRRENPNX) 7/09 � Phased array coil centered over kidneys. � Arms propped up anterior to kidney (Use rolled up sheets). � Weight based Gad � Power injector needed. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film # Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Ax No fat sat. 4-5 mm slices(Physio- Pace- Breath hold if needed). 1 HASTE Cor No fat sat. 4 mm slices(Physio- Pace- Breath hold if needed). 1 Diffusion Cor Through kidneys. 1 VIBE Ax Slab thickness to include kidneys and entire mass.

Try to get 2 mm effective thickness. 0


0



VIBE Cor History prior. 1 measure. 70 sec post contrast. 0 VIBE Ax History prior. 2 measures. 2 and 3 min post contrast. 1 VIBE Cor Large slab to include all of kidneys, ureters and bladder.

If collecting system is not full, do a delayed scan. 0

Do Subtraction Arterial phase FLASH – pre-contrast 0 Do Subtraction Axial and coronal VIBE – pre-contrast 0 Do MIP Arterial Phase Subtraction 1 SEND and Bill Send post-contrast and subtraction data to 3D processing lab

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Post-Ablation Renal Mass (AMRPOSTABL) 7/09 � Phased array coil centered over kidneys. � Arms propped up anterior to kidney (Use rolled up sheets). � Weight Based Gadolinium � Power injector needed. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed.

Sequence Plane Comment Film # Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Ax No fat sat. 4-5 mm slices(Physio- Pace- Breath hold if needed). 1 HASTE Cor No fat sat. 4 mm slices(Physio- Pace- Breath hold if needed). 1 Diffusion Cor Through kidneys. 0 VIBE Ax Slab thickness to include kidneys and entire mass.

Try to get 1.5 mm effective thickness. 0


0

Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 VIBE Ax 1 measure (0 sec)

Use standard timing formula. (SD = TP + ½ inject time – time-to-center) 0

VIBE Cor History prior. 1 measure. (70 sec)

0

VIBE Ax Hx prior. 2 measures (2 and 3 min)

1

Do Subtraction All phases (Vibe) – pre-contrast 0

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Urogram (AMRUROGRAM) 7/09 THESE PATIENTS NEED TO ARRIVE 45 MINUTES EARLY TO DRINK WATER

� Phased array coil centered over kidneys. � Empty bladder before study. Pt should drink 16-32 oz. of water 30-45 minutes before

study. � Arms propped up anterior to kidney (Use rolled up sheets). � Weight Based Gadolinium � Power injector needed. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed. � IF CONTRAST CANNOT BE ADMINISTERED DUE TO POOR GFR OR PATIENT

HAS ALLERGY TO GADOLINIUM- STILL DO ENTIRE STUDY MINUS THE CONTRAST PORTION

Sequence Plane Comment Film # Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Ax No fat sat. 4-5 mm slices.

Coverage from top of kidneys through bladder 1

HASTE Cor No fat sat. 4 mm slices. Coverage through kidneys, ureters and bladder

1

3D T2 w/ Rest or Space if available

Cor Obl FOV to include kidneys, ureters and bladder. 0

VIBE Ax Slab thickness to include kidneys and entire mass. Try to get 2 mm effective thickness.

0


Use standard timing formula. (SD = TP + ½ inject time – time-to-center)

0,1

VIBE Ax Hx prior. 2 measures (70 and 120 sec) 0 VIBE Cor Through kidneys, ureters and bladder

Run after a 5 minute delay. Repeat after 10 minutes if renal collecting system and ureters are not full.

1

Do Subtraction Arterial phase – pre-contrast 0 Do Subtraction Delay phase (Vibe) – pre-contrast 0 SEND Send post-contrast scans and 3D T2 to 3D image processing lab. 1

26

Kidney Donor (AMRRENDON) 7/09 � Use the body array plus a flex coil to cover down to the pelvis or extended body array if

available. � Have patient drink 12 oz glass of water immediately before getting onto table � Arms propped up anterior to kidney. � Weight based Gadolinium. � Power injector needed. � Assess the patient’s breath holding capability. If poor capability, give oxygen. If the

patient can’t hold his/her breath, call body radiologist. � Run sequences in the order listed.

Sequence Plane Comment Film # Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Cor No fat sat. 4 mm slices 1 VIBE Ax Slab thickness to include kidneys and proximal ureters. 0 3D FLASH Cor Obl Try to get effective thickness 1-1.5mm.

Keep the slab as small as possible (usually 96mm or less) – you don’t need to include the entire kidneys; just the renal vessels and the roots of the celiac and SMA.

0

Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 3D FLASH Cor Obl Use standard timing formula

3 measures (0, 7 sec gap, 90 sec) Use standard timing formula. (SD = TP + ½ inject time – time-to-center)

0,0,0

VIBE Ax Hx prior. 1 measure. Run as soon as possible after the FLASH sequences.

0

3D VIBE delay Cor Larger slab to include all of kidneys, ureters and bladder. If collecting system is not full, do a 10 min delayed scan.

0

Do Subtraction Arterial phase (FLASH) – pre-contrast 0 Do Subtraction Delay phase (VIBE) – pre-contrast 0 Do MIP Arterial Phase Subtraction 1 SEND and Bill Post contrast and subtraction to 3D image processing lab. 0 Do MIP Urogram – Subtraction is not necessary. 0

27

Routine Adrenal (AMRADRENAL) 7/09

� The general indication for this study is to evaluate for adrenal adenoma only. Not for

known adrenal cancer or surgical planning. � Phased array coil centered over upper abdomen.

� No Gadolinium

Sequence Plane Comment Film # DIXON Ax 3 mm slices (In/Out Phase 3-4 mm for sites without Dixon) 1,1

HASTE Cor 3-4 mm slices. Without fat sat. 1 HASTE Ax 4 mm. Without fat sat. 1 Diffusion Ax Through adrenals. 0 VIBE Ax Small slab.

With fat sat. 0

28

Pelvic Imaging

29

Routine Prostate w/o Endorectal Coil (AMRPROST) 7/09 MAIN CAMPUS ONLY

� Phased array coil centered over lower pelvis.

� Weight based Gd.

Sequence Plane Comment Film # T2 TSE Sag Small FOV 256 matrix T1 TSE Ax High resolution – 512 matrix. + Mag (small FOV) 1 T2 TSE Ax High resolution – 512 matrix. + Mag (small FOV) 1 T2 TSE Cor High resolution – 512 matrix. + Mag (small FOV) 1 HASTE Cor No fat sat. 5-6mm slices. Through pelvis. 1 DIFFUSION Ax 5 mm slices through prostate (b = 0, 500, 100, 1500, 2000) 0 T1 in Ax Coverage from aortic bifurcation to symphysis pubis. 1 True FISP Ax Coverage from aortic bifurcation to symphysis pubis. 1

If protocoled with contrast VIBE Ax Pre-contrast 2mm through pelvis 0 VIBE Ax Pre-contrast 3mm through prostate (20 slices) – for dynamic series 5º flip 0 VIBE Ax Dynamic scan. 50 measures (on 1.5T systems) - 12º flip

(Start injection after 4th measure of acquisition. 0

VIBE Ax Post-contrast. History to pre-contrast through pelvis

30

Routine Female Pelvis without contrast (AMRFPELWO) 7/09 � Phased array coil centered over pelvis. � No Gadolinium � Center on pelvis. Move for HASTE if needed. � Run sequences in the order listed.

Sequence Plane Comment Film # HASTE Cor Thru kidneys. (5mm slices)

Use body coil if necessary. (If body coil use large FOV 6-7 mm slices)

T2 TSE Sag Non-breath hold. 2-3 acq. Small FOV. Add anterior coronal sat band through fat.

1

T2 TSE Obl Ax Short axis

Short axis view. Orient to uterine fundus on sagittal view. Non-breath hold. 2-3 acq. Small FOV. Add anterior coronal sat band.

1

T2 TSE Obl Cor Long axis

Long axis view. Orient to fundus on BOTH sagittal and obl ax views. Non-breath hold. 2-3 acq. Small FOV.

1

T2 TSE Ax Straight orientation. Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add anterior coronal sat band.

0

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 VIBE Ax Coverage from aortic bifurcation to symphysis pubis. 0 Diffusion Ax 5 mm slices. 0

Obl Cor -long axis

Obl Axial -short axis

Obl Cor -long axis

31

Routine Female Pelvis with contrast (AMRFPELW) 7/09 � Phased array coil centered over pelvis. � Weight based Gd ok. � May be hand injected (don’t move the patient). � Center on pelvis. � Re-center for HASTE if needed � Run sequences in the order listed.

Sequence Plane Comment Film # HASTE Cor Thru kidneys. (5 mm slices) Reposition patient and use the body coil if

necessary. (If body coil use large FOV 6-7 mm slices)

T2 TSE Sag Non-breath hold. 2-3 acq. Small FOV. Add anterior coronal sat band.

1

T2 TSE Obl Ax Short Axis

Short axis view. Orient to uterine fundus on sagittal view. Non-breath hold. 2-3 acq. Small FOV. Add anterior coronal sat band.

1

T2 TSE Obl Cor Long Axis

Long axis view. Orient to fundus on BOTH sagittal and obl ax views. Non-breath hold. 2-3 acq. Small FOV.

1

3D T2 Ax Straight orientation. Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add anterior coronal sat band.

0

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 VIBE Ax Pre-contrast. Coverage from aortic bifurcation to symphysis pubis. 0 VIBE Ax Scan delay = 45 sec.

2 measures (0 and 180 sec). 0,1

Diffusion Ax 5 mm slices. 0

Obl Cor T2- Long Axis

Obl Ax T2- Short Axis

Obl Cor- Long Axis

32

Pelvis with contrast (AMRPELW) 7/09 EXAMPLE: PELVIS MASS, OR MALE PELVIS

� Phased array coil centered over pelvis. � Weight based Gd ok. � Use power injector. � Run sequences in the order listed.

Sequence Plane Comment Film # T2 TSE Sag Non-breath hold. 2-3 acq. Small FOV.

Add Cor sat band. 1

T2 TSE Ax Straight orientation. Non-breath hold. 2-3 acq. Small FOV. Add Cor sat band.

1

T2 TSE Ax Straight orientation. Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add Cor sat band.

0

STIR Ax Run 2 concatenated packages. If bad ghosting, run Ax HASTE with fat sat (7mm 0.2 gap)

1

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Cor No fat sat. 4mm slices. Skin to skin. 1,0 VIBE Ax, Sag Try to get effective thickness 3 mm or less.

Use FOV as small as possible. 0

Timing Run Ax Thru distal aorta 2 cc at 2cc/sec followed by 20 cc saline at 2cc/sec 0 VIBE Ax 3 measures (0, 45, 120 sec)

Start scanning at time to peak. 0,1,0

VIBE Sag History to pre-contrast. 0 Diffusion Ax 5 mm slices. 0 Do Subtraction All phases – pre-contrast 0

33

Pelvis without contrast (AMRPELWO) 7/09 � Phased array coil centered over pelvis. � Run sequences in the order listed. � USED ONLY FOR PATIENTS WITH GFR ISSUES OR ALLERGIES


Add Cor sat band. 1


1

T2 TSE Ax Straight orientation. Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add Cor sat band.

0


1

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Cor No fat sat. 4mm slices. Skin to skin. 1,0 Diffusion Ax 5 mm slices. 0 VIBE Ax Try use effective thickness of 3 mm.


34

Dynamic Pelvis (AMRDYNPEL) 7/09 MAIN CAMPUS ONLY

� Discuss study with the patient and get appropriate history. (See appendix for details) � Patient’s bladder should be almost full. � Instill 120 cc gel into the rectum. � Position pt supine. � Phased array coil centered over pelvis. � Run sequences in the order listed. Entire study is non-breath-hold.

Sequence Plane Comment Film # HASTE Sag Midline thru pelvis. Patient at rest. 1 HASTE Ax Mid pelvis thru perineum. Patient at rest. 1 HASTE Sag Midline thru pelvis. During Kegel maneuver. 0 HASTE Sag Midline thru pelvis. During maximal strain. 1 HASTE Ax Mid pelvis thru perineum. During maximal strain. 1 TruFISP-Cine Sag Single slice cine, midline thru rectum and urethra. Alternating strain and

relax. Runs for about 30 sec. 0

If done on Avanto TruFISP-Cine Sag 3 slice cine. Centered in midline. Alternating strain and relax. Runs for

about 30 sec. 0

TruFISP-Cine Ax Single slice cine along pubococcygeal line. Alternating max strain and

relax. Runs for about 30 sec. 0

T2 TSE Ax Non-breath hold. 3 acq. Small FOV. High resolution. Add Cor sat band.

1

T1 Ax Non-breath hold. 3 acq. Small FOV. High resolution. Add Cor sat band.

1

Sort Sort the 3 slice cine by slice position and time, if it was done, and save as a new sequence.

0

35

Pre-Uterine Artery Embolization (AMRPREUAE) 7/09 � Phased array coil centered over pelvis. � 20 cc Gd. � Power injector needed. � Run sequences in the order listed

Sequence Plane Comment Film # HASTE Cor Thru kidneys. (5 mm slices)

Reposition patient and use the body coil if necessary. 1

T2 TSE Sag Non-breath hold. 2-3 acq. Small FOV. Add Cor sat band.

1

T2 TSE Obl Ax Orient to uterus. Non-breath hold. 2-3 acq. Small FOV. Add Cor sat band.

1

T2 TSE Obl Cor Orient to uterus. Non-breath hold. 2-3 acq. Small FOV.

1

3D T2 Ax Straight orientation. Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add Cor sat band.

0

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 Diffusion Ax 5 mm slices. 0 VIBE Ax Pre-contrast. Coverage from aortic bifurcation to symphysis pubis. 0 FLASH Ax Use 2mm effective thickness.

Coverage from aortic bifurcation thru symphysis. Run breath-hold. May be done on inspiration.

0

Timing Run Ax Run thru femoral heads 0 FLASH 1 measure. History to prior.


VIBE Ax 2 measures (0 and 180 sec). 0,1 Subtract Pre-contrast studies from all post-contrast studies. 0 MIP Arterial phase. Do full rotation (every 15° or 20 views) 1

36

Routine Urethra (AMRURETH) 7/09 � Before the study:

o Patient’s bladder should be almost full. o Before they get on the table, have them partially void (Tell them to fill half of

a paper cup). � Phased array coil centered just above pubic symphysis. � Weight based GADOLINIUM � May be hand injected. � Run sequences in the order listed.

Sequence Plane Comment Film # T2 TSE Sag Non-breath-hold. (4mm 0.2 gap) 200 FOV. 1 T2 TSE Ax Non-breath-hold. (4mm 0.2 gap)

Cover Above uterus to meatus 0

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 T2 TSE Ax 512 Matrix. 3 mm with 0.2 gap. 2 acq.

Use small FOV. Orient perpendicular to urethra; cover from bladder base to meatus (see below).

1

3D T2 Ax Straight orientation. Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add Cor sat band.

0

HASTE Ax Thru pelvis. 4mm 0 HASTE Cor Thru kidneys. Use body coil if necessary. 0 VIBE Ax Small slab (bladder to urethra).

Use 1.5 mm thickness. 0

VIBE Ax Scan delay = 45 sec. 2 measures (0 and 180 sec).

0,1

Orientation of high-res

37

Rectal Carcinoma Staging (AMRRECTM) 7/09

SUGGEST 2 TIME SLOTS USED FOR THIS STUDY � Instill 120 cc gel into the rectum. � Phased array coil centered over pelvis. � Weight based GADOLINIUM � Must use power injector. � Run sequences in the order listed.

Sequence Plane Comment Film # T2 TSE Sag Non-breath hold. 2-3 acq. Small FOV. Include entire sacrum.

Add Cor sat band. 1


1

T2 TSE Cor Straight orientation. Non-breath hold. 2-3 acq. Small FOV. 0 T2 TSE Ax Straight orientation.

Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add Cor sat band.

0

T2 TSE Obl Ax Oriented perpendicular to the rectum. Small FOV (120-150 mm). 3 mm slices. 2-3 acq.

1


1

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Cor No fat sat. 4mm slices. Skin to skin. 1,0 VIBE Ax, Sag Try to get effective thickness 3 mm or less.




VIBE Sag History to pre-contrast. 0 Diffusion Ax 5 mm slices. 0 Do Subtraction All phases – pre-contrast 0 0

38

Perineal Fistula (AMRFISTULA) 7/09 � Phased array coil centered over pelvis. � Weight based GADOLINIUM � Must use power injector. � Run sequences in the order listed.


Add Cor sat band. 1


1

T2 TSE Cor Straight orientation. Non-breath hold. 2-3 acq. Small FOV. 0 T2 TSE Ax Straight orientation.

Non-breath hold. 2 mm slices. Small FOV. 3 acq. Add Cor sat band.

0


1

Dixon Ax 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Cor No fat sat. 4mm slices. Skin to skin. 1,0 VIBE Ax,

Cor,Sag Try to get effective thickness 3 mm or less. Use FOV as small as possible.

0



VIBE Cor,Sag History to pre-contrast. 0 Diffusion Ax 5 mm slices. 0 Do Subtraction All phases – pre-contrast 0

39

Abdomen/Pelvis Studies

40

Routine Abdomen & Pelvis Screen (AMRABDPEL) 7/09 � Extended body array coil or combination body array and large flex coil. � Weight based Gd � Must use power injector. � Assess the patient’s breath holding capability. If poor capability, give oxygen. � Run sequences in the order listed.

***NOTE: Axial coverage from the two stations should overlap so that there are no gaps. Sequence Plane Station Comment Film # STIR Ax Pelvis Run 2 concatenated packages. Multibreath-hold


DIXON Ax Pelvis 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1 HASTE Cor Pelvis No fat sat. 4mm slices. Run 2 or 3 sequential packages to get

skin to skin coverage. 1

Diffusion Cor Pelvis 5 mm slices. 0 VIBE Ax Pelvis Use effective thickness of 3 mm.


STIR Ax Abdomen Run 2 concatenated packages. Multibreath-hold


DIXON Ax Abdomen 3-4mm slices (In/Out Phase 5-6mm for sites without Dixon) 1,0 HASTE Cor Abdomen No fat sat. 4mm slices. Run 2 or 3 sequential packages to get


Diffusion Cor Abdomen 5mm slices 0 VIBE Ax Abdomen Try to get effective thickness 2mm.

Use FOV as small as possible. If >375 needed call MD. 0

Timing Run Ax Abdomen Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at 2cc/sec

0

VIBE Ax Abdomen 3 measures (0, 45, 120 sec) Start scanning at time to peak.

0,1,0

VIBE Ax Pelvis Hx to prior. 1 Do Subtraction All phases – pre-contrast 0

41

MR Enterography (AMRENTERO) 7/09

MAIN CAMPUS ONLY CASES TO BE DONE ON AVANTO SYSTEMS WITH iPAT ONLY. � Start IV before administering Volumen. � Oral contrast (Volumen 1350 cc) MUST be administered prior to the study. If the

patient is unable/unwilling to stay on schedule, then a feeding tube must be placed and the contrast given via the tube. This administration must be supervised by a dedicated individual, who owns the process.

o 1 Bottle (450 cc) 60 min before study o 1 Bottle (450 cc) 40 min before study o ½ Bottle (225 cc) 20 min before study o ½ Bottle (225 cc) 10 min before study o 250 cc water at 60 minutes o Plan to start scan 70 minutes after the start of ingestion.

� Administer glucagon (SLOWLY) 1.0 mg just before Vibe sequences � Extended body array coil or combination body array and large flex coil. Put patient arms

above the head. Don’t let hands or arms touch. � Single dose Gd � Must use power injector. � Assess the patient’s breath holding capability. If poor capability, give oxygen.

PRACTICE BREATH HOLDING SEVERAL TIMES. Sequence Plane Comment Film # HASTE Cor No fat sat. 4mm slices. Run 2 or 3 sequential packages to get


HASTE Ax No fat sat. 5 mm slice thickness. Cover small bowel. 0 TruFISP-Cine Cor Single slice cine, non breathhold. Run 7 packages every 10-15

mm middle slice centered in the abdomen. Runs for about 30 sec each total 3 min.

0

Give Glucagon VIBE Cor Effective thickness 2 mm. Use iPat factor 2 (<15 sec scan).

Cover top of small bowel to below anus (include perineum). 0

VIBE Ax Effective thickness 3 mm. Use iPat factor 2 (15 sec scan). 0 Timing Run Ax Thru kidneys – 1cc at 2cc/sec followed by 20 cc saline at

2cc/sec. 0

VIBE Cor 2 measures (0, 50 sec) Use timing formula for contrast administration. (SD = TP + ½ Injection time – time-to-center)

0,,1

VIBE Ax History to prior. 1 measure. VIBE Cor 2 measures (2 and 5 min)

Start scanning at time to peak. 0,1

Subtract Pre-contrast from all post-contrast scans. 0

42

Appendix

43

Cleveland Clinic NSF Policy The Cleveland Clinic Foundation Division of Radiology Standard Operating Procedures Guideline

Title: SAFETY GUIDELINES FOR INTRAVASCULAR GADOLINIUM IN PATIENTS WITH ACUTE AND CHRONIC KIDNEY DISEASE

Number: Effective date: 4-13-2007 PURPOSE:

Division of Radiology and the Departments of Adult and Pediatric Nephrology April 2007

The administration of intravenous gadolinium has been linked to Nephrogenic Systemic Fibrosis (NSF) in patients with acute and chronic kidney disease. Over 200 cases have been reported to date in patients with moderate to end stage kidney disease two days to eighteen months following gadolinium-based contrast injections. First identified in 1997, these patients may develop thickening and fibrosis of the skin, contractures, muscle weakness, pain, burning and itching in the areas of involvement, deep bone pain, and fibrosis in other organs. Progression may be fulminant and treatment options are limited. While a direct causative association has not yet been proven and it is unclear if this relates to all forms of gadolinium, the FDA currently advises caution in this situation. The following precautions should serve as guidelines for the use of gadolinium in MR or CT imaging in patients with kidney disease at the Cleveland Clinic.

1. Prior to any MR imaging, all patients should complete a Cleveland Clinic MR screening form which includes questions pertaining to kidney disease. All CT patients will undergo routine screening as outlined in the Cleveland Clinic “Policies for Measuring Creatinine Levels in Adult Patients and Administration of Intravenous Contrast Media for Radiological Procedures.”

2. In all patients with acute or chronic kidney disease in whom an intravascular injection of

gadolinium is planned, an estimated glomerular filtration rate (eGFR) shall be calculated by the Radiology nurse or MR/CT technician. The eGFR shall be estimated in adults using the calculator derived from MDRD data in patients over 18 years old based on recent serum creatinine (measured with methods that have been calibrated to be traceable to IDMS or

44

isotope dilution mass spectrometry), age, race and gender (http://www.nkdep.nih.gov/professionals/gfr_calculators/idms_con.htm). In the pediatric population, the Schwartz calculator is used to calculate GFR based on the child’s recent serum creatinine, gender, height, and age (http://www.nkdep.nih.gov/professionals/gfr_calculators/gfr_children.htm). In any patient with a eGFR less than 15ml/min/1.73m2, the use of intravascular gadolinium should be avoided if at all possible.

3. In any patient undergoing hemodialysis and/or has an eGFR <15ml/min/1.73m2 [Stage 5

Chronic Kidney Disease (CKD)] and requires intravascular gadolinium, the following guidelines should be followed:

A. Consider alternative imaging procedures B. Confirm necessity of gadolinium injection with referring service C. Provide informed consent to patient prior to study and document in the paper or digital

medical record D. Avoid high dose gadolinium (> 0.1mmol/kg) E. Avoid Omniscan (gadodiamide) and Optimark (gadoversetamide) F. In those patients already on hemodialysis, arrange with the primary service for the patient to

receive hemodialysis as quickly as possible, preferably within the first 2 hours after the MR exam using a high flux dialyzer. An additional hemodialysis session is recommended within 24 hours of the first dialysis session after the MRI exam.

i. Dialysis appointments must be prearranged prior to the MRI exam to coordinate the dialysis and MRI schedules

ii. The dialysis should be performed at the patient’s home dialysis unit for outpatients or at the hospital’s dialysis unit for inpatients

G. The nephrology service should be consulted prior to the MRI exam in all such patients who do not require dialysis.

4. In patients who have severe kidney disease with an eGFR of 15-30ml/min/1.73m2 (Stage 4

CKD) or Acute Kidney Injury (AKI), the following guidelines should be followed: A. Consider alternative imaging procedures B. Confirm necessity of gadolinium injection with referring service C. Encourage consultation for patient with nephrology service prior to MRI

i. Although IV hydration has not been shown to directly prevent NSF, gadolinium is excreted by glomerular filtration and IV hydration, if clinically safe, seems prudent. The suggested IV hydration guidelines are outlined below

1. Adult inpatients: Inpatients should be hydrated with IV NSS at 1 ml/kg per hour for 12 hours prior to and 12 hours after the exam. Patients with cardiac disease, who may not be able to tolerate this quantity of fluid, should be hydrated at a level that they are likely to tolerate

2. Adult outpatients: Outpatients will receive 500 ml of NSS intravenously over 3 hours unless there is a contraindication. Oral fluids should be encouraged after the exam.

3. Pediatric inpatients: Pediatric nephrology service should be consulted. 4. Pediatric outpatients: Outpatients will receive 20ml/kg ml of NSS

intravenously over 3 hours unless there is a contraindication. Oral fluids should be encouraged after the exam.

D. Provide informed consent to patient prior to the study and document in the paper or digital medical record.

E. Use lowest possible dose of intravenous gadolinium to obtain a diagnostic imaging study. F. Avoid Omniscan (gadodiamide) and Optimark (gadoversetamide).

45

5. Peritoneal dialysis is less effective for eliminating gadolinium so the use of intravenous

gadolinium should be strongly discouraged in patients maintained with CAPD (continuous ambulatory peritoneal dialysis) or CCPD (continuous cycling peritoneal dialysis). If the risk/benefit ratio suggests an intravenous gadolinium injection is warranted, the following guidelines should be followed.

A. Use lowest possible dose of intravenous gadolinium to obtain a diagnostic imaging study B. Initiate intensive peritoneal dialysis immediately after the imaging procedure, avoiding

periods with a dry abdomen, and performing more frequent manual exchanges or more frequent automated dialysis cycles

C. Prearrange dialysis prior to MRI exam

6. It is recommended that intravenous gadolinium injections should be avoided in patients with acute kidney disease until the renal status returns to baseline unless a risk-benefit analysis for the individual patient suggests the gadolinium injection is warranted.

7. Patients who are awaiting liver transplant, those who have recently undergone liver

transplant, and patients with hepatorenal syndrome may be at increased risk of developing NSF with the injection of gadolinium.

8. Caution should be exercised with the use of gadolinium in children less than one year of age

due to their immature kidneys and inherently low eGFR. Recognize that the Swartz formula for calculating eGFR (listed above) may be inaccurate in these children. Omniscan (gadodiamide) and Optimark (gadoversetamide) should be avoided in children of this age group.

9. Additional factors to be considered in each of the above patient groups include the following:

A. A repeat MR examination with intravenous gadolinium is strongly discouraged within one week of the initial study

B. The presence of proinflammatory conditions or events (e.g., tissue damage from recent surgery or vascular injury, systemic infections) in patients with impaired kidney function may increase the risk of developing NSF

C. Patients with spaces in the body that may accumulate gadolinium and are relatively protected from dialysis (e.g., amniotic fluid, ascites, large pleural effusions) may be at increased risk of developing NSF

Recommended language to be used during informed consent discussion with the patient:

1. NSF: Very rare fibrosing condition of the skin in patients with moderate/severe kidney disease that may affect the organs and may be fatal; overall risk reported to be on the order of 3-5% in patients with moderate to severe kidney disease who have received prior gadolinium injections; disease appears to be improved with improving renal function but is otherwise difficult to treat

2. Allergic reactions: rare 3. Minor adverse reactions uncommon: metallic taste, headache, nausea, dizziness; systemic reactions <

1:100 4. Placement of intravenous catheter and injection may cause pain, bleeding, infection

References:

46

1. www.fda.gov/cder/drug/advisory/gadolinium_agents.htm 2. http://www.fda.gov/cder/drug/infopage/gcca/qa_20061222.htm 3. http://www.fda.gov/cder/drug/InfoSheets/HCP/gcca_200612HCP.pdf 4. http://www.pathmax.com/dermweb 5. Kanal E, Barkovich AJ, Bell C, et al. ACR guidance document for safe MR practice: 2007. Am J

Roentgenol 2007; 188:1-27. 6. Sadowski EA, Bennett LK, Chan MR, et al. Nephrogenic systemic fibrosis: risk factors and incidence

estimation. Radiology 2007 Jan 31 [Epub ahead of print] Available at http://radiologyjnls.org/chi/content/full/2431062144v1

7. Kuo PH, Kanal E, Abu-Alfa AK, et al. Gadolinium based MR contrast agents and nephrogenic systemic fibrosis. Radiology 2007; 242:647-9.

8. Okada S, Katagiri K, Kumazaki T, et al. Safety of gadolinium contrast agent in hemodialysis patients. Acta Radiol 2001; 42:339-41.

47

Original author: Paul Ruggieri, MD Date: 4-13-2007 Reviewed by:: Paul Ruggieri, MD Mark Sands, MD Brian Herts, MD Joseph Veniero, MD Scott Flamm, MD Robert Heyka, MD Deepa Chand, MD Approved by: Signature on file 4/24/2007 _________________________________ Date: ____________________ Dr. Paul Ruggieri, Head, Section of MRI Signature on file 4/24/2007 _________________________________ Date: ____________________ Dr. Mark Sands, Head, Section of Angiography Signature on file 5/1/2007 _________________________________ Date: ____________________ Dr. Robert Heyka, Section of Nephrology Signature on file 4/26/2007 _________________________________ Date: ____________________ Dr. Deepa Chand, Section of Nephrology

48

Dynamic MR Evaluation of the Pelvis: Technologist Guidelines

Last Update: 12/15/05 1. DISCUSS THE STUDY WITH THE PATIENT. -Ask for the specific complaints/symptoms. -Ask if the patient has had children with vaginal deliveries. -Ask if the patient has had hysterectomy and/or ovary resection. -Explain that the study is designed to image the pelvis and look for abnormal motion of the urinary bladder, uterus, bowel and rectum. -Explain that the success of the study depends mostly on the patient. -They will be asked to perform maneuvers during the test. -For most of the test they will be lying at rest. -They will be asked to perform a Kegel maneuver (pull up the pelvic muscles-like trying to stop the stream of urine) (10-15 seconds) -They will be asked to strain/push down as hard as possible (like trying to have a bowel movement) (10-15 seconds) -They will be asked to repeatedly push down as hard as possible then relax and repeat this procedure for approximately 30 seconds while we record a movie. -In order to see the rectum on the MR images, we will put gel into the rectum. -Remind them its okay if some of the gel comes out during the test. Tell them not to try to stop it if it starts to come out because that will ruin the current images. Remind them that there is a pad on the table. 2. PATIENT PREPARATION -With the patient on her side put approximately 120 cc of ultrasound gel (two syringes) into the rectum using the irrigation syringes. (Be sure to remove all the air from the syringe) -Use some gel on the syringe tip for lubrication. -Explain that it shouldn't be painful. -Position the center of the body phased array coil over the pubic symphysis.

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-Position the patient's pelvis higher than the lowest spine coil element (element 4-5). 3. FOLLOW STANDARD IMAGING PROTOCOL (slightly different for each system) -Adjust the FOV to the size of the patient. -Make sure the patient understands the instructions and give them time to achieve maximal strain before imaging. -Encourage them during the maneuvers. -Repeat sequences if the patient did not follow instructions. 4. POST PROCEDURE INSTRUCTIONS -Remind the patient that they will be given towels to clean themselves up. -Make an assessment of the patient effort (good-okay-poor). -Report the reason for "bad" sequences. - Put history and other notes in IDX10. -Sort the multislice cine sequence by slice position (Avanto only).

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SYNGO Abdominal MRI Protocol Codes

Code Description AMRAABAO Routine abdominal aorta MR angiogram without and with contrast. AMRABDPEL Screening MR imaging of the abdomen and pelvis without and with

contrast. (e.g. metastatic disease evaluation) AMRADRENAL Non-contrast adrenal MR imaging. Not for known adrenal cancer. AMRAHEPAT Routine hepatic/splenic artery MR angiogram without and with

contrast. AMRAMES Routine mesenteric MR angiogram without and with contrast. AMRAOTHER Nonspecific MR arteriogram imaging protocol. To be explicitly

described by MD. AMRAPELVIS Routine pelvic MR angiogram without and with contrast. AMRARENAL Routine renal MR angiogram without and with contrast. AMRDIAPH Dynamic diaphragm MR imaging without contrast. AMRDYNPEL Dynamic pelvis MR imaging without contrast. AMRFISTULA Pelvic fistula evaluation without and with contrast. AMRFPELW Female pelvis MR imaging without and with contrast. (e.g. adenexal

mass) AMRFPELWO Routine female pelvis MR imaging without contrast. AMRFUNPANC Functional pancreas evaluation with Secretin administration. AMRFUNPANBIL Combination pancreas and biliary MR without and with IV contrast

and functional pancreas evaluation with Secretin administration. AMRLIV Routine liver MR imaging without and with contrast. AMRLIVDON Routine living liver donor MR imaging evaluation without and with

contrast. AMRMRCP Routine MR cholangiopancreatography without contrast. AMRNBHLIV Routine non-breathhold liver MR imaging without and with contrast. AMROTHER Nonspecific MR imaging protocol. To be explicitly described by MD. AMRPANCBIL Routine pancreas and biliary MR imaging without and with contrast. AMRPELW Other pelvis MR imaging without and with contrast. AMRPELWO Other pelvis MR imaging without contrast. AMRPEN Penile MR imaging without and with contrast. AMRPREUAE Pre-uterine artery embolization pelvis MR without and with contrast. AMRPROST Routine prostate MR imaging without contrast. AMRRECTM Primary rectal cancer staging without and with contrast. AMRRENALMS Routine renal mass MR imaging without and with contrast. AMRRENDON Potential renal donor evaluation MR imaging without and with

contrast. AMRRENPNX Partial nephrectomy pre-surgical planning MR imaging without and

with contrast. AMRRENTX Renal transplant MR imaging evaluation without and with contrast. AMRSCROT Scrotal MR imaging without contrast. Contrast to be specified if

needed. AMRSOTHER Nonspecific MR spectroscopy protocol (typically includes pre-

spectroscopy imaging). To be explicitly described by MD. AMRSPROST Prostate MR spectroscopy protocol. Includes pre-spectroscopy

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imaging. AMRURETH Female urethra MR imaging without and with contrast. AMRUROGRAM MR urogram without and with contrast (includes renal evaluation). AMRVHEPAT MR venogram of the hepatic veins without and with contrast.

(Includes contrast arteriogram.) AMRVIVC MR venogram of the IVC without and with contrast. (Includes contrast

arteriogram.) AMRVOTHER Nonspecific MR venogram imaging protocol. To be explicitly

described by MD. AMRVPELVIS MR venogram of the pelvic veins without and with contrast. (Includes

contrast arteriogram.) 11/19/2007

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Research Protocols Most research cases require special consent forms to comply with IRB regulations. Be sure they are filled out before the studies are done. Database This is one of the most important duties. All cases must be entered, and it is primarily the fellow’s responsibility to maintain the database. Check once a month for duplications, missing results, etc. Use that time to check in pathology for any surgical correlation on interesting cases. Or, to printout summaries of the cases for your own records. Try to mark interesting cases for conference or to be imaged as teaching cases. A sloppy database makes finding clinical cases more difficult and diminishes a lot of potential research opportunities!

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