meyer ca, schiebler ml, reeder sb, francois cj, nagle sk artifacts and pitfalls in mr angiography...
TRANSCRIPT
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Artifacts and Pitfalls in MR Angiography (MRA) for Pulmonary Embolism
Meyer CA, Schiebler ML, Reeder SB, Francois CJ, Nagle SK
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Disclosures
Financial: UW has a research agreement with GE Healthcare
Only gadofosveset (Ablavar®) is FDA approved for MRA
Use of other gadolinium based contrast agents is not FDA approved for MRA
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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MRA Technique
Multiphasic acquisition fluoro triggered arterial phase immediate post-injection phase 2nd post-injection “steady state” phase using lower flip angle each phase done during single breath hold
Full chest coverage High spatial resolution 2D parallel imaging
must use multichannel phased array coil recommend ≥ 8 channels
Freq
encoding
Phase encodingS
lice
en
cod
ing
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MRA Technique
k-space “corner cutting” eliminates 22% of readouts
Elliptical centric acquisition enables fluoro-triggering
0.1 mmol/kg of gadobenate dimeglumine typically 15-20mL diluted with saline to a total volume of 30 mL
Freq
encoding
Phase encoding
Slic
e e
nco
din
g
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MRA Technique
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Slab Orientation
Frequency encode long axis of slab (S/I) Sagittal slab excitation to minimize aliasing
Freqencode armarm
torso
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Findings:
Filling defects in pulmonary arteries (arrows)
Perfusion defects (arrowheads)
Pulmonary emboli
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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Bolus Timing
~15 sec elliptical centric acquisition 0.1 mmol/kg dose injected at 1.5
mL/s 200 lb patient: ~20 mL dose 13 s bolus 100 lb patient: ~10 mL dose 7 s bolus
The Problem: bolus duration < acquisition time
The Solution: extend bolus duration by diluting contrast in saline to
30mL injected at 1.5 mL/sec (20 s bolus)
Maki, et al., JMRI 6(4):642-51, 1996.
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Time
inject
Enh
ance
men
t
Acquisition
Contrast plateau leads tosharper vessels due to
higher signal at edge of k-space
Dilute Bolus
Standard Bolus
Bolus Timing
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PA
Aorta
k0 kmax
PA
Aorta
Ideal timingScan late or bolus short
PA
Aorta
Scan early
k0 kmax kmaxk0
Edgeenhanced
Blurred
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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Contrast Injection Pitfalls Transient Interruption of Bolus*
Flow-related phenomenon Related to valsalva during breath-hold Increased unopacified blood return from the IVC
Dual Injector Error Inadvertent reversal of the saline and contrast syringe Fluoro-triggering detects the small amount of contrast
mistakenly used to “flush” the IV line during set up. Results in scanning when primarily saline is
intravascular
* Wittram C, Yoo AJ. J Thorac Imaging 2007; 22: 125-9
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Dual Injector Error
Pre-Injection During Injection 1st Post Injection 2nd Post Injection
Small amount of contrast in aorta
No contrast in pulmonary artery
Dense contrast in subclavian vein
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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Gibbs Ringing Occurs near high-contrast edges Occurs centrally in vessels 3-5 pixels wide
based on true resolution May be mistaken for pulmonary embolism Measure signal drop within vessel
If < 50% signal drop, suspect artifact If > 50% signal drop, suspect embolus
Do not aggressively window vessels Ensure that background noise is visible in
image
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Gibb’s Ringing Pulmonary Embolism
Simulated true vessel cross-sectionSimulated Gibb’s ringingActual cross section
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With Corner Cutting Without Corner Cutting
2 pixels
4.5 pixels
7 pixels
Corner Cutting
With corner cutting, the point-spread function is circularly symmetric andGibb’s ringing looks more like true embolism.
Without corner cutting, there is less risk of misinterpreting Gibb’s ringing as true embolism.
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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Wrap and Parallel Imaging Wrap (aliasing)
occurs if excited tissue extends outside FOV sagittal slab excitation avoids wrap from arms
Parallel imaging propagates wrap artifacts into the center of the image must completely include AP dimension of patient
Don’t rely only on mid-sagittal and mid-axial scout images! Largest AP dimension usually at breasts or belly
image noise worse in center of image (increased G-factor)
Solution: Increase number of AP slices while maintaining
reasonable breath-hold time, even at the cost of lower AP resolution
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Residual Aliasing & G-factor
Wrap
Wrap
Parallel imaging
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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Amplifier Over-ranging Problem:
Prescan adjusts amplifier gain to use the entire dynamic range of the analog to digital converter
Actual signal intensity of the acquisition may exceed this range due to IV contrast
Solution: Decrease amplifier gain and reinject If this is a regular problem, then routinely decrease
amplifier gain during manual prescan prior to injection.
True k-spaceOver-range
portion
True image Over-rangeportion
ObservedImage
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Amplifier Over-ranging
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OutlineMRA Technique
ContrastRelated
MRI Reconstruction
Related
PatientRelated
Bolus Timing
Bolus Duration
Transient Contrast Interruption
Dual Injection Error
Gibbs Ringing
Wrap and Parallel Imaging
Amplifier Over-ranging
Respiratory Motion
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Respiratory Motion Artifact Patient’s often dyspneic if PE suspected If motion occurs in the middle of K space
smearing occurs Injection startle motion quiescent Solution:
1. Multiphasic injection – motion common on arterial phase (1st) acquisition
2. Repeat injection with fewer, thicker slices to shorten acquisition time
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1st Injection has respiratory motion
2nd Injection
Respiratory Motion Artifact
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Conclusion
Contrast-enhanced MRA is a mature and robust technology
High quality scans require careful attention to k-space sampling strategies, injection protocols, and technologist training
Accurate interpretation requires under-standing common pitfalls and artifacts