mrcp: technique and interpretation “10 rules in mrcp” lieven van hoe md phd olv hospital group...
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MRCP: technique and interpretation
“10 rules in MRCP”
Lieven Van Hoe MD PhDOLV Hospital Group Aalst -
[email protected] www.lievenvanhoe.com
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Procedure Axial and coronal double echo HASTE
(5mm)NON-FATSAT
TE 60 TE 360
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10% of your patients has focal liver lesions
Double echo HASTE: lesion characterizarion
SITE 60
SITE 300-400
cyst ++ / +++ as bright as CSF
hemangioma
+ / ++ not as bright as CSF
solid ± / + ± isointense
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60 msec 360 msec
solid
hemangioma
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Axial and coronal double echo HASTE (5mm)
• Thin-section MRCP
• Scout for breath-hold single-slice MRCP
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Procedure
Single-slice MRCP - RARE sequence– slice thickness 3 cm, TE 1100– 3 sec / image– breath hold
= overview images
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Procedure
Axial non-FATSAT turboFLASH T1= magic tool for detection of pancreatic cancer
and focal liver lesions
Liver whitePancreas white
Tumor dark
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Procedure
Multiphase contrast-enhanced VIBE
• Problem-solving tool• Pancreatic lesions• Only if required
T
P
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Rule N° 1
Never use MRCP without cross-sectional imaging
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Man, 43-year, elevated liver enzymes, previously papillotomy for biliary stone disease. Stone?
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Aerobilia
Always correlate with axial T2-weighted images !!
Air-fluid levelExtensive air may make MRCP nondiagnostic
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Liver function abnormalities
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Missed pancreatic carcinoma
Never perform MRCP without cross-sectional imaging
never, never, never
TFLASH: 700 msec/slice – HASTE: 400 msec / slice
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Rule N° 2
Use dynamic (repetitive) MRCP
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May 13, 200310hr:12min:15sec
May 13, 200310hr:12min:23sec
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Temporal variability in shape of the sphincter of Oddi
It works !
Only possible with breath-hold single-slice MRCP
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Rule N° 3
Use the correct slice thickness
Not 10 cm !
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10cm 5cm
2cm 3cm
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Rule N° 5
Be aware of biliary flow phenomena on axial images
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Flow void in
common bile duct
Compare with single-slice MRCP
Believe single-slice MRCP if results are different
axial T2
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Rule N° 6
Be aware of the pseudo-calculus sign
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Pseudocalculus sign
30 sec later
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Rule N° 7
Small stones not surrounded by fluid are invisible
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Not included in slice
Not included in slice
Does the patient has stones in distal CBD ??
Normal size
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Impacted stone
May be difficult diagnosis !No surrounding fluid
Repetitive imaging useful
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Rule N° 8
Anticipate differences between MRCP and ERCP
images
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MRCP:- imaging in the physiologic state
(no ductal distention)
- limitations in spatial resolution
• Low-grade stenoses can be missed• The length of stenoses can be overestimated (physiologic collapse)• Small polypoid ductal lesions can be missed
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MRCP – ERCPThe same things look different !!
(distention)
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Aberrant right posterior duct
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Rule N° 9
For lesion characterization, use all information available (T1, T2,
MRCP, multiphase contrast-enhanced images)
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Cirrhosis. Incidental finding.
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The double duct sign can be caused by chronic pancreatitis with pseudomass. Refer to axial T1- and T2-weighted images for differentiation with carcinoma.
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Rule N° 10
Be aware of susceptibility artifact
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Watanabe et al. RadioGraphics 1999 19: 415-429
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Susceptibility artifactair
metal
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Thank you !!
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The double duct sign can be caused by chronic pancreatitis with pseudomass. Refer to axial T1- and T2-weighted images for differentiation with carcinoma.
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Rule N° 4
Be careful with MIP images
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The patient recently underwent laparoscopic gallbladder surgery and now suffers from jaundice. Injury to CBD?
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MIP
Projects 3D reality on 2D image
Pathology may be masked