FieldStrength 49

Publication for the Philips MRI Community

ISSUE 49 ndash 2013 2

Transforming care together

Dear Friends

Because Philips understands the challenges in todayrsquos healthcare environment we develop

MR products and features for fast and robust MR imaging with high quality Where

conditions demand it our technology allows you to choose new imaging strategies and use

inventive approaches and new applications so yoursquoll be well equipped when changes come

This issue of FieldStrength features MR users who are using the power of Ingenia with

dStream to change their way of working You can read how liver imaging with high

dS SENSE acceleration has improved image quality so that patient management may

change at Lyon South Hospital Leiden University Medical Center is employing mDIXON

TSE for excellent robust head and neck imaging that is even faster

Palo Alto Medical Foundation has reduced MSK exam times signif icantly while

maintaining outstanding image quality The 32-channel dS Head coil helps Qscan

Radiology Clinic to consistently achieve excellent detail in its neuro images

Wersquove also highlighted how Cincinnati Childrenrsquos Hospital and University College London

Hospital use Ingenia with dStream to start using a different approach for performing

fetal imaging and whole body imaging respectively

Donrsquot miss reading about our RSNA presence which demonstrates products and

features that are built for fast robust MR imaging with high image quality giving you the

f lexibility and control you need Without you itrsquos just a machine

Enjoy reading how we are transforming care together

Tamanna Bembenek

Senior Director Product Marketing MRI at Philips Healthcare

Editorial

NetForumwwwphilipscomnetforum

Visit the NetForum online community to download ExamCards and view application tips case studies online training and more Scan the QR code with your smartphone or use wwwphilipscomnetforum

EXPLOREShare clinical results

OPERATESupport your scanning

GROWSupport your business

User experiences

Educational

MR News

NetForum

Application tips

Calendars

In this issue

Results from case studies are not predictive of results in other cases Results in other cases

may vary Results obtained by facilities described in this issue may not be typical for all facilities

12 24 40

4MR News

Philips MR at RSNA 2013Transforming care together

The Philips booth at the 2013 RSNA meeting presents MR products and services that help transform patient care With dStream technology and the remarkable Ingenia 15T and 30T systems Philips continues to drive fast robust high quality MR imaging while ensuring good economic value New solutions for neurology and oncology and the latest edition of IntelliSpace Portal expand diagnostic capabilities for referring physicians iPatient for MR is introduced to deliver patient-centric imaging and support consistency and efficiency

dStream is a decisive solution to deliver premium image quality With digitization in the coil dStream delivers a pure digital signal that delivers up to 40 SNR improvement depending on the clinical area of interest The extra signal can be used to enhance image quality and accelerate imaging

Through its optimized coil topology and the SNR advantage of the pure digital signal dStream and dS SENSE deliver high acceleration for clinical use This allows for fast and robust imaging especially in body imaging

Using the advantages of the dStream platform Philips has developed time-efficient imaging techniques for greater speed and consistency The Philips patented 2-point mDIXON technique delivers superb fat-free imaging with premium quality at amazing speed ndash only 23 of the time needed for a 3-point technique Together with dStream this allows for new approaches in imaging that support standardization consistency and speed

dStream and dS SENSE come standard with every Ingenia and SmartPath to dStream system

Compared to an analog system (Achieva)

mDIXON TSE with and without fat suppression in one scan Ingenia 30T voxels 08 x 09 x 30 mm scan time 537 minCourtesy of Phoenix Childrenrsquos Hospital Phoenix AZ USA

dStream drives clinical excellence and productivity in MRI

FieldStrength - Issue 49 - 201324

CONTINUE

Easy access to dStream on your current magnetPhilips sees high interest among existing MR users to get access to dStream in a cost-effective way The SmartPath to dStream program converts an Intera or Achieva system into a state-of-the-art digital MR scanner enabling fast and robust MRI imaging Equipped with the integrated posterior coil powerful dS SENSE as well as workflow enhancements this gives essentially the same dStream benefits as with an Ingenia Additionally this conversion to dStream gives access to the above mentioned new clinical features and also includes iPatient and the enhanced user interface

Ingenia Intera or Achieva SmartPath to dStream

iPatient provides patient-centric workflowiPatient represents efficient personalized imaging in which exams can quickly and easily be tailored to individual patients and situations iPatient supports users to deliver consistent image quality for their patients

Lightweight and easy-to-handle coils streamline patient setup and enhance patient experience ExamCards facilitate use of personalized and automated imaging strategies by enabling smooth routine exams as well as advanced scanning methods

An intuitive interface allows users to adapt imaging to the patient in a consistent manner aided by SmartExam SmartSelect and user guidance As fewer clicks are needed users can depend on a smooth direct route to personalized high-quality exams even in high-end or complex cases

FieldStrength 5

MR News

Advanced diagnostics imaging viewing and analysis

New methods for advanced neuro imaging include SWIp for fast susceptibility weighted imaging with exquisite quality for instance for imaging of venous blood pCASL allows non-contrast high SNR brain perfusion imaging On IntelliSpace Portal this can be easily viewed as color overlay on an anatomical image to assist the radiologist in diagnosis Similar to BrainView MSK View provides excellent image resolution in all orientations after just one 3D acquisition

IntelliSpace Portal as a delighter to every MR scannerAdvanced visualization completes advanced imaging IntelliSpace Portal supports efficient and comprehensive interpretation of advanced data with applications and features for Oncology Cardiology Neurology and MSK Whether you need to run advanced Cardiac functional analysis request an Oncology therapy RECIST follow-up analysis or want a pre-surgical review of the brain all is enabled with IntelliSpace Portal 6

IntelliSpace Portal provides an intelligent approach to visualization the ability to access and diagnose any time and virtually anywhere without being tied to a modality workstation With a multi-modality clinical approach the user is directly taken to the clinical dilemma at hand

Integration into an entire radiology department or hospital enterprise is easy with IntelliSpace Portal the thin-client technology data review can be launched virtually anywhere With multi-vendorcapabilities there is no concern about the origin of data Workflow is supported by bookmarks to enable sharing with peers in a comprehensive manner

Discover the powerful combination of intelligence integration and interpretation Philips IntelliSpace Portal can transform the way you work think and care for patients and it adds to our advanced imaging on Philips MR systems

Comprehensive cardiac functional review with IntelliSpace Portal

Ingenia 30T Courtesy of Phoenix Childrenrsquos Hospital Phoenix AZ USA

pCASL and overlay on anatomical images

Consult your Philips sales representative for

detailed information

Advancing MRI beyond diagnostic imaging

Ingenia MR-OR

Dual-room MR-ORWith a world-class Ingenia MR system at its heart the Ingenia MR-OR delivers outstanding images during neurosurgery procedures to help improve procedural success rates The dual-room MR-OR layout allows regular diagnostic use of the MR system when not in use for intraoperative purposes

The possibility of both front and rear docking in a triple-room setup and the smooth patient transfer between OR and MR further increase efficient utilization of the set-up

With our innovative MR-Therapy portfolio we are committed to touching even more lives The unique capabilities of MRI can be used beyond diagnostic imaging in guiding and monitoring therapeutic procedures

Ingenia MR-RT Oncology Configuration

The open dS Breast 16ch coil provides excellent diagnostic scans and supports breast biopsy

New coilsA new coil on display is the open 16-channel dS Breast coil This coil is designed to support both diagnostic scans and breast biopsy Other new coils include the dedicated dS Pediatric coils and the dS Microscopy coils

MRI in radiotherapy treatment planningThe Ingenia MR-RT Oncology Configuration is a dedicated solution for radiation oncology departments that want to take full advantage of MRIrsquos excellent soft-tissue contrast for their treatment planning workflow With an Ingenia as its backbone the Ingenia MR-RT provides images acquired in the treatment

position and optimized for use in RT planning with remarkable geometric accuracy This comprehensive solution considers the entire workflow from scan to planning and treatment including quality analysis tools tailored training and RT-specific ExamCards

FieldStrength 7

Multi-parametric prostate and whole-body oncology MRI examsUCLH uses Ingenia 30T for multi-parametric MRI exams to help localize and characterize lesions

In multi-parametric MRI the multiple contrast mechanisms provide more information about lesions that can help in diagnosis Multi-parametric MRI can include T1-weighted T2-weighted diffusion-weighted imaging (DWI) DCE and spectroscopy Dr Shonit Punwani and his team at the University College Hospital London developed multi-parametric MRI exams for prostate imaging and whole body imaging

UCLH (University College London Hospital) is a leading hospital in the UK It has an Achieva 30T and an Ingenia 30T installed at the MacMillan Cancer Centre The Achieva system is used predominantly for prostate MRI but also for general work The Ingenia system is used for dedicated scanning of oncology patients In addition to the clinical services provided the radiology department is at the forefront of medical research

MRI has a range of applications in prostate imagingldquoWhen prostate MRI is used for staging after cancer has been diagnosed the goal of imaging

is to visualize the lesions and determine if and where these are extending outside the prostaterdquo says Dr Punwani ldquoThat requires high quality anatomical imaging However when MRI is used to assist in the initial diagnosis a multi-parametric approach offers more information I use the additional information particularly for small tumors For instance when I see a lesion with low signal on T2-weighted images and the additional DWI and the ADC map confirm the lesion has a reduced ADC then I know that the lesion is likely to be cellular Increased cellularity restricts the movements of water molecules which leads to high signal on DWI and restricted ADCrdquo

User experiences

Dr Shonit Punwani is a Senior Lecturer in Oncological Imaging at University College London and Honorary Consultant Radiologist specializing in oncological radiology at University College London Hospital He co-leads the 3T MR Research Facility at UCLH developing novel MRI techniques for first-in-man oncological imaging studies He has a specialist clinical and research interest in the application and development of local and whole-body quantitative and functional MRI methods for imaging prostate

ldquoWhen MRI is used to assist in the initial diagnosis

a multi-parametric approach offers more

informationrdquo

ldquoNot using an endorectal coil is more comfortable for the patient and currently the surface coil approach provides enough SNR for prostate imaging When performing prostate MRI without endorectal coils air in the rectum may cause susceptibility effects particularly at 30T So in order to reduce the susceptibility effect we use a small field-of-view DWI for generating the ADC map We also include a separate high b-value DWI and have found both particularly useful When I see focal areas of high signal on b2000 images and the rest of the gland is dark I have a very high suspicion of cancer being presentrdquo

Why change the approachldquoThere is a clear need to change the way that we localize disease within the prostate We would never perform a breast biopsy without first trying to localize the lesion using imaging That is why we are now developing the necessary tools to localize disease within the prostate with multi-parametric MRI We have been performing multi-parametric MRI of the prostate without an endorectal coil at 15T since 2006 The arrival of our Achieva

30T TX system and use of the 32-channel SENSE Cardiac coil significantly improved the signal to noise of our T2 and diffusion weighted imagesrdquo

Dr Punwani and his team are also looking at MRI to help assess the effect of treatment ldquoBeing able to localize lesions also opens the possibility to provide focal therapies which treat only a part of the prostate rather than removing the entire organ In such cases we can use MRI to monitor the effect of treatment For post-treatment surveillance if PSA is increasing we can use multi-parametric MRI to localize recurrentresidual diseaserdquo

Multi-parametric whole-body MRI provides more informationldquoThe multi-parametric approach for whole body oncology imaging is a more recent development which has been facilitated by the installation of the Ingenia 30T scanner The dS Torso coil solution makes whole body imaging using multiple contrasts within a reasonable overall imaging time a reality We are very pleased with the results so farrdquo

ldquoOne of the key benefits of multi-parametric MRI for whole-body exams is that unlike PET there is no radiationrdquo says Dr Punwani ldquoThis is especially important for pediatric patients who need many follow-up scansrdquo

ldquoAlso FDG-PET does not detect all bone lesions DWI methods have been shown to be useful at visualizing bone disease and could complement PET or other nuclear medicine techniquesrdquo

ldquoWe perform all our multi-parametric whole body MR scans on the Philips Ingenia 30Trdquo says Dr Punwani ldquoThe new core technologies on the Ingenia allow us to use a multi-parametric whole-body approach in a reasonable amount of time For anatomical imaging we do a free breathing TSE sequence

CONTINUE

ldquoBeing able to localize lesions opens the possibility to provide focal therapiesrdquo

Axial ADC map Axial T2W Axial b2000 diffusion weighted

Multi-parametric prostateThe axial ADC map demonstrates reduced diffusion within the anterior left transition zone of the prostate This is consistent with increased cellularity within a tumor Note that this region would not be undersampled by a standard TRUS biopsy procedure and without MRI assisting in targeting a diagnosis of localized tumor could not be confirmed The axial T2-weighted images demonstrate a subtle more homogenous area of reduced T2 signal within the anterior left transition zone similar in appearance to adenoma The axial b2000 diffusion weighted image demonstrates significant residual signal within the left anterior transition zone at the tumor site Signal elsewhere is almost completely absent This was scanned on Achieva 30T TX

FieldStrength 9

UCLH (University College London Hospitals NHS Foundation Trust) situated in the West End of London is one of the largest NHS trusts in the United Kingdom and provides first-class acute and specialist services The state-of-the-art University College Hospital that opened in 2005 is the focal point of UCLH alongside five cutting-edge specialist hospitals UCLH is committed to research and development and forms part of UCL Partners which in March 2009 was officially designated as one of the UKrsquos first academic health science centers by the Department of Health UCLH works closely with UCL translating research into treatments for patients For more information see wwwuclhnhsuk Facebook (UCLHNHS) Twitter (UCLH) or Youtube (UCLHvideo)

ldquoIngenia allows us to use a multi-parametric whole-body approach

in a reasonable amount of timerdquo

User experiences

Bone scan

DWI b1000

T1 mDIXON in phase

Multi-parametric whole body using Ingenia 30T Bone scan and mp-MRI concordant lesions in a patient with known prostate cancer Two lesions are demonstrated on the bone-scan at T12 and T7 vertebral body levels The coronal mDIXON in-phase image demonstrates both lesions as foci of low T1 signal Coronal reformat of an axial diffusion b1000 scan (inverted contrast) demonstrates restricted diffusion within the T12 lesion The axial T2-weighted image at the T12 level confirms low T2 signal

ldquoThese T2-weighted images are excellent We also perform diffusion imaging of the whole body Wersquore using SPAIR spectral fat suppression not STIR as in DWIBS to acquire four b-values These help us to differentiate the diffusion components from other effects The ADC maps are quite good In the neck though the susceptibility gradient may cause distortion in the ADC map One of the things we can do is add a STIR EPI on the neck after scanning the entire body which tends to have fewer artifactsrdquo

ldquoNext we use body mDIXON imaging acquiring in-phase out-phase images and

deriving fat and water images This provides us with excellent anatomical resolutionrdquo

ldquoThe liver is a special case in most whole-body images because we want to be able to pick up liver lesions which we donrsquot necessarily see without contrast So we do dynamic imaging which is acquired every 20 seconds and has multiple breath holds through the liverrdquo

ldquoIrsquom getting more and more clinical requests in for multi-parametric MR to visualize disease and response to treatment in different clinical areasrdquo says Dr Punwani

Summary why a multi-parametric approach ldquoCombining multiple contrast mechanisms allows us to look at different aspects of tumor biology ndash for example cellularity vascularity fatwater percentages ndash and together these provide more information than any one particular technique And I think thatrsquos very powerful particularly where patients have heterogeneous tumors where not all lesions are seen by any one technique Also by evaluating multiple aspects of tumors we may be able to not only see the disease but hopefully develop methods to better predict the responses to treatmentrdquo

Bone scan

DWI b1000

T1 mDIXON in phase

Multi-parametric whole body using Ingenia 30T Bone scan and mp-MRI discordant lesion in a patient with known prostate cancer suggesting mp-MRI may be more sensitive than bone scan No iliac bone lesion is seen on the bone scan The coronal mDIXON in-phase image demonstrates subtle hypointense T1 signal within the left ilium (red arrow) The axial diffusion b1000 image (inverted contrast) demonstrates restricted diffusion at the corresponding site within the left ilium (red arrow) The axial T2-weighted image at the site confirms a typical appearance of a low T2 signal metastatic deposit (red arrow) Combining multiple contrast mechanisms provides more information than any one particular technique which is powerful when not all lesions are seen by any one technique

FieldStrength 11

Liver imaging takes a step forward with IngeniaLyon South Hospital strives to move from several studies ndash first CT then MR or PET ndash to using just one comprehensive liver MRI exam for oncology cases

The Lyon South Hospital (Lyon France) is part of the Lyon University Hospital Center It has nearly 1000 beds mostly dedicated to cancer care including oncology radiotherapy interventional radiology and surgery The hospital uses Ingenia 30T and Ingenia 15T to perform about 800 MR exams a month about 200 of which are for abdominal conditions

Prof Pierre-Jean Valette MD is Chief of Radiology and Nuclear Medicine Service at Lyon South Hospital ldquoIn oncology patients liver MRI is performed in several situations to help us characterize lesions in follow-up after chemotherapy and to assist in treatment planning in a concept of multidisciplinary care when a complete tumor removal appears to be feasiblerdquo he says ldquoSo we need our imaging to provide a comprehensive visualization of the liver and all lesions their size volume and location relative to other critical anatomical structures ndash such as bile ducts and portal branches ndash that influence tumor resectability This helps determine the treatment options it may be resection or tumor ablation or maybe radiotherapyrdquo

Challenges and goals in liver MRIldquoMRI of liver tumors offers more than CT in certain aspectsrdquo says Prof Valette ldquoas it provides visualization and characterization of lesions with combined T1 T2 and DWI sequences in addition to good tumor contrast uptake resolution and anatomical biliary tree imaging Therefore we always perform MRI before surgery or interventional radiology in case of bile duct tumor and liver primary cancers (HCC) or metastasesrdquo

ldquoLiver tumor MRI is almost always associated with CT and contrast-US for imagingrdquo he adds ldquoHowever we think that MRI could become the sole examination as soon as it can provide image quality robustness similar to CT better control of its inherent artifacts and increased spatial resolution for vascular imagingrdquo

Ingeniarsquos high image quality helps to overcome challengesLyon South Hospital installed Ingenia 30T in 2011 and an Ingenia 15T

User experiences

Prof Pierre-Jean Valette MD is head of the Lyon South Hospital imaging department His specialties include diagnostic and interventional gastrointestinal imaging with a special interest in MRI applications in digestive pathology He has also contributed to the design of dedicated medical image processing software and therapeutic planning of patients

CONTINUE

was recently added Prof Valette likes using the Ingeniarsquos dS Torso coil solution because it has a large coverage ldquoWith this coil whole abdomen acquisition is a single step for most patients So it is much faster to perform for instance bowel MRI for inflammatory diseases or tumorsrdquo With the most recent Ingenia software release installed Prof Valette has worked to improve reproducibility image quality and acquisition time of the hospitalrsquos liver sequences ldquoWe were able to realize improvements thanks to high dS SENSE in RL direction and improved MultiVane T2-weighted imaging We are now convinced that we are on the way to definitely overcome the challenges We optimized for image quality and control of artifacts The arterial phase detection of very small liver or pancreatic hypervascular tumors is also improvedrdquo

Only one MRI exam instead of multiple studies ldquoWith all these improvements I believe that resolution of vascular liver MR imaging is now approaching CTrdquo says Prof Valette ldquoThatrsquos important because we are moving from doing several studies - CT first then MR or PET ndash to just one and itrsquos saving a lot of timerdquo

ldquoFor instance when assessing bile duct tumors we need to see the location and boundaries of the tumor but also the bile ducts adjacent to the tumor the vessels the hepatic artery the portal vein because all these are needed to determine whether the tumor is resectable or not When we get for example bile duct images from MR or CT and the tumor on PET and maybe the vessels from CT itrsquos difficult to combine all these views And it means two or maybe three examinations have to be performed The idea is to do everything with just one multiparametric technique and that is MRIrdquo

A robust high quality MRI exam Prof Valettersquos liver MRI includes some basic sequences and a set of optional sequences that may be used in special circumstances ldquoOur extended liver ExamCard includes a range of sequences for patients with limited capability to hold their breath and also for obese patientsrdquo he says ldquoIf the patient is not able to maintain a breath hold we reduce the acquisition time by limiting the coverage to a selected region of interest andor increase the voxel size depending on the caserdquo

ldquoWe are moving from doing several studies ndash CT first then MR or PET ndash to just

one and itrsquos saving us a lot of timerdquo

Visit the online NetForum community to download the liver ExamCard of Prof Valette

T1 mDIXON arterial phase

T1W mDIXON portal phase

VRT liver vessels

Focal nodular hyperplasia in liverIn a 45-year-old woman recently operated for a breast cancer ultrasound revealed a right hepatic nodular lesion T1-weighted images at arterial and late phase demonstrate a small mass markedly hypervascular at the arterial phase isointense to the liver at the late phase except persistent enhancement of fibrous septa making a characteristic aspect of FNH On the T2-weighted image the nodule is moderately hyperintense The 3D image demonstrates the spatial arrangement of the hepatic artery the portal vein and hepatic veins showing the anatomical relationship of the hepatic nodule with the vascular liver structures Ingenia 30T with dS Torso coil solution patient feet first arms up

FieldStrength 13

User experiences

ldquoThe use of high dS SENSE in RL direction provides shorter breath hold times higher resolution and

sharper imagesrdquo

Liver exam at Lyon South Hospital

Basic sequences

bull T2 MultiVanebull mDIXON FFE with all image types reconstructed bull mDIXON FFE water only arterialportal (2)venous breath hold ca 18 secbull DWI b1200

Optional sequences

bull T2 single shot if respiratory motion artifacts in T2 MultiVane bull 3D respiratory gated T2 MRCP for bile ducts tumor Axial acquisition if hilar tumor +++ bull single shot T2 if artifacts in 3D T2 MRCPbull mDIXON FFE early arterial and portal if vascular anatomy is needed

MIP bile ducts

VRT bile ducts and portal vein

Large centro-hepatic cholangiocarcinomaA 54-year-old male is admitted for jaundice CT revealed a large centro-hepatic mass but the local extension to hilar structures could not be determined precisely The T2-weighted image shows a large well-defined mass in segment IV T1-weighted images at arterial and portal phase show late heterogeneous enhancement of the lesion suggesting a fibrous component and possibly mucinous content or central necrosis DWI demonstrates restriction predominantly at the peripheral part of the mass No evidence of adjacent lesions into the liver The MIP and VRT MRCP views confirm the hilar bile duct invasion of which details are clarif ied on reformatted views in an axial plane There is no associated compression of portal branches Ingenia 30T with dS Torso coil solution patient feet first arms up Final diagnosis is hepatic cholangiocarcinoma invading the convergence of the bile ducts with prominent extension of the right side Resectability may be considered in the absence of portal damage but was not attempted because of insufficient left lobe volume

New way of patient positioning benefits image resolutionldquoThanks to Ingeniarsquos wide 70 cm borerdquo says Prof Valette ldquowe have been able to improve our imaging strategy by implementing the high dS SENSE speedup in RL direction with arms-up patient positioning This allows using a narrowed acquisition volume without the patientrsquos arms causing artifacts This provides shorter breath hold times higher resolution and sharper images because of reduced blurring in TSE and less distortion in DWI This positioning is accepted by almost every patient but requires an examination time not exceeding 20 to 25 minutesrdquo

ldquoThe use of high RL dS SENSE factors in combination with arms-up provides a real advantage So often with MR when you change something you lose something somewhere else In this case I see just advantagesrdquo he concludes

ldquoOur extended liver ExamCard includes a range of sequences for patients with limited capability to

hold breath and also for obese patientsrdquo

T1W mDIXON pre contrast

T1W arterial phase

T1W portal phase

Multifocal liver hepatocellular carcinomaA 57-year-old male with decompensated cirrhosis is referred to MRI to visualize the hepatocellular carcinoma (HCC) and the lesion extension and to help assess the feasibility of an Yttrium radioembolization CT shows a heterogeneous liver without obvious nodule The left portal branch is the site of a suspended thrombus T2-weighted MRI demonstrates large effusion ascites heterogeneous liver with the presence of multiple slightly hyperintense nodules On DWI a multi-nodular lesion is seen in the liver with marked diffusion restriction The portal vein nodule is also hyperintense suggesting a tumor thrombus On T1-weighted mDIXON the lesion shows arterial enhancement and portal phase wash-out MRI supports the diagnosis of decompensated liver cirrhosis with multinodular HCC Early opacification of the left portal vein at arterial phase suggesting the presence of arterioportal fistulas by which radioembolization would not appear to be safe Ingenia 30T with dS Torso coil solution patient feet first arms up dS SENSE in LR direction T2W SP with MultiVane DWI with b0-b1200 free breathing

FieldStrength 15

Ingenia 15T helps overcome fetal imaging challengesHigh SNR digital coil setup and the wide bore contribute to a smart approach for fetal MR imaging at Cincinnati Childrenrsquos Hospital

Cincinnati Childrenrsquos Hospital Medical Center (CCHMC Cincinnati Ohio USA) is one of the largest pediatric radiology facilities in the United States performing over 200000 imaging studies per year Using an Ingenia 15T the Hospital performs up to 10 fetal MRI exams per week Most of these are patients referred from the Fetal Care Center of Cincinnati which provides mothers and babies with comprehensive prenatal and postnatal care

User experiences

Suraj Serai PhD MRI physicist Department of Radiology at CCHMC works to improve image quality and optimize MR imaging protocols to suit pediatric needs and contributes to multiple research projects related to pediatric radiology His specialties include MR physics T2 mapping spectroscopy diffusion fMRI and optimization of MR imaging protocols for enhanced image quality and better diagnosis

Beth M Kline-Fath MD Associate Professor of Radiology and Chief of Fetal Imaging at CCHMC developed the fetal imaging program for the department and is a staff member of the Fetal Care Center of Cincinnati In addition to Pediatric Neuroradiology her areas of interest include fetal imaging and MR spectroscopy

ldquoOur patients have already had an ultrasound and MR is the next stagerdquo says CCHMC radiologist Beth M Kline-Fath MD ldquoWe image fetal CNS abnormalities twins with twintwin transfusion syndrome chest masses including congenital diaphragmatic hernia lung masses mediastinal masses and babies with multiple congenital anomalies We try to help guide their prenatal care and perinatal intervention where necessaryrdquo

A moving fetus is a challenge for MRIldquoThe biggest challenge in obtaining diagnostic fetal MRI is to acquire images when a fetus is not moving The most important thing for us is to get the mother extremely comfortable and alleviate her anxieties because a disquieted mother affects fetal motionrdquo says Dr Kline-Fath ldquoWe do not give sedation to the mom I do my fetal exams early

CONTINUE

ldquoWhen the fetus moves we just move the FOV and Ingeniarsquos SmartSelect automatically chooses the elements to obtain the best possible SNR Thatrsquos very very helpfulrdquo

ldquoWith the extra SNR we were able to improve the resolution on our single-shot T2 sequencesrdquo

in the morning because in my opinion a fetus typically moves less in the morning Most of our patients prefer to lie on their side so we position the mother in a decubitus position and put her in feet first with her head outside the scanner as much as possible In this way she can see the person who is with her in the room If shersquos claustrophobic we have her focus on the outside of the roomrdquo

Ingenia allows a smart approachldquoThe other difficulty in these exams is that imaging the mother requires a large field of view but the fetus is very small and embedded deep inside the mother so SNR is inherently lowrdquo explains Suraj Serai PhD MRI physicist at CCHMC ldquoAnd because the fetus may also move we try to keep the image acquisition time as short as possiblerdquo

SSh TSE Balanced TFE

Chiari II malformation with myelomeningoceleA 31-year-old pregnant female with fetus at 22 weeks with suspected myelomeningocele was evaluated for intrauterine repair The sagittal T2-weighted SSh TSE image shows a hindbrain abnormality with cerebellar tonsils in the foramen magnum (long arrow) and lack of visualization of the fourth ventricle (short arrow) This finding is consistent with Chiari II malformation The T2-weighted BFFE sagittal spine image shows a lumbosacral spinal defect (arrow) consistent with myelomeningocele This was done on Ingenia 15T Based on the radiologistrsquos report it was decided to be a candidate for prenatal intrauterine repair of myelomeningocele

FieldStrength 17

User experiences

Coronal T2-weighted SSh TSE Twin-to-twin transfusion syndrome33-year-old female pregnant with monochorionic diamniotic twins at 19 weeks gestation with concern for twin-to-twin transfusion syndrome The coronal T2-weighted SSh TSE image through the pregnancy showing the larger ldquorecipientrdquo twin (arrow) and smaller ldquodonorrdquo twin (dotted arrow) Note the larger twin has large surrounding amniotic fluid and large bladder (short arrow) whereas the smaller twin is stuck against the uterine cavity and no bladder is present (curved arrow) Imaging shows absence of brain injury prior to fetoscopic laser ablation of the connecting vascular anastomosis across the placenta MRI was done on Ingenia 15T

Coronal T2-weighted SSh TSE Axial T2-weighted SSh TSE

Right congenital diaphragmatic herniaA 22-year-old pregnant woman with a fetus at 33 weeks being evaluated for fetal lung lesion MRI was done on Ingenia 15T The coronal T2-weighted SSh TSE image demonstrates a fluid filled small bowel (long arrow) and dark meconium filled colon (short arrow) in the left chest confirming presence of congenital diaphragmatic hernia Note the normal location of stomach (dotted arrow) in the left upper abdomen The axial SSh TSE T2-weighted image again shows small bowel (long arrow) and meconium (short arrow) in the right chest The heart (dotted arrow) is displaced into the left chest These findings led to counseling and preparation for respiratory support at delivery

Visit NetForum to view or download the fetal ExamCard developed by CCHMC

ReferencesSerai S Merrow A Kline-Fath B Fetal MRI on a multi-element digital coil platform Pediatric Radiology ndash May 2013 wwwncbinlmnihgovpubmed23649206

ldquoThe key is to maximize SNR We can do that using Ingenia with its digital architecture Because the signal is digitized directly in the coil it helps to obtain high SNRrdquo he says ldquoOur approach is to ndash with the mother on her side ndash use one digital Anterior coil on her back and another one on her front These two coils used together with the Posterior integrated table-coil cover the patient on all sides This setup offers big advantages when the fetus moves no repositioning of the coil is needed We just move the field of view as the coil elements are already there and Ingeniarsquos SmartSelect automatically chooses the elements to obtain the best possible SNR Thatrsquos very very helpfulrdquo

ldquoIngeniarsquos wide bore is another advantage With pregnant patients it really makes a differencerdquo

Tailoring the ExamCardsldquoWe worked on our ExamCards to get the image quality to where we want We generally strive for better image quality over speed Itrsquos really all about making a diagnosisrdquo says Dr Kline-Fath

ldquoWe typically run single shot T2W 3D T1W and Balanced TFE (SSFP) sequencesrdquo says Dr Serai ldquoIngeniarsquos strong gradients allow us to set up fast imaging and that helps reduce fetal motion that can influence the scan The gradients also helped to reduce the TR and TE for high quality in the Balanced SSFP images With the high SNR we were able to improve the resolution on our single-shot T2 sequences We also changed some of the filter settings later on in postprocessingrdquo

ldquoOur techs are trained in fetal MR imagingrdquo he adds ldquoIt takes a bit of time to get used to the anatomy especially in the presence of a malformation and to image a moving fetus In fetal imaging much like any imaging we want to see the fetusrsquos standard anatomy so we need a standard axial a good coronal and a great sagittal which can be a little more difficult with a moving fetusrdquo

Cincinnati Childrenrsquos also performs fetal diffusion imaging regularly and sometimes fetal spectroscopy on Ingenia ldquoThe diffusion of the fetus is very nice and spectroscopy is greatrdquo says Dr Kline-Fath ldquoThe Ingenia performs very well with routine imaging as well as these newer higher-end imaging techniques Irsquove been very happy with the results on Ingeniardquo

ldquoWe use two of the digital Anterior coilstogether with the integrated Posterior coil

we obtain our best SNRrdquo

FieldStrength 19

20User experiences

Chris G Goumas MD

Need to decrease exam time leads to shorter MSK scans while maintaining high resolutionPalo Alto Medical Foundation has developed MSK protocols for Ingenia 30T that save several minutes per scan

In response to an anticipated influx of patients due to US healthcare reforms next year Palo Alto Medical Foundation (PAMF Palo Alto California USA) needed to find a way to increase throughput in the MRI department Since it had already expanded its hours to the limit the only option was to shorten its examination times PAMF looked to its Ingenia 30T system to help them shorten examination time slots to about 20 minutes while maintaining a high level of quality

The USA sees pressure on reimbursements and the upcoming healthcare reforms in 2014 ldquoWe think the healthcare reforms will increase the number of patients seeking healthcare who have never really had access to healthcare in the past This made us decide to make our muskoloskeletal MRI fasterrdquo says radiologist Chris G Goumas MD ldquoWe have chosen to decrease the length of our MSK exams by decreasing the acquisition times of each series to about 3 minutes whereas in the past we focused on very high resolution acquisition in about 5 minutes We usually run 5-6 acquisitions for a full study so wersquore saving 10-15 minutes of time per study so about 40 overallrdquoldquoBecause of the high SNR on Ingenia 30T the shortened MSK scans are still exceeding the resolution of our 15T exams and those are

5-minute acquisitionsrdquo explains Dr Goumas ldquoSo Irsquom confident that wersquore still doing excellent work while exceeding 15T capabilities In a sense wersquore just making Ingenia a much more cost-efficient unit A 30T system may cost more up front but if you have higher throughput over the typical lifespan of the system the long-term economic benefit is quite favorablerdquo

High resolution and fast scans how itrsquos doneThe challenge of course was being able to maintain high resolution within a time limit of approximately 3 minutes per sequence ldquoIt was a matter of trial and error just seeing how much time we could save and still do better than we can on our 15T that was our mark We found

ldquoWe have chosen to shorten our MSK exams by decreasing the acquisition timesrdquo

that we were able to increase the voxel size of our images slightly but then decrease the number of signal acquisitions by one thatrsquos basically how we achieved the time savingsrdquo

ldquoWhatrsquos changedrdquo he adds ldquois that the slice thickness went up a bit so we can get faster coverage through the joint Wersquore essentially back to doing our Achieva 30T protocols but wersquore doing them faster Wersquore doing this in both our MSK and neuro exams Our knee ExamCards used to take about 25 minutes ndash now theyrsquore down to 11 minutes But we still want to keep a very high level of quality particularly in our local market where we have academic centers and other very competitive groups surrounding us Itrsquos a difficult balancerdquo

Ingenia helps achieve the balanceThe high SNR and excellent homogeneity of Ingenia 30T with dStream Xtend FOV and MultiTransmit have been essential in achieving this balance ldquoWhen we first got the Ingenia system we immediately noticed about a 30 increase in SNR compared to our Achieva 30T In a collaborative effort with Philips MR specialist Dave Hitt we really pushed the resolution We were able to further decrease the voxel size by about 30 on the same patient on the same knee with similar SNR However wersquove now dialed it back a bit in order to get still outstanding images that are equivalent to our Achieva images these take 5 minutes on Achieva and wersquore doing it on Ingenia in 3 minutesrdquo

CONTINUE

ldquoThe 3-minutes Ingenia 30T scans are still exceeding the resolution of our 5-minutes 15T examsrdquo

Cor T1W 027 x 038 x 15 mm 114 min

Cor PDW FS 027 x 039 x 15 mm 141 min

Sag T1W 027 x 039 x 225 mm 256 min

Sag PDW FS 028 x 038 x 225 mm 248 min Ax PDW FS 027 x 039 x 20 mm 140 min

Ax T1W 027 x 038 x 20 mm 057 min

Tears in TFCC ligaments 69-year-old female fell with outstretched arms landing on both wrists Triquetral fracture was immediately diagnosed but 6-8 weeks later she has continued pain on the ulnar side of the wrist She underwent MRI on Ingenia 30T with 8-channel dS Wrist coil The coronal sequences demonstrate tears in the scapholunate and triangular fibrocartilage complex (TFCC) ligaments The axial fat suppressed proton density images also show intraosseous cysts in the trapezoid

FieldStrength 21

User experiences

Scan times and voxel size

Ingenia 30T fast

Ingenia 30T high resolution

Achieva 30T high resolution

Knee 1201 min 026 x 042 x 25 mm

2650 min 023 x 034 x 20 mm

2458 min 028 x 037 x 25 mm

Shoulder 1712 min 026 x 042 x 25 mm

3050 min022 x 036 x 175 mm

3214 min027 x 039 x 30 mm

Ankle 1750 min029 x 043 x 20 mm

3202 min 025 x 036 x 175 mm

3032 min 027 x 035 x 35 mm

Wrist 1116 min 027 x 039 x 225 mm

3114 min023 x 033 x 11 mm

2919 min023 x 033 x 125 mm

ldquoOur knee exams used to take about 25 minutes ndash now theyrsquore

down to 11 minutesrdquo

T1W 026 x 041 x 25 mm 122 min

PDW 026 x 040 x 25 mm 224 min

PDW FS 026 x 042 x 25 mm 250 min

PDW FS 026 x 042 x 25 mm 232 min

PDW FS 026 x 042 x 25 mm 310 min

Cartilage defect and ruptured Bakerrsquos cyst52-year-old female with anterior knee pain underwent MRI on Ingenia 30T with 16-channel dS Knee coil This examination demonstrates cartilaginous defect lateral tibial plateau with subchondral sclerosis and marrow edema Edemahyperemia is also seen in the superior aspect of the fat pad abutting the inferior margin of the patella On the axial proton density fat suppressed image a ruptured Bakerrsquos cyst is visualized posteromedially

ldquoIngenia gives us the flexibility needed in todayrsquos demanding healthcare environment The way Philips has designed its hardware and software allows us to go for extreme resolution or extreme speed and every balance in betweenrdquo says Dr Goumas ldquoIf we have a very critical case where we need a second look or a professional athlete where itrsquos important to be highly diagnostic then we can adjust to that Ingenia gives us the ability to adjust not only to our local environment but also to the overall healthcare environment as it changes over timerdquo

ldquoA 30T system may cost more up front but if you have higher throughput the long-term economic benefit is quite favorablerdquo

Cor T1W 026 x 041 x 25 mm 243 min

Sag PDW FS 026 x 041 x 25 mm 248 min

Cor T2W 026 x 042 x 25 mm 242 min

Sag T2W 026 x 042 x 25 mm 253 min Axial PDW FS 026 x 043 x 25 mm 309 min

Shoulder sprain58-year-old male with chronic shoulder pain underwent MRI on Ingenia 30T with 8-channel dS Shoulder coil The study demonstrates tendonosis of the supraspinatus tendon with calcific tendonitis Associated degenerative cysts are seen in the humeral head Minimal fluid is seen in the subacromial subdeltoid bursa Advanced degenerative changes are seen in the acromioclavicular joint

FieldStrength 23

24User experiences

Ben Kennedy Chief MRI Technologist at Qscan Radiology Clinics in Queensland Australia holds a Postgraduate Masterrsquos Degree in MRI from the University of Queensland Australia Kennedy has been an invited speaker for the ISMRMSMRT the European Society of Magnetic Resonance and Micro Biology (ESMRMB) the Australian Institute of Radiography (AIR) and the Queensland Radiology training program

ldquoLooking at IACs or the pituitary we can easily see the structures within small structures rather than just identifying structuresrdquo

Qscan Radiology Clinic (Brisbane Australia) has five MRI systems including an Ingenia 30T while most of the other systems are 15T The Ingenia 30T services all types of MR imaging including neuro MSK cardiac body prostate breast and sports injuries Since Qscan received the 32-channel dS Head coil this coil is being used for almost all head imaging because of its robustness and excellent performance

The 32-channel dS Head 32ch coil for Ingenia 30T is designed for advanced neuro applications including fMRI spectroscopy MRA The coil includes both front and rear facing mirrors for visual stimuli and movie projection It allows comprehensive high resolution coverage of the brain and allows dS SENSE parallel imaging in all three directions

32-channel dS Head coil demonstrates robustness high image detailQscan Radiology Clinic uses 32-channel dS Head coil for all its Ingenia 30T neuro work because of its robustness image quality and exceptional spatial resolution that even reveals detail within small structures

Ben Kennedy is Chief MRI Technologist at Qscan ldquoBefore we had the 32-channel coil we were already happy with our neuro imagingrdquo he says ldquoThe standard dS Head coil is a very good coil But we have a great interest in increasing the amount of work we do for neurosurgeons The desire to implement advanced neuro imaging such as fiber tracking and fMRI was an important reason to get the 32-channel dS Head coil Meanwhile we use the 32-channel coil for all our brain imaging nowrdquo

Exceptional resolution reveals tiny structuresldquoThe 32-channel dS Head coil excels in visualizing tiny but important structures within the brainrdquo says Kennedy ldquoThis coil is very robust in providing uniform signal distribution across the whole brain we see less noisiness in the center of the brain We are seeing structure

within the pons and the midbrain and within the brain stem which I canrsquot remember ever seeing before In the pons and the basal ganglia the images are just so excellent Wersquore seeing small vasculature and tiny vessels inside and recognize areas of degenerative brain where the vasculature is slightly more obvious Itrsquos just so much clearer our radiologists like what they seerdquo

ldquoWith the 32-channel dS Head coil we are using smaller voxel sizes than we used before to visualize anatomy that we assumed is there but we couldnrsquot see nearly as well as we do with this coil For instance when we look at IACs (internal auditory meatus) or at the pituitary we are able to use sub-half-millimeter voxel size and we can easily see the structures within small structures rather than just identifying structuresrdquo

CONTINUE

3D T1W 05 x 05 x 2 mm

3D FLAIR 06 x 08 x 15 mm

Ax T2W 04 x 049 x 35 mm

Venous BOLD 1 x 1 x 06 mm reformatted

Brain MRI demonstrating amyloid angiopathy76-year-old male with history of amyloid angiopathy was imaged on Ingenia 30T with 32-channel dS Head coil The sagittal T1-weighted images show chronic deep white matter ischemic changes Axial T2-weighted and FLAIR show high quality brain anatomy demonstrating chronic ischemic changes and old hemorrhage hemosiderin staining On the axial Venous BOLD (Susceptibility Weighted Imaging) image the high quality vascular anatomy and increased sensitivity to chronic ischemic changes and old hemorrhage hemosiderin staining are seen Imaging appears consistent with amyloid angiopathy no other intracranial lesions found The 32-channel dS Head coil is allowing excellent SNR and resolution in routine clinical imaging It enhances visualizing of the subtle anatomy of brain parenchyma fibers and fine vascular structures

FieldStrength 25

User experiences

3D T1W 05 x 05 x 2 mm

T1W FS 05 x 05 x 2 mm

T2W 04 x 049 x 35 mm

T1W FS 05 x 05 x 2 mm

3D FLAIR 06 x 08 x 15 mm 3D FLAIR 06 x 08 x 15 mm

Follow up of MS progression A 60-year-old male with a history of Multiple Sclerosis (MS) underwent an MRI exam on Ingenia 30T with 32-channel dS Head coil On the sagittal 3D T1W image some hypointense MS plaques are seen Plaques are also well visible on the high quality T2-weighted and FLAIR images Note also the excellent quality of the pons and peduncle brain fibers and vascular structures on the T2-weighted and FLAIR images The T1-weighted ProSet fat suppressed images show high quality brain anatomy and high detail fine vascular information in conjunction to the MS plaques

The multiple pericallosal and subcortical white matter hyperintense foci with several small foci in the posterior fossa and a single focus at the craniocervical junction are consistent with the history of Multiple Sclerosis Two of the foci were not seen in previous examinations This has been thought to be likely due to the high SNR and high resolution demonstrated by the 32-channel dS Head coil as there are no indications to suggest any acute lesions

Robustness and diagnostic confidenceldquoI think it is quite amazing how we are able to use such small fields of view and really thin slices for small anatomyrdquo says Kennedy ldquoHowever I think the biggest thing for us is just the robustness we can trust the coil We know the dStream benefits on top of the 32-channel coilrsquos architecture are really adding to the signal to noise and the quality of the signal that wersquore getting Obviously the more pathology we see using the coil the more we appreciate how diagnostically confident we can be with what wersquore seeingrdquo

ldquoThe other great thing about this coil is that itrsquos quite roomy inside so we can fit a large-sized head in if neededrdquo Kennedy adds

Fine-tuning 30T neuro examsldquoThere are two ways you can go with this type of hardware being fast and being really high detail We have a good balance with this coil in that we can go relatively fast and still have very good detail Generally instead of super-fast scans we lean toward good image quality which the neurosurgeons appreciaterdquo says Kennedy

ldquoOne of the biggest challenges in 30T neuro imaging is the higher sensitivity to pulsatile CSF flow Adjusting the TR to a lower range is one way to reduce this as it leaves less time for CSF flow to affect the acquired dataset In general that makes a big difference for avoiding vascular artifacts and for 30T it works as wellrdquo

ldquoBesides using 3D acquisitions instead of 2D makes a big difference The SNR and contrast that we get from the 3D FLAIR is higher than traditional 2D FLAIR ndash especially when looking for demyelination ndash and allows us to obtain really thin contiguous slices in the brain Similarly Irsquove been able to get much thinner slices with sagittal 3D T1-weighted imaging And because 3D provides much higher SNR than 2D it allows a very nice in-plane resolution as well in a relatively short time We can do it in two minutes With 2D FLAIR we often spend as much time - if not longer ndash for the same sequence The techniques that wersquove been using we have hardly any artifacts at allrdquo

32-channel dS Head coil used for almost all head imaging ldquoThe dS Head 32ch coil has basically replaced the standard dS Head coil for all our brain imaging We only still use the standard head coil when we need to scan from the skull base and move downwards as for instance in oncology neck From the cases where wersquove done one view through the brain and then went back to the standard head coil to go down through the neck wersquove noticed a marked difference between coils itrsquos just a jump in image qualityrdquo

ldquoBefore we received the dS Head 32ch coil the voxel size we were using was just a little bit larger and we were very happy with the SNR But after seeing the image quality we currently get itrsquos hard to go backwards We use the 32-channel coil for all our neuro imaging nowrdquo

ldquoWersquore seeing small vasculature and tiny vessels inside and recognize areas of degenerative brain where

the vasculature is slightly more obviousrdquo

ldquoAfter seeing the image quality we currently get itrsquos hard to go backwards We use the 32-channel coil for all our neuro imaging nowrdquo

Visit the online NetForum community to download ExamCards devleoped by Ben Kennedy for use with the dS Head 32ch coil

FieldStrength 27

Changing MRI methods in head and neck imagingmDIXON TSE Diffusion TSE address MRI challenges in the headneck area and allow different imaging strategies

Robust head and neck imaging is becoming routine at Leiden University Medical Center (Leiden The Netherlands) thanks to new techniques that provide better fat suppression and shorter scan times Large-coverage fat-free imaging is now a reality in imaging skull-base lesions in otology and in imaging of the orbit and nerves

User experiences

Berit Verbist MD PhD became certif ied radiologist at the Catholic University of Leuven Belgium She is senior staff member in headneck radiology and neuroradiology at Leiden University Medical Centre and Radboud University Nijmegen Medical Centre In 2003 she spent visiting fellowships in Head and Neck radiology at the University of Florida Gainesville USA and Oregon Health and Science University Portland USA She is board member of the ESHNR

Berit M Verbist MD PhD points out the challenges of obtaining good image quality in head and neck images ldquoWe need very detailed images from a complex anatomical area and the area is prone to movement artifacts so we need short acquisition times We also need to minimize the number of sequences because it gets tiring for the patient if it takes too long Another big problem is susceptibility artifacts because of the boundaries between air bone and tissue and because many patients have undergone complex surgical procedures that include osteosynthetic materials which leads to more artifacts and inhomogeneous fat suppression There is also an interest in scanning with a large field of view mainly for the lower neck and thoracic inletrdquo

To overcome these challenges Dr Verbist is using mDIXON TSE (turbo spin echo) on the Ingenia 30T with the dS HeadNeckSpine coil The mDIXON technique provides four images in one acquisition water images (fat suppressed) in-phase images (without fat suppression) out-of-phase images and fat images ldquomDIXON TSE delivers very homogeneous fat suppression even when we use a large field of view It addresses the problems with distortion due to susceptibility and it allows us to use large fields of view Irsquove applied it in

ldquoThese techniques simply provide better images with fewer artifactsrdquo

oncology patients and in brachial plexopathy patients Soon I will use it for eye and orbit pathology and skull base lesions as wellrdquo

mDIXON TSE addresses fat suppression speed and image qualityldquoWe often had to choose between scanning with or without fat suppression to keep the examination short Sometimes it turned out we made the wrong choice because of imperfect fat suppressionrdquo says Dr Verbist ldquoThe great thing about mDIXON TSE is that we donrsquot have to choose we get both in one acquisition ndash and excellent image quality within an acceptable time ExamCard times are reduced as fewer sequences need to be usedrdquo

Philipsrsquo patented mDIXON TSE uses 2-echo technology instead of the slower 3-echo method and this enables fast scan time and high resolution simultaneously

ldquoWith better image quality we get better diagnostic accuracyrdquo Dr Verbist explains ldquomDIXON TSE can trigger a change in imaging strategies in head and neck imaging as it provides excellent image quality

and we need fewer scans in an exam because we get the images with and without fat suppression in only one scan We can also enlarge the field of view so it will be easier to image the entire neck And reading these high quality images is faster itrsquos just easier to look at themrdquo

ldquoFor fat suppressed spine imaging of post-operative patients patients with suspicious lesions or spondylodiscitis we currently use the STIR sequence but that has an inherently lower SNR and T2 weighting isnrsquot very good with this technique The homogeneous fat suppression of mDIXON TSE can also be an attractive alternative here For MSK scanning mDIXON TSE can allow us to enlarge the field of view and for instance easily scan both hips at the same timerdquo

CONTINUE

ldquomDIXON TSE delivers homogeneous fat suppression even when

we use a large field of viewrdquo

T2W mDIXON TSE

T1W mDIXON TSE

mDIXON TSE in a patient with brachial plexopathyAn 88-year-old female presented with painful progressive paralysis of the right arm She had a history of breast carcinoma on the right 6 years earlier which was treated with mastectomy Five years ago she underwent radiotherapy for a local recurrence In the right brachial plexus MR images show thickening and high intensity in cervical roots C5 C6 and C7 extending to the lateral and posterior cords (white arrows) A parasternal lymph node (arrow head) and a lesion in the sternum (black arrow) are also noted Note also an enlarged multinodular thyroid gland (sa subclavian artery)

The mDIXON TSE images provide homogeneous fat suppression in a large field of view even in areas with air-bone-soft tissue interfaces This delivers good visualization of the lower neck region and thoracic inlet revealing pathologic changes to the brachial plexus and other abnormalities Biopsy has confirmed recurrence of the breast cancer The diagnosis is lymphatic and hematogenous tumor spread Ingenia 30T with dS HeadNeckSpine coil was used Scan time 541 min for T2-weighted 623 min for mDIXON TSE Scans were optimized for high image quality rather than speed

FieldStrength 29

User experiences

ldquoThe great thing about mDIXON TSE is that we donrsquot have to choose between scanning with or without fat

suppression we get both in one acquisitionrdquo

T1 TSE SPIR

mDIXON TSE water only

mDIXON TSE in-phase

mDIXON TSE skull base imaging of trigeminal neuralgia (maxillary branch)A 56-year-old female with severe pain along the cheekbone and upper jaw on the left and unremarkable clinical examination was referred for imaging of the trigeminal nerve (CN V) This requires highly focused imaging of the peripheral and central segments of the CN V Fat suppression may be needed but has the risk of increased susceptibility artifacts along the skull base With mDIXON images with and without fat suppression can be obtained at the same time Images are from the levels of the infraorbital nerve (top row) and the foramen rotundum (bottom row) Post-contrast T1 TSE SPIR images (047 x 059 mm pixels) show inhomogeneous fat suppression (for instance in the cheek) and susceptibility artifacts along the orbital floor and skull base which obscure the regions of interest Scanning an additional T1 TSE without fat suppression is required for better visualization of the infraorbital nerve (white arrows) and foramen rotundum (other color arrows) Instead one mDIXON TSE scan

provides four image types including images with and without fat suppression (water only and in-phase respectively) in one acquisition Homogenous fat suppression and decreased susceptibility artifacts in the mDIXON images provide excellent delineation of all branches of the trigeminal nerve Shown here are the infraorbital nerve (arrows top row) maxillary nerve in the foramen rotundum (arrow bottom row) and inferior alveolar nerve (branch of the mandibular nerve V3 arrowheads) This image quality is indispensable to help rule out underlying disease in neuralgia ndash as in our patient ndash or for evaluation of perineural area in oncologic patients Ingenia 30T with dS Head coil was used Scans were optimized for high image quality rather than speed T1 TSE SPIR scan time 432 min and 904 min for both with and without fat suppression mDIXON TSE scan time 403 min

Diffusion TSE helps reduce susceptibility distortion Dr Verbist has also begun to use Diffusion TSE in headneck imaging ldquoAgain the motion and the susceptibility in this area can distort standard EPI diffusion images enormously In the brain we can use EPI diffusion but in head and neck we need a method that is less prone to susceptibility artifacts In addition we need very thin slices and yet it shouldnrsquot take too long Diffusion TSE solves this by providing high quality images in a short acquisition timerdquo

ldquoThere are several indications for Diffusion TSE in head and neck such as otology and oncology Itrsquos a very interesting and growing field at the moment Irsquove been using it a lot to help in assessment for cholesteatoma which can result after chronic infection in the middle ear Usually when patients have surgery for this condition they will have another surgery about a year later to look for residual disease but when we are able to visualize recurrent or residual disease with Diffusion TSE we can make a better selection of the patients who will undergo a second operation Itrsquos also becoming more common to use Diffusion TSE for imaging primary cholesteatoma in patients who have not yet had surgery Those patients are first scanned with CT but often CT shows total obscuration of the middle ear making it difficult to determine whether itrsquos inflammatory changes or cholesteatoma Diffusion TSE helps to differentiate thatrdquo

As Dr Verbist brings mDIXON TSE and Diffusion TSE into routine practice she is pleased with the process ldquoItrsquos an easy transition because these are time-efficient techniques they simply provide better images with fewer artifactsrdquo

Senior technologist Guido van Haren at LUMC

Preoperative CT

T2 weighted

Diffusion TSE

T1 weighted

Postoperative Diffusion TSE of residual cholesteatoma A 44-year-old male was operated on for recurrent cholesteatoma after previous ear surgeries Due to the extent of the disease and the patientrsquos wish to preserve hearing the cholesteatoma could not be completely removed Preoperative CT images show a large expansive mass extending along the posterior border of the temporal bone towards the superior semicircular canal (SSCC) (arrows) Postoperative MRI was ordered to evaluate the residual disease Coronal T2-weighted images show hyperintense signal medial to the SSCC (arrow) as well as lateral to the vestibular system (asterisk) On Diffusion TSE (non-EPI DWI pixels 179 x 232 mm scan time 420 min) hyperintense signal is present medial to the SSCC with low signal intensity on the corresponding ADC mapping This restricted diffusion is compatible with residual cholesteatoma T1-weighted images (pixels 047 x 059 mm 347 min) confirm the presence of cholesteatoma (arrows) medial to the SCC whereas the mastoid cavity is filled with granulation tissue (asterisk) Diffusion TSE (non-EPI DWI) is quick and easy to obtain and has been shown to have a high sensitivity and specificity for detection of cholesteatoma Achieva 30T 32-channel SENSE Head coil

FieldStrength 31

transforming care together

digital clarity and speed

do more with your scanner

dStream premium image quality new clinical indications

consistent fat suppression

high quality

use the full potentiallow lifecycle cost

Ingenia

iPatient reproducible diagnostic quality

easy operation

patient experience

advanced neurochange

productivity

throughputoncologycardio

more per timeslot

comfortable scanning

fast patient setup

speed-up with dS SENSE

trainingopportunity accelerating

mDIXON

biopsy

clinical performance

full body scan

medical research

spectroscopy

challenging patients

easy coil handling

advanced viewing

wide bore

IntelliSpace Portal

transforming care

motion-free

MR-guided biopsy

pleasure to work with

support

contrast

expand clinical applications

multi-parametric MR

upgradingSmartPath to dStream

fast image processing

multi-modality viewing

intuitive

plug and play expansion

focal therapymultiparametric technique

challenges

short breath hold times

high resolution

premium image quality

coronalMRI

sagittal

high image detail

diagnostic accuracy

advanced viewing

musculoskeletalclarity

MR News

MasterSeries provides ExamCards from expert users ExamCards developed by experts now available on every Ingenia

The latest Ingenia software release includes ExamCards designed and validated by expert Philips users In addition to the standard Philips factory protocols the MasterSeries ExamCards are delivered directly on the scanner

Based on clinical workflows of key opinion leaders in MR imaging the MasterSeries include ExamCards for both 30T and 15T systems created by world-renowned institutions as Barmherzigen Bruder Hospital (Trier Germany) Palo Alto Medical Foundation (Palo Alto California USA) and Fletcher Allen Health Care (Burlington Vermont USA) A multitude of ExamCards encompasses brain spine MSK and more

The MasterSeries can help Ingenia users leverage the expertise of Ingenia expert users around the world It may also help new users to reduce their adoption time after receiving a new system or when redesigning their workflow The MasterSeries will be continually updated and expanded as new experts are added to the collaboration

Ingenia 30T MSK MasterSeries from PAMFThe high resolution musculoskeletal ExamCards developed by Chris Goumas MD of Palo Alto Medical Foundation (PAMF) are now available as MasterSeries on every Ingenia 30T at software level 413 and above ldquoThe MasterSeries allows users to have a choice in how they want to run their scanners and saves them up to hundreds of hours of imaging time to work it all outrdquo says Dr Goumas ldquoInstead of having to reinvent the wheel somebody has already gone through that process and discovered the current capability of the system It maximizes their efficiency because they can just select an ExamCard on their own scanner and go and they can produce the high resolution images on their own systemrdquo

FieldStrength 33

34Application tips

Contributed by Marius van Meel and Vijayasarathy ElanchezhianMR Clinical Marketing Managers Best The Netherlands

Take advantage of mDIXON TSE in MSK imaging without time penaltymDIXON provides excellent fat suppression and can save time by providing images with and without fat suppression in one scan

Philips mDIXON provides images with and without fat suppression in a time efficient manner The patented 2-echo implementation versus conventional 3-point techniques is key to delivering superb fat suppression at routine scan times

The fast and robust fat suppression provided by mDIXON TSE makes the method well suited for enhancing routine musculoskeletal (MSK) MR imaging These tips are intended to help you implement mDIXON TSE in your MSK protocols and ExamCards

Choose a good starting point Use a fat suppressed protocol as starting point Choose a protocol in which SNR resolution and scan time are already well balanced for your purpose

Contrast adjustments

Switch on mDIXON Adjust NSA to balance scan time and SNR

mDIXON TSE is compatible with all common profile orders however protocol optimization is easiest with an asymmetric profile order as it gives full control over TE TR BW and echo spacing

On the Contrast tab set lsquoprofile orderrsquo to asymmetric TE and TR may be adjusted according to your preference Use a TR range for convenience The table provides some recommended settings

On the Contrast tabSet lsquoFat suppressionrsquo to No to switch off SPIR or SPAIRSet lsquomDIXONrsquo to yesIf volume shim is present set to Auto to reduce workflow stepsSet lsquoWFSrsquo to user defined select 13 (pixels)

Scan time first increases by switching on mDIXON Scan time reduces again by changing NSA

Scan time

mDIXON uses 2 echoes (2-point mDIXON) to calculate the in-phase (IP) and water (W) images This effectively doubles scan time but also increases the signal-to-noise ratio similar to doubling NSA which doubles scan time and increases SNR by 41 (factor radic2)

After switching to mDIXON the easiest way to revert to the original scan time is by reducing NSA on the Motion tab to use less averages If a scan has only 1 NSA use SENSE to reduce scan time

TIP 3 TIP 4

T1-weighted scans PD-weighted scans T2-weighted scansTE 15 ms 30 ms 60-80 msTE spacing user defined 10-11 ms user defined 10-11 ms user defined 10-11 msTSE factor 3 or 5 12 or 13 20TR range 450-650 ms 2500-5000 ms 3000-6000 ms

CONTINUE

FieldStrength 35

Application tips

Adjusting to partial fat suppressionSpecifically in MSK imaging some radiologists prefer a partial fat suppression This is easy to obtain with mDIXON

To achieve this also the fat (F) images need to be reconstructed On the Postproc tab expand the parameter lsquomDIXON imagesrsquo and add the fat image

When the mDIXON scan is finishedbull Load the scan into the lsquoImage Algebrarsquo

post processing package

bull Choose Addition (A+B)

bull In viewport A (lower left) scroll to the fat (F) image using the left and right arrow keys

bull Viewport B (lower right) should contain the water (W) image

bull Use the ratio slider to adjust the amount of fat added In general a ratio of 005 to 010 is advised for MSK The upper right viewport displays a preview helping the user to fine-tune the level of fat suppression interactively

bull Create the series by clicking the lsquoGeneratersquo button

bull After performing this once this postprocessing step will be saved in the ExamCard as a SmartLine step It can be copied to other mDIXON scans

Viewport A fat image (F) Viewport B water image (W)

Ideas to simplify your ExamCards with mDIXON TSEThis example is based on Ingenia 15T MasterSeries ExamCards 2-point mDIXON TSE allows you to explore new scan strategies One mDIXON sequence can replace both the fat saturated and non-fat saturated scans in an ExamCard Depending on the setup of an ExamCard this can save a considerable amount of scan time

mDIXON TSE may also allow reduction of the number of ExamCards needed in a sitersquos collection For example optional scans with fat saturation can be integrated into the routine ExamCard Ultimately every TSE scan in an ExamCard could be replaced by the 2-point mDIXON TSE technique to deliver two image weightings in one acquisition

ExamCards without mDIXON TSE

mDIXON TSE can help to simplify an ExamCard by replacing two ore more separate sequences This can reduce redundancy and support standardization

Why not take advantage of mDIXON for each TSE scan to double the information in the same scan

Visit the online Philips NetForum community for more application tips

FieldStrength 37

38Application tips

CSF flow compensation in spineIn TSE imaging of the spine CSF flow may cause flow voids These may be most notable in axial imaging of the cervical spine where CSF flow velocity can be quite high and the imaging plane is perpendicular to the flow direction Flow voids are visible as dark areas The signal loss occurs because moving spins may not experience both the full excitation pulse and the refocusing pulse and thus have a slightly different phase than immobile spins in the slice

The tips below apply to Ingenia 30T and 15T release 413 SP1 as well as Ingenia and Achieva systems at release 5

Reducing flow voids

Flow void reduction is more relevant at 30T than at 15Tbull In general sensitivity to flow voids may be decreased by increasing

slice thickness and shortening TE However in cervical spine a small slice thickness is usually desired

bull Increasing the number of packages can also help but this will usually increase scan time

At 30T acquire the T2W TSE sequence in multiple packages for instance 6 packages for cervical spine A lower number of packages may be used for the thoracic spine (4 packages) and the lumbar spine (2 packages) For 15T using 4 packages for cervical spine is recommended to maintain a reasonable scan time

bull Set scan direction to interleavedbull Switch on flow compensation in the slice direction

(through-plane)

Contributed by Mark Pijnenburg and Marco Nijenhuis MR clinical application specialists Best The Netherlands

Through-plane flow compensation

Through-plane flow compensation is another way to address flow voids This flow compensation in slice direction maintains the phase of the signal for spins moving with constant velocity Signal losses (flow voids) due to CSF flow will therefore be reduced

In general flow voids are more pronounced at higher field strengths So particularly 30T users may want to switch on through-plane flow compensation in their 2D multislice TSE scans

Combining it with a multiple package approach is recommended for robust flow artifact reduction on transversal T2-weighted spine images

To enable through-plane (slice direction) flow compensation go to the Motion tab and set Flow compensation to yes That offers the option to select in-plane or through-plane flow compensation

Through-plane flow compensation in spine Through-plane flow compensation can help to reduce flow voids in transverse T2W TSE sequences in the spine Example for cervical spine on Ingenia 30T

ReferencesC Lisanti C Carlin KP Banks D Wang Normal MRI Appearance and Motion-Related Phenomena of CSF AJR 2007 188716ndash725 or httpwwwajronlineorgdoifull102214AJR050003

AT Vertinksy MV Krasnokutsky M Augustin R BammerCutting Edge Imaging of the SpineNeuroimaging Clin N Am 2007 February 17(1) 117ndash136

Without flow compensation 2 packages With through-plane flow compensation 6 packages

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40Educational

Vascular permeability analysis based on MR dataMR Permeability package on the IntelliSpace Portal calculates permeability based on MR data

Vascular permeability depends on tissue and its conditionFast cell growth requires extra blood and nutrient supply and is often characterized by angiogenesis (growth of extra blood vessels from existing vessels) Angiogenesis is a process that occurs in tissue growth and repair

Angiogenesis is often accompanied by increased vascular permeability Vascular permeability is the ability of a blood vessel wall to allow molecules to pass through Permeability depends on tissue type and organ

In a healthy brain the blood brain barrier (BBB) effectively separates circulating blood from the extracellular fluid in the central nervous system This means that the vessel wall restricts diffusion of larger objects like bacteria and certain molecules into the brain Only small molecules like O2 hormones and CO2 can pass into the tissue Therefore the measured permeability in a healthy brain is very low close to zero

The vessels in other organs for instance the prostate are much more permeable with values larger than zero

Acquisition and processing of MR data for calculating permeability Based on MR data the MR Permeability tool on IntelliSpace Portal can be used to determine the leakage of contrast agent (gadolinium chelates) into the extra-vascular extracellular space (EES) The most important use is currently in prostate and brain

The MR scanning starts with two separate 3D T1-weighted scans with different flip angles to determine the T1 relaxation time of the tissue Then Dynamic Contrast Enhanced (DCE) imaging is performed with high spatial and high temporal resolution [1]

The Permeability analysis tool will automatically combine the 3D T1-weighted and DCE series to immediately provide permeability results An important choice for the calculation is the Arterial Input Function (AIF) used to fit all results to the Tofts model [1] The MR Permeability package provides two ways to define the AIF based on the injection protocol or based on actual DCE data

The MR Permeability tool calculates permeability maps but it also conveniently provides color maps that combine the quantitative results with the source data and with anatomical data ndash typically T2-weighted and diffusion images ndash always geometrically aligned with the original DCE acquisition

Permeability parametersBased on the Tofts model [1] the MR Permeability tool provides maps of the kinetic parameters Ktrans and Kep

Ktrans describes the transfer of the diffusible tracer (contrast agent) into the EES This transfer will depend largely on the permeability and also on the flow of the blood plasma that carries the contrast agent

Kep describes the efflux of the same tracer from the EES back to the blood plasma This efflux rate depends on permeability but also on the EES volume compared to the blood plasma volume a tissue with a small percentage of EES will have a relatively large vessel wall area to enable the efflux

Schematic representation of physiology related to flow and permeability in blood vessels Depending on the tissue characteristics some of the contrast agent leaks into the extravascular extracellular space (EES) The MR contrast agent does not enter the cells but will wash in and out of the EES

Permeability analysis in brainIn brain imaging permeability analysis may be an important addition to anatomical imaging to detect areas with changes in permeability

ldquoThis technique uses T1-weighted acquisition which does not suffer from susceptibility artifacts ndash as experienced with EPI-based sequences like T2 perfusion ndash which can make proper diagnosis of eg the frontobasal region very challenging This can be of considerable importance especially in post-surgery patients where the absence of distortions due to suture material andor blood deposits allows a cleaner read and analysis of the imagesrdquo

ldquoDifferentiation of therapy-related tissue changes is often challenging Values like Ktrans and Kep by themselves do not provide an absolute truth but they can help in monitoring of therapy effectiveness especially when used in a multimodal approachrdquo

Dr S van Cauter University Hospitals Leuven Belgium

An 18-year-old female underwent surgical resection in the frontobasal region and combined radiochemotherapy Three months post-radiotherapy MRI shows enhancement DCE-perfusion shows regions with lower forms of leakage (orange ROI and curve) indicative of therapy-related changes Six weeks later MRI also shows a further reduced enhancement in these regionsCourtesy Leuven University Hospitals Belgium

This article is based on the white paper Extra window in oncology with vascular permeability analysis by S van Cauter MD PhD (University Hospitals Leuven) O Rouviegravere MD PhD (Edouard Herriot Hospital Lyon) U van der Heide MD SWTPJ Heijmink MD (The Netherlands Cancer Institute ndash Antoni van Leeuwenhoek Hospital Amsterdam) FGC Hoogenraad PhD (Philips Healthcare)

References1 PS Tofts et al Estimating Kinetic Parameters from dynamic contrast-enhanced T1-weighted MRI of a diffusible tracer standardized quantities and symbolsJMRI 10 223-232 (1999)

2 Sciarra A et al Advances in magnetic resonance imaging how they are changing the management of prostate cancerEur Urol 59 962-77 (2011)

3 Barentsz JO et al ESUR prostate MR guidelines 2012Eur Radiol 22 746-57 (2012)

4 Girouin N et al Prostate dynamic contrast-enhanced MRI with simple visual diagnostic criteria is it reasonableEur Radiol 17 1498-509 (2007)

ldquoThe MR Permeability analysis from Philips is an easy tool for quantification of permeability and will allow independent groups to characterize prostate lesions and hopefully improve diagnostics and patient managementrdquo

Dr O Rouviegravere Edouard Herriot Hospital Lyon France

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42Educational

Fast susceptibility weighted imaging with premium image quality The new SWIp method for susceptibility weighted imaging provides exquisite contrast and resolution in short scan times

The gain in SNR is demonstrated to be 55 to 110 depending on the T2 of the tissue

Susceptibility weighted imaging (SWI) enhances the contrast between tissues with susceptibility differences for instance the contrast between deoxygenated blood or some mineral deposits (eg calcium deposits) and surrounding tissue Due to this contrast enhancement SWIp images are sensitive for structures containing venous blood When used in combination with other clinical information SWIp may help radiologists in the diagnosis of various neurological pathologies

Typical SWI methods Image contrast in susceptibility weighted imaging is based on differences in tissue susceptibility The susceptibility of a tissue is the degree of magnetization it gets in a magnetic field which influences T2 and the phase

The long available T2FFE technique is fast with well established contrast A high resolution 3D T2FFE method with long TE already shows some contrast in veins Conventional SWI uses phase information which enhances the contrast in veins but this typically takes a long scan time

0 50 100 150T2

X 67Y 2107

T2 FFE 2-3 min 3D T2 FFE long TE Typical SWI 5 min

Single echo SWI SWIp Typical susceptibility weighted imaging has relatively long scan times which limits feasibility for routine use Philips therefore developed the SWIp technique It is based on a high resolution 3D whole brain acquisition It uses phase information to get enhanced susceptibility contrast in combination with a 4-echo FFE acquisition to increase SNR compared to single echo techniques A short scan time while maintaining high SNR may then be obtained leveraging dS SENSE

Comparing multi-echo SWIp to single-echo SWI shows the gain in SNR

SWIp combines premium image quality with fast and robust scanning

The SWIp technique provides exquisite images with high sensitivity to venous blood products SWIp can be acquired with high resolution and quite short scan time

10 x 10 x 10 mm 617 min

06 x 06 x 10 mm 430 min

Venous blood

Calcification

06 x 06 x 10 mm 432 min

06 x 06 x 10 mm dS SENSE 45 230 min

Adding dS SENSE factor 45 to SWIp with high resolution (voxels 06 x 06 x 10 mm) reduces scan time from 430 min to only 230 min while maintaining excellent image quality Ingenia 30T with 32-channel dS Head coil

SWIp may help provide arterial and venous information based on signal intensity differences

Phase maps may be used for advanced diagnosis On phase images venous blood typically shows as hypointense signal whereas as calcification typically shows as bright signal

Courtesy of University of Michigan USA

VenBOLD SWIp

SWIpSWIp

SWIp SWIp phase

SWIp phase

Artery

FieldStrength 43

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FieldStrength 49