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  • 1. MAGNETOM Flash The Magazine of MR Issue Number 3/2010 RSNA EditionClinicalTumor staging in caseof Wilms tumorPage 6syngo SWI case reportsPage 18NeurographyPage 26Spine and tumorimaging at 3TPage 48How I do itWhole spine imagingPage 30Liver imaging withdynaVIBEPage 66
  • 2. Editorial Matthias Lichy, M.D. Dear MAGNETOM user, Each new technology, evolution or revolution A few years ago this was simply not possible to existing ones, changes the way how we because of limitations in coil and MR deliver healthcare to our patients. Good sequence technology. examples how MRI in combination with latest Taking into account the life cycle of a typical advantages in coil technology and image MR scanner and the fast progress of MR tech- sequences can deliver all required clinical nology and its clinical applications, Siemens information at highest quality and replace MR is committed to offering access to the and / or complement existing imaging in a latest developments e.g. by system upgrades. meaningful way can be found in this issue of You will therefore find in this issue informa- MAGNETOM Flash. tion on liver imaging with software version The impact of higher field-strength and open- syngo MR B17 or an article on how to use the bore technology can be seen in the articles Tim Planning Suite for performing whole- by Weber et al. (Heidelberg University) deal- spine examinations on your system. ing with complex pathologies of the spine and with young patients, exemplary cases MAGNETOM Flash and additional, clinically show how the latest 3T MR technology adds relevant information is available online at important clinical information and how this also increases the confidence in treatment decision of the referring physicians. Enjoy reading this issue of MAGNETOM Flash! Another good example can be found in the case report by Schneider et al. (Homburg University): whole-body imaging for tumor staging in pediatrics with diffusion-weighted imaging is now reality in clinical routine. Matthias Lichy, M.D.2 MAGNETOM Flash · 3/2010 ·
  • 3. EditorialThe Editorial TeamWe appreciate your comments.Please contact us at Hellwich Okan Ekinci, M.D. Peter Kreisler, Ph.D. Heike Weh,Associate Editor Center of Clinical Competence – Collaborations & Applications, Clinical Data Manager, Cardiology, Erlangen, Germany Erlangen, Germany Erlangen, GermanyBernhard Baden, Ignacio Vallines, Ph.D., Wellesley Were Milind Dhamankar, M.D.Clinical Data Manager, Applications Manager, MR Business Development Sr. Director, MR ProductErlangen, Germany Erlangen, Germany Manager Marketing, Malvern, USA Australia and New ZealandMichelle Kessler, US Gary R. McNeal, MS (BME) Dr. Sunil Kumar S.L.Installed Base Manager, Advanced Application Specialist, Senior Manager Applications,Malvern, PA, USA Cardiovascular MR Imaging Canada Hoffman Estates, USA MAGNETOM Flash · 3/2010 · 3
  • 4. Content Content Content 6 Tumor Staging 18 syngo SWI Case Reports 30 30 xxxxxSAR in pTx Spine Imaging Full 48 MSK Imaging at 3TFurther clinical information Clinical Clinical Technology Product News Visit the MAGNETOM Pediatric Imaging Orthopedic Imaging 60 Image Quality Improvement 76 VIBE for Liver Imaging of Composed MR Images by with syngo MR B17 World Internet pages at 6 MR Tumor Staging for Treatment 26 3T MR Imaging of Peripheral Applying a Modified Homomor- Agus Priatna, Decision in case of Wilms Tumor Nerves Using 3D Diffusion- phic Filter Stephan Kannengiesser magnetom-world G. Schneider, P. Fries Weighted PSIF Technique for further clinical Vladimir Jellus, et al. 12 Cerebral Arterio-Venous Malforma- Avneesh Chhabra, et al. information and talks tion detected by syngo TWIST MRA 30 How I do it: Full Spine Imaging by international experts. Ali Yusuf Oner, et al. utilizing the Tim User Interface Clinical James Hancock Abdomen / Pelvis Clinical 38 How I do it: Knee Imaging with 66 Value of Automated Retrospective Neurology 4-Channel Flex Coils. The Influence of Patient Positioning and Coil Correction of Contrast-Enhanced Dynamic Liver MRI. Initial Clinical 14 Case Report: Imaging of Cerebral Selection on Image Quality Experience Amyloid Angiopathy (CAA) using Birgit Hasselberg, Marion Hellinger H.-P. Schlemmer, et al. Susceptibility-Weighted Imaging 43 Case Report: Knee MR Imaging 71 How I do it: Non Rigid 3D-Regis- (syngo SWI) of Haemarthrosis in a Case of tration for Accurate Subtraction Markus Lentschig Haemophilia A of Dynamic Liver Images for 18 Case Report: Susceptibility-Weighted M. A. Weber; J. K. Kloth Improved Visualization of Liver Imaging (syngo SWI) at 3T Lesions with syngo dynaVIBE Kate Negus, Peter Brotchie 48 Advantages of MSK Imaging Matthias P. Lichy, et al. at 3 Tesla with special focus on Spine and Tumor Imaging Marc-André Weber The information presented in MAGNETOM Flash is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating the MR System. The source for the technical data is the corresponding data sheets.4 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 5
  • 5. Clinical Pediatric Imaging Pediatric Imaging ClinicalMR Tumor Staging for 1A 1BTreatment Decision in Caseof Wilms TumorG. Schneider, M.D., Ph.D.; P. Fries, M.D.Dept. of Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg/Saar, Germany 1C 1DIntroduction Patient historyNephroblastoma – also known as Wilmstumor – is the most frequent renal Europe or COG (Children’s Oncology Group) in North America. Therapy A 4-year-old girl presented with a large palpable mass in the left upper quadrant *malignancy in childhood with the high- includes primary surgery (COG), pre- and unspecific abdominal pain. Ultra-est incidence of this tumor within thefourth year of life. 80% of patients are operative chemotherapy (SIOP), and/or adjuvant chemotherapy. If not treated, sound had already revealed a large tumor of the left hemiabdomen with +less than 5 years old, however it is a rare prognosis of a Wilms tumor is poor. mass effect towards the liver. Thecondition in neonates (<1%). Independent of prognostic factors such patient was referred to our MRI depart-In general, there are no known risk fac- as stage and grading, the overall out- ment because of suspicion of Wilmstors for the development of nephroblas- come is good and approximately 90% of tumor.toma, but it may be associated with rare all children will be cured.conditions like Denys-Drash (triad of Questions for imaging are: a) supporting MRI protocolcongenital nephropathy, Wilms tumor the suspicion of a Wilms tumor for initia- MRI was conducted using a 1.5 Teslaand intersex disorders), WAGR (also tion of therapy, b) evaluation of tumor MAGNETOM Aera with the combination 1E 1 Transversal high-resolution T2w images showing thecalled Wilms tumor-aniridia syndrome) volume, c) contralateral tumor manifes- of the 18-channel body coil and the inte- Wilms tumor (*) and multiple lung metastases (arrows).and Beckwidth-Wiedeman (giantism tation and d) lymph nodes metastasis grated spine coil. For the MRI procedure Due to the space occupying aspect of the large tumor, theassociated with tumors and malforma- or infiltration of neighboring structures the patient received an intravenous residual kidney is swollen (+) and also slight edema of thetions) syndrome. The incidence isapprox. 1: 100,000 for western coun- e.g. diaphragm or liver. Tumor staging has to include at least the sedation using propofol. The imaging protocol included diffusion-weighted * liver hilum can be seen (arrowheads).tries including the US, while a lower whole abdomen and thorax (lung filiae imaging (DWI, syngo REVEAL), acquiredincidence is reported for Asian countries. are the most common presentation of during free breathing, and transversalIf not associated with a syndrome, clini- metastatic disease). Imaging modalities T2w TSE and HASTE sequences withcal symptoms – if present at all – are used are ultrasound, MRI, and CT in case navigator triggering.very often unspecific and abdominal of lung metastases. Depending on final A single-shot echo planar diffusionpain and palpable tumor can be the only tumor histology, a bone (often scinti- imaging with Stejskal-Tanner diffusionfindings at the time of diagnosis. gram) and brain MRI scan have to be encoding scheme was applied. ForMRI is considered the imaging modality performed in case of CCSK (clear cell sar- fat saturation, an inversion recoveryof choice for tumor staging and subse- coma) and RTK (rhabdoid tumor of the technique was used. The sequencequent treatment planning. If imaging is kidney), too. MRI is recommended inde- parameters were:conclusive, often no biopsy is performed pendent of the above-mentioned reasonsprior to initiation of therapy. Clinical in any case where a) a caval vein tumortreatment is according to protocols of thrombus, b) infiltration of liver and dia-SIOP (Society of Pediatric Oncology) in phragm, or c) continuous tumor exten- sion into the thoraxic cavity is suspected. Continued on page 106 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 7
  • 6. Clinical Pediatric Imaging Pediatric Imaging Clinical2 5A 5B 2 Rotating MIP based on high b-value images. 5C 5D3A 3B 3C 3D 3E 3F 3G 5E 5F 3 (A) Coronal DWI MIP. Original b-value images at 0 and 800 s/mm2 (B, C and E, F) as well as calculated b-value at b 1400 s/mm2 (D, G) are shown. (Arrows pointing to lung metastases.)4A 4B * * * 5 Based on ADC maps and high b-value images (b 1400 s/mm2 is shown), a clear differentiation between residual but swollen kidney 4 Calculated ADC map (A) and corresponding T2w image (B) demonstrating the tumor heterogeneity. The area marked by the arrows has a clear tissue (arrows) and the Wilms tumor (arrowhead) is possible. Both types of tissue differ in their cellular density, however, on T2w images restriction in diffusibility but based on T2w imaging alone, no differentiation between this area and the one marked with * is possible. While the no clear differentiation is possible in this case (compare Fig. 1). Nevertheless, not all areas of the tumor are characterized by high signal high signal area on T2w and high ADC values may represent cysts or calceal dilation, the area with the high restriction of diffusion represents a on the very high b-value images, demonstrating well the tumor heterogeneity. (A, B) ADC maps. (C, D, E) b 1400 s/mm2 images. (F) Coro- very densely packed areal e.g. mucous tumor cells. nal thick-slice MPR based on b 1400 s/mm2 images (* spleen).8 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 9
  • 7. Clinical Pediatric Imaging Pediatric Imaging Clinical6A 6B 7A 7B 7 Follow-up examination with CT (A) still showing a small residual lung metastasis (arrow), which can also be visualized by MRI (B). The main tumor is also clearly reduced in its mass after first cycle of chemotherapy (C–F) in caudo- cranial sorting. 7C 7D 6 Corresponding images of the initial ultrasound examination of the Wilms tumor in sagittal (A) and transversal (B) orientation are shown.Continued from page 6 Imaging findingsTR 15400 ms, TE 75 ms, TI 180 ms, PAT A large occupying tumor deriving from displaced spleen is also within normalfactor of 2, 3-scan trace (averaged), FOV the lower pole of the left kidney with age-related range.309 x 380, matrix 208 x 128 (interpo- compression of the residual kidney and On a follow-up study after chemotherapylated to 208 x 256), slice thickness 5 mm, mass effect towards the liver and espe- and before surgery a tremendous reduc- 7E 7Fno gap, 4 averages. Real voxel size was cially the left liver lobe is shown. Due to tion of tumor size can be noticed. Only1.5 x 3 x 5 mm3. Two b-values at b 0 and the mass effect, slight edema of the liver small residual tumor tissue of one lungb 800 s/mm2 were acquired. ADC maps hilus can be seen. However, the border metastases is visible on CT and MRI.and additional high b-value images at of the mass is well circumscribed and nob 1400 s/mm2 were calculated auto- evidence of diffuse tumor infiltration of Conclusionmatically by the scanner software, based the liver, spleen or diaphragm can be Whole-body imaging in staging of Wilmson linear signal decay. DWI covered the seen. Since no encasement of retroperi- tumor can replace CT imaging and giveswhole body trunk from skull base toneal vessels or other structures is seen all necessary information for therapytowards upper lower extremities. Acqui- DD of neuroblastoma can be ruled out. planning. With the help of newer imag-sition time was approx. 15 min. For pre- Also the lumen of the abdominal aorta is ing modalities in MRI, especially DWI,sentation and fast overview about tumor regular and neither a tumor infiltration the prediction of tumor response needsspread, a rotating maximum intensity of the large vessels nor a tumor-throm- to be evaluated. This can easily be doneprojection (MIP) based on b 800 s/mm2 bus can be visualized. The right kidney by correlating histological data withwas generated. and the other abdominal organs are free imaging data from patients enrolled inFor detailed morphology and assess- of metastases. However, already well prospective clinical trials. As preopera-ment of tumor infiltration, navigator visualized by the MIP DWI, a large tumor tive chemotherapy is only part of thetriggered T2w TSE was applied for the mass at the right lung hilum can be seen SIOP studies such investigations can pre- References Contact 1 Kaste, S.C., Dome, J.S., Babyn, P.S., Graf, N.M.,abdomen including the lower thorax and with compression of central lung struc- dominantly be performed in Europe. PD Dr. Dr. Günther Schneider Grundy, P., Godzinski, J., Levitt, G.A., Jenkinson,mediastinum. Sequence parameters were tures and edema of the depending lung H. 2008 Wilms tumour: Prognostic factors, stag- Dept. of Diagnostic and InterventionalTR 3508 ms, TE 102 ms, 2 averages. tissue. In addition, at least four addi- Radiology ing, therapy and late effects Pediatric Radiology Saarland University HospitalPAT factor 2, FOV 188 x 250 mm2, matrix tional lung metastases are detected. 38 (1), pp. 2-17. Kirrberger Strasse269 x 512, slice thickness 6 mm, 20% No evidence for bone metastases. The 2 Graf, N., Tournade, M.-F., De Kraker, J. 2000 The 66421 Homburg/Saar role of preoperative chemotherapy in the manage-gap, acquisition time was approx. 8 min. bright signal of the bone marrow on Germany ment of Wilms’ tumor: The SIOP studies. Urologic high b-value images has to be con- Clinics of North America 27 (3), pp. 443-454. sidered as age related. The size of the10 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 11
  • 8. Clinical Pediatric Imaging Pediatric Imaging ClinicalCerebral Arterio-Venous 1A 1BMalformation detectedby syngo TWIST MRAAli Yusuf Oner; Turgut Tali; Nil TokgozGazi University, School of Medicine, Department of Radiology, Ankara, TurkeyPatient history Sequence details ConclusionA 17-year-old patient suffering from All images were acquired using a 3T Anomalies of neuronal migration anduntractable epilepsy was referred to our MAGNETOM Verio with software version vascular malformations are two impor-institution for imaging evaluation. He syngo MR B17 and the standard head tant and relatively frequent causes of 1 T2-weighted image in the axial plane (A) and inverted STIR image (B) in the coronal plane show right parietal polymicrogyric cortex (arrows)underwent an initial brain MRI on a 3T matrix coil. epilepsy. However their coexistence, as with indistinct gray-white matter interface. Note the small vascular flow voids, raising suspicion of a possible accompanying AVM arrowhead.MAGNETOM Verio, which showed a right in the presented case, is less usual.parietal polymicrogyric focus with a Axial TSE T2W: TR 4000 ms, TE 107 ms, Although their diagnosis is straightsuspected neighboring arterio-venous FOV 220 x 220 mm2, matrix 410 x 512, forward by MRI and TOF MRA, 4D MRA 2 3malformation (AVM) not readily depicted 2 averages, iPAT factor of 2, slice thick- techniques following contrast injectionby time-of-flight (TOF) MR angiography ness 5 mm, gap 1.5 mm. such as syngo TWIST can be the(MRA). A second contrast enhanced problem-solving tool in cases with lowsyngo TWIST MRA succesfully showed Coronal T2W TIRM: TR 9000 ms, flow AVM’s.the AVM nidus and the patient was TE 94 ms, FOV 200 x 220 mm2, matrixreferred for stereotactic radiosurgery. 232 x 256, 1 average, iPAT factor of 2, slice thickness 5 mm, gap 2 mm.Imaging findingsT2-weighted turbo spin-echo (TSE) 3D TOF MRA: TR 21 ms, TE 3.60 ms,images in the axial plane and coronal FOV 181 x 200 mm2, matrix 331 x 384, ContactTIRM images show right pariteal shallow 1 average, iPAT factor of 2. Ali Yusuf Oner, M.D.sulci, with indistinct gray-white matter Gazi Universityinterface, lined by polymicrogyric cortex syngo TWIST MRA: TR 2.79 ms, School of Medicine(Fig. 1). On the T2-weighted images TE 1.01 ms, FOV 350 x 400 mm2, matrix Department of Radiology 2 Coronal maximum intensity projection (MIP) of a 3D 3 Highly temporal resolved post-contrast 4D MRA in the coronal Ankarasmall vascular flow voids are noted. The 245 x 384, iPAT factor of 2, slice thick- TOF MRA fails to demonstrate the AVM nidus. plane shows a low-flow AVM mostly fed by the anterior arterial TurkeyAVM nidus goes undetected on a 3D TOF ness 2.5 mm, 25 measurments with a system, with a central drainage (arrows). Phone: +90 312 202 5163MRA due to its low flow status (Fig. 2), temporal resolution of 1.09 seconds per a post-contrast syngo TWIST single slab.MRA readily shows the AVM nidus fedby the anterior system, together withthe early central draining veins (Fig. 3).12 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 13
  • 9. Clinical Neurology Neurology ClinicalCase Report:Cerebral Amyloid Angiopathy (CAA) 1A 1Busing Susceptibility-Weighted Imaging(syngo SWI)Markus LentschigMR, Nuclear Medicine and PET/CT Center Bremen Mitte, Bremen, GermanyBackgroundWith the development of a 3D gradient- technique is available which enables magnitude images and the finally post-echo (GRE) based susceptibility- either the direct visualization or quanti- processed SWI are available for imageweighted imaging sequence (syngo fication of the amyloid deposits. But as analysis. Also, a thick-slice MPR (multi-SWI), a neuroimaging MR technique is an indirect sign, typically microhemor- planar reconstruction) which is gener- 1 DarkFluid (FLAIR) images of a patient with cerebral amyloid available in clinical routine which rhages within and around the arteriole ated Inline is available.maximizes tissue magnetic susceptibility vessel wall lobar microbleeds are found DarkFluid (FLAIR): TR 9000 ms, TE 94and makes use of these differences to and related to CAA. Usually CAA is ms, FOV 230 / 84 %, Matrix 256 / 95 %generate a unique contrast, different involving the cortex and subcortical (interpolated to 512), SL 5 mm, TA 2:26 2A 2Bfrom that of proton density, T1, T2, and white matter within the frontal and pari- min:s, voxel size 1.0 x 0.9 x 5 mmconventional T2* imaging we are used etal lobes. In contrast, hypertensive orso far in clinical routine. Compared to atherosclerotic microangiopathy shows Imaging findingsother imaging techniques syngo SWI – a microhemorrhages in a deep or infraten- Multiple T2w hyperintense isolated focilong TE flow compensated gradient echo torial location. in the periventricular white matter areimaging providing enhanced contrast shown on DarkFluid (FLAIR) imageswith the combination of phase and mag- Sequence details (arrows figure 1A). In addition, dorsal ofnitude information – has already pro- A 68-year-old patient with suspicion of the posterior horn and lateral ventriclevided superior results in clinical studies TIA (transient ischemic attack) has been converging hyperintense periventricularin detecting intracranial bleeding but referred to our institution for imaging T2w hyperintense areas are shown,also in depicting minute intracranial vas- and to rule out further diseases of the which can be interpreted as age-relatedcular malformations. brain. All images were acquired at 3 Tesla periventricular gliosis (arrowheads fig- using a MAGNETOM Verio with the stan- ure 1). However, also in the temporalCerebral Amyloid Angiopathy dard 12-channel head coil. Sequence lobe cortical and subcortical T2 hyperin-Cerebral amyloid angiopathy (CAA) is a parameters for shown images were: tense spots with only slightly increasedsmall vessel disease which is character- T1 SE: TR 500 ms, TE 8.4 ms, FOV 230, signal can be visualized by DarkFluidized by deposition of amyloid protein matrix 256 / 95 % (interpolated to 512), (FLAIR) imaging (arrows figure 1B). Inwithin the cerebral arterioles. It is known SL 5 mm, TA 1:53 min:s, voxel size 1.0 x addition, there is a widening of thethat there is a clear association of CAA 0.9 x 5 mm internal and external cerebral fluid inter-with the following aging, dementia, syngo SWI: TR 27 ms, TE 20 ms, FOV spaces. On native T1w MRI, no hyperin-Alzheimer’s disease, postradiation 230 / 75 %, Matrix 256 / 95 % (interpo- tense signal can be demonstrated; only 2 Corresponding native T1-weighted images.necrosis, and spongiform encephalo- lated to 512), SL 2.5 mm, TA 2:48 min:s, in the case of the largest periventricularpathies. But so far, no in vivo imaging voxel size 0.9 x 0.9 x 2,5 mm. Phase and white-matter foci, a corresponding14 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 15
  • 10. Clinical Neurology3A 3B Try them on your system Trial licenses for most of the applications featured in this 4 issue of MAGNETOM Flash are available free of charge for a period of 90 days: Please contact your local Siemens repre- sentative for system requirements and ordering details or visit us online* at for further details, product overviews, image galleries, step-by-step videos, case studies and general requirement information. 1 3 syngo SWI showing multiple cortical and subcortical bleedings.hypointense lesion can be found. How- tive to iron accumulation in the brain; 4 Schrag M, McAuley G, Pomakian J, Jiffry A, Tung 1 syngo TWIST (page 13). S, Mueller C, Vinters HV, Haacke EM, Holshouserever, SWI looked completely different: this is observed in ageing process, B, Kido D, Kirsch WM. Correlation of hypointensi-multiple smallest cortical and subcorti- reflection of brain damage, diseases of 2 ties in susceptibility-weighted images to tissuecal bleedings were visualized in the tem- iron metabolism and haemorrhages. histology in dementia patients with cerebral amy-poral, parietal and less prominent in the Iron involvement is already accepted in loid angiopathy: a postmortem MRI study. Actafrontal lobe (figure 3). Hallervorden-Spatz disease, neuroferri- Neuropathol. 2009 Nov 25. [Epub ahead of print]In conclusion the findings in our patient tinopathy, aceruloplasminemia, Fried-are a mixture of unspecific vascular / age reich’s Ataxia. However, larger studiesrelated findings (periventricular gliosis, are still needed to determine the role of Contactreduced brain volume, microinfarcts) SWI in iron measuring especially in neu- Markus G. Lentschig, M.D.and CAA. However, extent and severity rodegenerative diseases (Alzheimer’s MR and PET/CT Imaging Center Bremen Mitteof CAA is only visualized by syngo SWI in disease, Parkinson, ALS, and in Multiple Sankt-Jürgen-Str. 1detail and would have been clearly Sclerosis). 28177 Bremenunderestimated based on conventional GermanyMRI only. ReferencesConclusion 1 Haacke EM, Mittal S, Wu Z, Neelavalli J, Chengsyngo SWI has shown in this case to be a YC.Susceptibility-weighted imaging: technical aspects and clinical applications, part 1. AJNR Amsensitive tool for precise assessment of 2 syngo SWI, susceptibility-weighted imaging (page 23). 4 syngo Composing (page 63). J Neuroradiol. 2009 Jan;30(1):19-30. Epub 2008CAA. In general, SWI can provide useful Nov 27. Review.additional information in the evaluation 2 Mittal S, Wu Z, Neelavalli J, Haacke EM. Suscepti- 3of various pediatric and adult neurologic bility-weighted imaging: technical aspects andconditions and can be incorporated eas- clinical applications, part 2. AJNR Am J Neuroradi- ol. 2009 Feb;30(2):232-52. Epub 2009 Jan 8.ily into the routine imaging assessment. Review.It is known that SWI is more sensitive in 3 Haacke EM, DelProposto ZS, Chaturvedi S, Sehgaldetection of small bleedings and small V, Tenzer M, Neelavalli J, Kido D. Imaging cerebralvascular malformations than conven- amyloid angiopathy with susceptibility-weighted *Direct link for US customers:tional T2* imaging and that it is an imaging. AJNR Am J Neuroradiol. 2007 Feb;28(2):316-7. technique which is highly sensi- Direct link for UK customers: MAGNETOM Flash · 3/2010 · 3 Tim Planning Suite (page 33). MAGNETOM Flash · 3/2010 · 17
  • 11. Clinical Neurology Neurology ClinicalCase Reports: 1A 1BSusceptibility-WeightedImaging (syngo SWI) at 3TKate Negus; Peter Brotchie, MBBS, Ph.D.Barwon Medical Imaging, The Geelong Hospital, Geelong, Victoria, AustraliaIntroductionThis is a pictorial review of susceptibil- The phase images can be windowed to The resolution is high enough to diag- 1C 1Dity-weighted imaging (syngo SWI) using see contrast between iron deposition nose clinically relevant lesions and thea MAGNETOM Trio system with software and normal tissue and also to visualize sequence short enough to include in allversion syngo MR B15 and a 32-channel gyral pattern to anatomically orientate protocols that would benefit from thishead coil at The Geelong Hospital, lesions more accurately. The SWI sliding new technique, without a time penalty.Victoria, Australia. minIP is useful to visualize change in tis- Whole brain coverage of our sequencesyngo SWI is a 3D FLASH sequence that sue susceptibility caused by structures means that lesions in unexpected loca-is flow compensated in slice, read and such as veins that cross many slices. tions would not be missed due to lack ofphase directions. The data received con- coverage.tains a combination of phase and mag- SWI sequence details for all case studies:nitude information. The susceptibility- swi3d1r, transverse plane, TR 28 ms, Case 1: Thrombosis andweighted images are produced by first TE 20 ms, flip angle 15, bandwidth 120 Associated Venous Infarctfiltering the phase images of unwanted Hx/px, FOV 220 (FOV phase 84.4%), res- Patient historyfield inhomogeneities and then weight- olution 199 x 256, slice thickness 3 mm,ing the magnitude images with this 48 slices, voxel size 0.9 x 0.9 x 3 mm, A 65-year-old male presented to ourphase mask. Two maps are automati- 1 average, acquisition time 2:19 min. emergency department with dysphagia,cally calculated; phase mask multiplied word-finding difficulty and right sidedmagnitude images and SWI minIP (mini- Since SWI is more sensitive to haemor- weakness.mum intensity projection of 8 images rhage than conventional T2* gradienton a sliding scale). In addition, the echo imaging, we replaced the T2* gra- Imaging findings 1 A) Native CT scan. B) T2* GRE at 1.5 Tesla. C) T2w TSE with syngo BLADE at 3 Tesla. D) Corresponding syngo SWI at 3 Tesla.phase and magnitude images can also dient echo sequence with syngo SWI in Non-contrast CT identified a hypodensebe produced by modifying the recon- all of our brain protocols. In order to do mass lesion in the left thalamus with astruction tab card. this without increasing scan time, the hyperdense border. Contrast CT and CTThe SWI images are T2*-weighted and SWI sequence as provided by the stan- venogram demonstrated a segment ofare enhanced by flow compensation dard protocol tree with the software ver- non-filling likely due to thrombosis inand phase masking, so there is exquisite sion syngo MR B15 was modified by the left internal cerebral vein with asso- Discussiondetail of areas of susceptibility due to increasing the voxel size from 0.8 mm x ciated venous infarct in the left thala- foci of restricted diffusion in the left The patient was recalled to our Siemens SWI nicely demonstrated the venousvenous blood, haemorrhage and iron 0.7 mm x 1.2 mm (resolution 256 x 384 mus. MRI was obtained to confirm the centrum semiovale likely related to the 3T MAGNETOM Trio scanner the follow- tributaries of the left internal cerebralstorage. and 1.2 mm slice thickness) to 0.9 mm x vein thrombosis and extent of infarction. venous infarction, but no definite ing day. The sequences performed vein with signal dropout due to the 0.9 mm x 3 mm (resolution 199 x 256 Initial MRI on our Philips Edge 1.5T sys- restricted diffusion involving the left included axial T2w, T1w, Diffusion- presence of deoxyhaemoglobin in the and slice thickness 3 mm), giving us tem confirmed a non-filling section of thalamus or the left basal ganglia. MR Weighted Imaging (DWI), Susceptibility- vessels. Signal dropout is also seen in lower resolution but allowing us to image the left internal cerebral vein in keeping spectroscopy of the basal ganglia region Weighted Imaging (syngo SWI) and MR the thrombosed internal cerebral vein the whole brain rather than only a sec- with thrombosis, extending to the vein showed an increased lactate peak sug- venography. This imaging confirmed the and within the thalamic haemorrhage, tion of it, in half the time of the standard of Galen. There was an area of suscepti- gestive of ischaemia. left internal cerebral vein thrombosis and demonstrating the high sensitivity but sequence. The 3 mm slice thickness also bility artefact in the gradient echo associated venous infarct. low specificity of this sequence. correlates to our other brain sequences images in the left thalamus represent- allowing direct comparison to be made. ing haemorrhage. There were 2 small18 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 19
  • 12. Clinical Neurology Neurology ClinicalCase 2: Amyloid Angiopathy Case 3: Cerebral haemorrhage in case of AVM2A 2B 3A 3B 3C 3D 3E 3 A) Initial SWI scan at 3Tesla. B) Follow up T2* at 1.5 Tesla three months later. C) Corresponding T2w TSE at 1.5 Tesla. D, E) 3T MRI performed in the same month as figures B and C; D) conventional T2* GRE, E) syngo SWI. 2 All images acquired at 3 Tesla. A) T2w TSE. B) syngo SWI.Patient history Imaging findings Discussion Patient history Imaging findingsAn 83-year-old male presented for MRI Haemosiderin staining over the cortical The SWI demonstrated signal loss due to A 33-year-old male with a known brain A collection of serpiginous flow-voids within the left parietal lobe, measuringfrom the memory clinic query fronto- surface of the frontal and parietal lobes haemorrhage which was not appreciable arterio-venous malformation (AVM) pre- was evident within the left superior 2.0 x 1.5 x 3.0 cm in size. On thetemporal dementia versus Alzheimers was evident on the SWI, consistent with on the routine imaging. Micro haemor- sented to our emergency department parietal lobule, similar in appearance to previous imaging from 3 months prior,Disease with frontal features. previous subarachnoid haemorrhage, rhages in the arterioles of the grey with a history of 5 minutes of motor the patient’s previous study. However a small focus of hypointensity at this most likely secondary to amyloid matter may lead to vascular dementia problems in his right hand. MRI was per- there was a region of hypointense sig- site was evident measuring 1 x 1 x 1 cmSequence details angiopathy. associated with amyloid angiopathy. formed to rule out cerebral haemorrhage. nal present within the region of the in diameter.The standard dementia protocol was syngo SWI may provide useful informa- vascular malformation that was not visi-performed: T1 volume, axial T2, FLAIR, tion in the imaging of dementia. Sequence details ble on the SWI from a previous study Discussionsyngo SWI, DWI whole brain images T1 volume, axial T2, FLAIR, field-echo performed on the patient 3 months The SWI appearance indicated thewith PRESS 30 MR spectroscopy of the whole brain images, 3D Time-of-Flight prior. This was suspicious for acute development of haemorrhage into theparietal grey matter. (TOF) and contrast-enhanced MR haemorrhage. vascular malformation within the left angiography and MR venography The patient was recalled for SWI at 3 parietal lobe, which had occurred since sequences were performed on our Tesla, so we could have a direct compar- the previous study. The signal dropout Siemens 1.5T MAGNETOM Avanto ison with the previous imaging that was on the SWI shows the margin of the system. also performed on our 3T scanner. This haemorrhage and the associated anom- demonstrated the development of a alous vessels more accurately than region of hypointensity situated cen- other routine sequences. trally within the vascular malformation20 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 21
  • 13. Clinical Neurology Neurology ClinicalCase 4: Traumatic haemorrhage Case 5: Cerebral metastases in case of oesophageal adenocarcinoma 4A 4D 5A 5BPatient history 5 A) T2w TSE at 3 Tesla.48-year-old female presented to our B) T2w FLAIR at 3 Tesla.emergency department with vomiting C) syngo SWI atand headache after previously discharg- 3 Tesla: cavernousing herself following a diagnosis of cor- haemangiomatical vein thrombosis. marked by arrow, DVA marked bySequence details asterisk, hemor- rhagic metastasesPre and post contrast T1 whole brain marked by arrow-images, axial T2, DWI, syngo SWI whole head.brain images with MR venogram. D) Follow-up after one month withImaging findings a conventional T2* sequence atsyngo SWI demonstrated a number of 1.5 Tesla.hypointense foci within the sulci of the 4B 4Efrontal lobes bilaterally and a number ofextra-axial locations. These were associ-ated with a number of small foci of 5C 5Drestricted diffusion within the cerebralcortex. The history of recent headtrauma, subsequently elicited from thepatient, indicated that the appearancewas most likely due to regions of extra-axial haemorrhage and small corticalcontusions. *DiscussionSWI is more sensitive to very small areasof traumatic haemorrhage because ofits higher resolution and better sensitiv-ity to blood products than the routine 4C 4Fsequences. Patient history Imaging findings Discussion A 48-year-old male with oesophageal No evidence of orbital mass or mass The patient returned for a follow-up adenocarcinoma presented with right within the paranasal sinuses was dem- scan on our 1.5T MAGNETOM Avanto retro orbital pain for 8 weeks and was onstrated. scanner 1 month later and standard T2* scanned for query cerebral metastases. Numerous T2 hypointense lesions with gradient echo imaging was performed. marked signal dropout on SWI were Compared to the 3T SWI, the standard Sequence details evident throughout the left cerebral gradient echo imaging at 1.5T is not as Pre- and post contrast T1 volume, axial hemisphere. However, some of these sensitive to the multiple haemorrhagic 4 All images acquired at 3 Tesla. A, D) DWI B, E) T2w TSE 4 C, F) syngo SWI. T2, FLAIR, DWI, syngo SWI whole brain were unaltered in appearance from areas, failing to show some of the images, coronal T1, fat sat T2, post the previous study from 2 years earlier smaller lesions evident on the 3T SWI contrast fat sat T1 images of orbits and and were consistent with cavernous sequence. paranasal sinuses. haemangiomas. The others represent haemorragic metastases.22 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 23
  • 14. Clinical NeurologyCase 6: Haemorrhagic component of MCA infarction6A 6B 6C Don’t miss the talks of experienced and renowned experts covering a broad range of MRI imaging Jörg Barkhausen, M.D. University Hospital Essen 6 All images acquired at 3 Tesla. A) DWI B) T2w TSE C) syngo SWI Dynamic 3D MRA – Clinical Concepts (syngo TWIST)Patient history Case study discussion References 1 syngo SWI powered by Tim. Hot Topic by Siemens John A. Detre, M.D.A 48-year-old female presented to our syngo SWI has allowed smaller suscepti- Healthcare. Available online at www.siemens. University of Pennsylvaniaemergency department with sudden bility lesions to be demonstrated than com/magnetom-world (go to Publications > Hotonset of left face, arm and leg weak- previously possible, in cases of vascular Topics). Clinical Applications of Arterial Spin Labeling 2 Susceptibility Weighted Imaging, Opening newness. CT brain was reported as right malformation, tumor, stroke, trauma doors to clinical applications of Magnetic Reso- (syngo ASL)middle cerebellar artery infarction. MRI and dementia. nance Imaging – E. Mark Haacke PhD Comment:was performed to confirm this finding. In many cases cited in the literature, MRM, 2004 Sep;52(3):612-618. SWI was the only imaging sequence to 3 Susceptibility-weighted MR imaging: a review ofSequence details show the abnormality due to its clinical applications in children. Tong KA, Ashwal Tammie L. S. Benzinger, M.D., Ph.D. S, Obenaus A, Nickerson JP, Kido D, Haacke EM.Pre- and post contrast volume T1, axial increased sensitivity to iron content. AJNR Am J Neuroradiol. 2008 Jan;29(1):9-17. Washington University School of MedicineFSE T2, FLAIR, syngo SWI, DWI images In all 6 of our cases the SWI sequence Epub 2007 Oct 9. Review.of the whole brain and 3D TOF MRA demonstrated increased detail of the 4 Susceptibility-weighted imaging to visualize Clinical Applications of Diffusion-Tensor Imagingcircle of Willis. pathology compared with the routine blood products and improve tumor contrast in (syngo DTI) the study of brain masses. Sehgal V, Delproposto imaging sequences. In cases 2, 4 and 5, Z, Haddar D, Haacke EM, Sloan AE, Zamorano LJ,Imaging findings some lesions appeared to be too small Barger G, Hu J, Xu Y, Prabhakaran KP, ElangovanAbnormal signal was seen within the to see on other imaging sequences, IR, Neelavalli J, Reichenbach JR. J Magn Resonright caudate head and lentiform nucleus indicating how the sensitivity of syngo Imaging. 2006 Jul;24(1):41-51. John F. Nelson, M.D. 5 Reliability in detection of hemorrhage in acute Battlefield Imagingwith significant susceptibility artefact SWI may benefit diagnosis. stroke by a new three-dimensional gradientwithin these structures that was most The increased signal and susceptibility recalled echo susceptibility-weighted imagingconsistent with the presence of blood effects at 3T enhance the use of syngo technique compared to computed tomography: Breast Cancer Management –products. The pathology is contained SWI, allowing full brain coverage in a a retrospective study. Wycliffe ND, Choe J, Cross Modality Approachwithin the middle cerebral artery distribu- short amount of time. Holshouser B, Oyoyo UE, Haacke EM, Kido DK. J Magn Reson Imaging. 2004 Sep;20(3):372-7.tion and appearances on syngo SWI aremost consistent with a cerebral infarctionwith haemorrhagic transformation. John A. Carrino, M.D., M.P.H.Discussion Contact Johns Hopkins University, School of Medicine Kate Negus Assoc. Prof. Peter Brotchie, MBBS, Ph.D.The SWI sequence demonstrated the full MRI Supervising Technologist Director MRIextent of the haemorrhagic component Barwon Medical Imaging Barwon Medical Imaging MRI in Sports Medicineof the infarction better than any of the The Geelong Hospital The Geelong Hospital PO Box 281 Geelong, 3220, Victoria, Australia Visit us atroutine sequences. The presence ofhaemorrhage with stroke is important Geelong, 3220, Victoria, Australia Phone: +61 3 5226 7032 Phone: +61 3 5226 7070 demonstrate as it changes treatment Go tooptions. Education > e-trainings & Presentations24 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 25
  • 15. Clinical Orthopedic Imaging Orthopedic Imaging Clinical3T MR Imaging of Peripheral Nerves press vascular signal with saturation bands often fails in distal locations of the body, as the peripheral nerves frequently 1 1 Sagittal 3D-PSIF image of the forearmUsing 3D Diffusion-Weighted and wrist demonstrates course through various obliquities. the median nerve Due to recent advances in 3T MR imag- (arrow) along its entire course.PSIF Technique ing with incorporation of optimized extremity coils and new pulse sequences, 3-dimensional high-resolu- tion and high-contrast demonstrationAvneesh Chhabra1, M.D.; Theodore Soldatos1, M.D.; Aaron Flammang1; Wesley Gilson1; Abraham Padua2; of the peripheral nerves is possible.John A Carrino1, M.D., M.P.H. The 3-dimensional diffusion-weighted1 Johns Hopkins University, Baltimore, MD, USA sequence based on reversed fast2 Siemens Healthcare, MR RD Management, Malvern, PA, USA imaging with steady-state precession (3D-PSIF) has been recently imple- mented in high-resolution MR Neurog- raphy imaging protocols and has a potential to overcome most of the above mentioned challenges in smallHigh-resolution magnetic resonance peripheral nerve imaging. The 3D-PSIF(MR) Neurography is a novel imaging Table 1: Acquisition parameters for 3D-PSIF at 3T is a balanced gradient echo steady-statetechnique, which enables multiplanar free precession (SSFP or PSIF) sequenceimaging of peripheral nerves, as well as The typical acquisition parameters employed for the 3D-PSIF sequence in a with inherent features of a spin-echodiagnosis and localization of entrap- Siemens 3T MAGNETOM Verio scanner. The spatial resolution of this technique sequence, as compared with otherment and non-entrapment peripheral yields 0.9 x 0.9 x 0.9 mm voxel sizes and, whenever possible, this dimension unbalanced spoiled or refocused gradi-neuropathies related to etiologies, such is preserved. When examining areas requiring larger or smaller coverage, the ent-echo techniques, such as fast low-as inflammation, tumor and trauma. scan matrix and the FOV are adjusted accordingly. This and number of slices angle shot (FLASH), fast field-echo, andTypically, MR Neurography techniques are all that is changed. Scan time is typically kept below 6 minutes 30 seconds gradient recall acquisition using steady- through the use of parallel acquisition. High quality thin MIP projections areutilize a combination of fat-saturated states (GRASS or FISP). Therefore, the rendered for display purposes.T2-weighted, short inversion time 3D-PSIF sequence demonstrates lessrecovery (STIR), or T2 spectral adiabatic influence of local magnetic field inho- Acquisition parameter Valueinversion recovery turbo spin echo mogeneities on the spin relaxation. The(T2 SPAIR TSE) images for the detection Slabs 1 water-excitation technique enables uni-of the nerve signal, contour and size FOV 172 mm form fat suppression and is unaffectedchanges, as well as T1-weighted spin Slice thickness by the chemical shift effect. Although 0.9 mmecho or fluid attenuated long inversion 3D-PSIF may also be performed without TR 12 msrecovery (FLAIR) images for the ana- fat saturation, fat-suppressed imagestomic assessment of the involved areas, TE 4.1 ms usually provide better nerve-to-back- 2 2 Coronal 3D-PSIF imagebased on the abundant intra- and Averages 1 ground contrast ratio. In addition, the of the lumbosacral plexusperineural fat. However, the diagnostic Coil 8-channel knee coil application of diffusion moment pro- demonstrates excellentability of conventional MR Neurography vides suppression of water signal. In discrimination of the nerve PAT GRAPPA 2 roots from adjacent soft-is limited in the evaluation of smaller most cases, a diffusion moment value Flip angle 30 tissue structures.peripheral nerves of the axial and of 80–90 mT/m*ms provides an accept- Fat suppression Water Excitation Normalappendicular skeleton, where the simi- able compromise in peripheral nerve-to-lar caliber and T2 signal intensity of Diffusion mode Phase background contrast and image signal-peripheral nerves and adjacent vessels Diffusion moment mT/m*ms 85 to-noise ratios (SNR). Since the signalrender discrimination of the above Diffusion directions 1 depends strongly on the steady-statestructures difficult, if not impossible. Dimension condition, all moving structures, such as 3DSince nerve injuries and entrapments flowing blood, demonstrate a loss of Elliptical scanning Oncommonly lead to effacement of signal intensity. As a result, the high T2perineural fat in the area of involve- Asymmetric echo Off signal intensity of peripheral nerves isment, T1-weighted images are often not Receiver bandwidth 230 Hz/Px effectively differentiated from thehelpful. In addition, an attempt to sup- Acquisition time 4 min 37 sec nulled signal of adjacent vessels (Figs. 1, 2). Although 3D-PSIF images provide predominantly T2 contrast, there is a potential to perform post-contrast imag-26 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 27
  • 16. Clinical Orthopedic Imaging3 differentiating small peripheral nerves Missing information? 3 Coronal 3D- from adjacent vessels. In the extremi- PSIF maximum intensity projec- ties, and particularly distal to the knee tion (MIP) of the and elbow joints, the commonly thigh demon- encountered T2 hyperintense subcuta- strates the neous and/or fascial edema restricts course of the the identification of small peripheral sciatic nerve. nerves on conventional T2-weighted sequences. In contrast, the inherent diffusion sensitive gradients of 3D-PSIF enable selective suppression of the water signal of the stationary subcuta- neous and fascial edema, thus improv- ing the conspicuity of small peripheral nerves in the above areas. On the other hand, the inherent high TE values of 3D-PSIF images result in lower SNR as compared to conventional fat-saturated T2-weighted images, which remain superior in delineating the fascicular structure of the nerves. In post-contrast imaging, as compared to the three- dimensional volumetric interpolated breathhold examination (3D VIBE) sequence, the 3D-PSIF technique pro- vides better visualization of the nerve fascicles, as well as more adequate assessment of the anatomic relationship between fascicles and enhancing intra-ing following administration of intrave- employed to further enhance the con- neural and/or extraneural tumors.nous gadolinium. In 3D-PSIF imaging, spicuity of the nerves and provide In summary, the 3D-PSIF sequence withthe acquisition of isotropic voxels images, which can be distributed to high spatial resolution and high con-enables the data set to be reformatted referring physicians for better depiction trast provides reliable and objectiveinto any imaging plane without signifi- and understanding of nerve anatomy identification of peripheral nerve anat-cant loss of resolution. The latter and pathology (Fig. 3). Table 1 displays omy and may be incorporated as part offeature may provide confirmation of the typical acquisition parameters the high-resolution MR study of periph-anatomic continuity, as well as identifi- employed for the 3D-PSIF sequence in a eral nerves, whenever accurate nervecation of branching, focal enlargement, Siemens 3T MAGNETOM Verio scanner. localization and/or pre-surgical evalua-course deviation and/or displacement of In clinical practice, 3D-PSIF has proven tion are required.peripheral nerves. In addition, maxi- more efficient than the conventionalmum intensity projections (MIPs) can be STIR and T2 SPAIR TSE sequences in k Don’t miss the talks on peripheral nerve Contact To make sure you have all the information you need, register for imaging on John A. Carrino, M.D., M.P.H. Associate Professor of Radiology and our free monthly newsletter on clinical MRI information. ■ Imaging of peripheral nerves – status quo Orthopedic Surgery Check out case reports from MAGNETOM users around the world Section Chief, Musculoskeletal Radiology by Mirko Pham University of Heidelberg, The Russel H. Morgan Department of and stay up-to-date with Siemens software applications. Germany Radiology and Radiological Science ■ Peripheral nerve imaging from head to toe 601 North Caroline St. /JHOC 5165 Baltimore, MD 21287-0856 by Meng Quan-Fei. The First Affiliated Register at USA Hospital of Sun Yat-sen University, Guangzhou, China Go to Publications > Subscriptions28 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 29
  • 17. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-itFull Spine Imaging utilizingthe Tim User InterfaceJames Hancock Tim planning 2A ■ When performing aMRI Radiographer Benson Radiology, Adelaide, South Australia full spine examination you need to activate the Tim Planning Suite user interface.Planning a full spine with TimPositioning technique■ The spine coil is on the table and is ■ Position the patient on the examina- ■ Place the top half of the c-spine coil plugged in. tion table with the head comfortably on and clip it into place (this depends■ Place the base of the head coil on the placed in the head coil. Shoulders on patient size). table and plug it in. against the neck coil. ■ Use the laser to centre on the indi-■ Place the base of the C-spine coil on ■ The triangular leg pad should be cated position on the neck coil. the table and plug it in. placed to reduce back strain. ■ Press the isocenter button to move the patient into the magnet bore. 2A Open the Tim Planning Suite from the drop-down menu.1 2B ■ Figure 2B shows the layout for the Tim User Interface. Depending on the clinical indica- tion, at our institution we have two basic pro- tocols saved for full spine imaging: The “Met Screen” protocol can be used for all full spine examinations except in the presence of a potential cord lesion when the “Cord Lesion” protocol should be used instead, as the sagittal slices are thin- ner and there are more of them. 1 Patient positioning. 2B The Tim user interface.30 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 31 1/2010
  • 18. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-itRunning the localizers 3 Setting up the slice positions■ First step to planning is to run the C-Spine localizers. Drag the appropriate HASTE ■ Once the FOV has been set you need place it into the two square windows. ■ Position the C-Spine slice group. localizer into the queue for running. to set the slice group locations for each One of these should be a sagittal and Before moving any of the slice groups This localizer begins in the cervical of the subgroups. Applying a systematic the other should be a coronal. take “coupled graphics” off. This will spine then moves the table before approach, begin with the cervical spine. ■ In the rectangular window place the allow you to work with and angle an running localizers in the thoracic and ■ The best way to do this is to load your composed full spine image and choose individual group of slices. lumbar spine. We end up with three individual C-Spine station localizer and the coronal orientation. localizers in the running queue. Thus it covers three stations. Once com- 5 plete, Tim composes these three sta- Using the Coronal tions into one complete image for the localizer in these entire spinal cord in both sagittal and boxes lets you locate your slice coronal planes. These images allow us 3 The measurement queue with the 3 localizers. group and angle to plan the setup for the rest of the appropriately. scans. With “coupled graphics” off, the changes you make only affect this individual slice group.Setting up the correct fields-of-view By having a sag-■ Drag the T2 sagittal sequences across 4 ittal localizer in Note the three sep- this box you can into the queue and open it. This arate FOV boxes. keep an eye on sequence displays three separate sub The upper FOV is your FOV. protocols one for each region of the yellow, indicating spine. that it is currently■ When setting up for a full spine it is active. By utilising T-Spine “coupled graphics” best to take a systematic approach. ■ Once you are happy with the C-Spine ■ Keep the Full Spine coronal image in ■ With “coupled graphics” off you can you can grab and■ Initially set up your FOV to ensure that drag all of the three slice group location you can move on the rectangular window. now proceed to angle the slice group you are going to cover the entire and move them as to the T-Spine. Again to set this up fol- ■ To select the thoracic spine subgroup to follow the thoracic spine. You will spine. This involves placing a com- one. This makes low the same systematic approach. click on the small number 2 displayed note that there is some overlap posed sagittal image of the full spine setting up your cov- ■ Load a sagittal and coronal T-Spine next to the second subgroup. You will between groups 1 and 2 – this is erage very easy. into the middle rectangular window. Each FOV is also localizer image into the square win- know you have the group selected as needed for the composing process■ When setting up your FOV coverage, numbered and you dows. it will turn yellow. later on. ensure that “coupled graphics” is on. can select them by This can be achieved by right clicking clicking on the lit- 6 tle numbers. Using the coronal in any of the three boxes and selecting localizer in these the option. boxes lets you■ With “coupled graphics” on you can locate your slice then move your FOV and position it group and angle appropriately. appropriately for the correct coverage. With “coupled See the example in figure 4. graphics” off, the changes you make only affect this individual slice group. By having a sagit- tal localizer in 4 Easy FOV set up to cover the whole spine. this box you can keep an eye on your FOV.32 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 33 1/2010
  • 19. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-itL-Spine Performing your axial scanning■ Once you are happy with the T-Spine ■ Keep the full spine coronal image in ■ With “coupled graphics” off you can ■ Axial scans can be planned for each nal image in one of the square win- ■ Run the required axial sequences slice group location you can move the rectangular window. now proceed to angle the slice group individual region as per normal. dows to aid in planning. which can be taken from the individ- on to the L-Spine. Again to set this up ■ To select the lumbar spine subgroup to follow the lumbar spine. You will ■ Make use of a nicely composed full ■ With “autocoil select” on wherever you ual spine protocols as needed. follow the same systematic approach. click on the small number 3 displayed note that there is some overlap spine sagittal image in the rectangular move a slice group, the appropriate■ Load a sagittal and coronal L-Spine next to the third subgroup. You will between groups 2 and 3 – this is window and an individual region coro- coils will be switched on. localizer image into the square win- know you have the group selected as needed for the composing process dows. it will turn yellow. later on. 7 Using the Compose Task Card By having a sag- ittal localizer in ■ All full spine sagittal images need to together. To do this we access the this box you can be sent to the composing task card individual sequences from the browser keep an eye on where they are filtered and stitched and send them to be composed. your FOV. 9 In the browser you select each indi- vidual step by holding control and Using the coronal clicking each step with the mouse. localizer in these This process is performed individu- boxes lets you lo- ally for each type of contrast be it cate your slice T2, T1 or STIR. group and angle appropriately. With “coupled graphics” off, the Once you have selected the individ- changes you ual sequences the composing func- make only affect tion is found under the Applications this individual menu. Click this and it will open slice group. composing. 10 8 When composing, the software will open and ask you which algorithm you wish to use. Always chooseImportant notes “Adaptive”.■ Any presets that you position will can try adding more slices to allow affect all three subgroups. you to cover the region.■ Changes made to one subgroup will ■ Worst case scenario: Choose your not affect the other groups, so never angles for each region of the spine, assume! but you will not be able to compose a■ Overlaps are built into the protocols. full spine image. This may be neces- Be careful when setting up your FOV. sary if the patient is very scoliotic. Keep these overlaps in place to ensure ■ Avoid in-plane rotation as this will smooth composing of final images. cause composing to fail. Thus, when setting up your FOV leave ■ Rotation of subprotocols in the F-H “coupled graphics” on. (axial) plane should be avoided. A dif- You can see how each subgroup for■ When setting up your slices for the ference of just 1 degree between sub- the T2 sagittals has its own number: 2.1, sagittal sequences you will often be protocols will cause composing to fail. 2.2, 2.3 etc. Thus if you need to rerun angling in the A-P (coronal) plane to ■ If you need to repeat a region of the a region simply hold shift and click follow the spine. Avoid using big dif- spine due to patient movement then the one you need to repeat. Drag and ferences in angle between one group you only need to select the region drop that region back into the queue. A cross will run through the compose and another. Too much angle will affected by the movement and rerun indicator, showing that it is only going affect the composing software. that particular subgroup. See the to run that one region again.■ If the patient is very scoliotic then you example in figure 8.34 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 35 1/2010
  • 20. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-it 11 13 Initially your composed images will look like those opposite. We run a normalize filter across the images which helps to smooth out the signal and stitching points. 12 The saved series will appear in the browser and Once the images you can then send it to viewing and film it. The have been nor- initial compose images are highlighted in blue malized you (long red arrow) with our saved series appear- need to save the ing at the bottom of the list (short red arrow). entire series, Your composed series can be sent to PACS from thus select “Save here also. all As” as shown. Give the sequence a name such as T2 SAG Compose, etc. Ensure you save them as a new Contact series. Repeat James Hancock the process for Benson Radiology the other sagittal Adelaide contrast weight- South Australia ings. MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 37 1/2010
  • 21. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-itKnee Imaging with 4-Channel Flex Coils. 4 Right Done right, the patient is again posi-The Influence of Patient Positioning and tioned supine on the table in feet first orientation. However, in this case theCoil Selection on Image Quality left knee is raised by a cushion in order to avoid the aliasing effect. The kneeBirgit Hasselberg; Marion Hellinger which is not examined is positioned higher than the examined knee.Siemens Healthcare, Erlangen, Germany The resulting transversal image shows no aliasing effects.2 Wrong Correct patient positioning and the selection of the right coil have a huge influence on image quality as the following examples clearly show. The patient is positioned supine on the table in feet-first orientation. In the first case, the patient lies straight on the table; both knees are positioned 4 Patient correctly positioned for knee exam. The knee not being examined is in one plane. positioned on a cushion. The resulting transversal clinical image shows aliasing effects from the left knee (which is not being examined) in 5 the left-right phase-encoding direction. 2 Patient positioned for an examination of the right knee. Both knees are positioned in one plane.3 3 Using the Siemens protocol from clinical library arthrography Pd_tse_fs_tra_320, due to incorrect patient positioning, infolding effects of the not examined left knee are visible. 5 Again using the Siemens protocol from the clinical library arthrography Pd_tse_fs_tra_320. No infoldings due to correct patient positioning.38 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 39 1/2010
  • 22. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-it6 Wrong 8 Right Besides correct patient positioning, the In the second case, the small 4-channel size of the knee in combination with the flex coil is used for the examination of a chosen coil has an effect on the image small knee. At the popliteal fossa we left quality. The so-called “coil filling-factor” the coil open is demonstrated below. When you The resulting sagittal image shows a good choose a coil which is too large for the SNR with an adequate image quality. examined body part, you get less overall signal which results in a minor image quality. In the first case, the large 4-channel flex coil is used for the examination of a small knee. The resulting sagittal series shows minor image quality: apart from minor signal-to-noise ratio, this also results in inhomogeneous signal distribution 6 A small knee positioned in a large 4-channel flex coil. as well as fat suppression. 8 A small knee positioned correctly in a small 4-channel flex coil.7 9 7 T1_tse_fs_sag_256 of a small knee in a large 4-channel flex coil, resulting 9 T1_tse_fs_sag_256 of a small knee examined with a small 4-channel flex coil, result- in minor image quality. ing in good SNR, good image quality. Compared to figure 7 there is good contrast and homogenous fat saturation in the bone.40 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 41 1/2010
  • 23. Clinical CardiovascularHow-I-do-it Orthopedic Imaging Clinical1 Case Report: Knee MR Imaging of Haemarthrosis in a case of Haemophilia A M. A. Weber; J. K. Kloth University Hospital Heidelberg, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany Background Patient history 1 4-Channel Flex coil large and small In daily patient-care imaging of joints in also an invaluable tool to rule out differ- In this case we report on the imaging childhood is often still a domain of x-ray ential diagnoses e.g. malignancies. findings of a 14-year-old male adoles- and ultrasound. However, the applica- However, MR in pediatrics requires dif- cent with known haemophilia A. Very tion of MRI in pediatric imaging is of ferent imaging approaches to those for often these patients present after an growing importance not only because adults. Imaging speed and high resolu- initial traumatic event with recurrentFinally, remember to position the around coil is made of soft and flexible of the excellent soft tissue contrast and tion are key elements. And since these bleedings into the large joints, domi- Contactpatient in the isocenter of the magnet. material. Due to its 4-channel design it the superior capacity of this technique two requirements are in direct conflict, nantly in the knees but also hips, shoul- Marion HellingerThe flexibility of the large and small is iPAT-compatible. The coil can easily be Siemens Healthcare to visualize and evaluate the extension several working groups recommend the ders etc. Bleeding into muscles can4-channel flex coils gives perfect sup- combined with other coils such as Spine H IM MR PLM AW T Workflow of involvement of soft tissues but also usage of 3Tesla MR in combination with also occur, but this is less common thanport in optimal left-right positioning. 32 and Body 18. Allee am Roethelheimpark 2 because of its capability to early and multi-channel coils to overcome at least in the joints. Recurrent haemarthrosisAs shown above, the 4-channel flex In summary, we can state that in knee D-91052 Erlangen precisely detect bone destruction. In partially the contradiction of fast and causes early destruction of the joints. Germanycoils come in 2 sizes and are part of the examinations correct patient position- addition to its high sensitivity, MRI is highly resolved MR scans in children. Severe pain and disability are the most marion.hellinger@siemens.comstandard system configuration. They ing and the selection of the right coilprovide superior signal-to-noise-ratio have a huge influence on the resulting(SNR) and can be used for the examina- clinical images. 1A 1B 1 Conventionaltion of various body parts. The wrap x-ray of the left knee (same examination date as MRI) with subchondral k Get free-of-charge erosion of both application training at femor condyles and thinning of the lateral joint magnetom-world space. In this 8 min online training on fat saturation you will learn ■ how to identify the fat and water peaks ■ to calculate fat and water separation ■ to perform the optimal fat saturation process k Visit us at fatsat-video42 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 43
  • 24. Clinical Orthopedic Imaging Orthopedic Imaging Clinical2 factor of 2, bandwidth 280 Hz/px, no 3A 3B averaging, TA 3:41 min). ■ Transversal PDw TSE with spectral fat saturation (TR 3420 ms, TE 77 ms, FOV (197 x 220) mm2, matrix (804 x 896, interpolated) px2, slice thickness 4 mm, parallel imaging factor of 2, bandwidth 162 Hz/px, no averaging, TA 2:38 min). * * ■ Coronal native T1w SE without fat sat- uration (TR 872 ms, TE 11 ms, FOV (165 x 220) mm2, matrix (384 x 512) px2, slice thickness 3 mm, no parallel imaging, bandwidth 150 Hz/px, no averaging, TA 3:19 min). ■ Transversal enhanced T1w TSE with- out fat saturation (TR 458 ms, TE 12 ms, FOV (194 x 220) mm2, matrix (396 x 448) px2, slice thickness 4 mm, parallel imaging factor of 2, band- width 180 Hz/px, two averages, TA 5:30 min). 3C 3D ■ Coronal enhanced T1w TSE with spec- tral fat saturation (TR 1210 ms. TE 13 ms, FOV (165 x 220) mm2, matrix (326 x 512) px2, slice thickness 3 mm, parallel imaging factor of 3, band- width 181 Hz/px, no averaging, TA 2:50 min). Total imaging time was approximately * 25 minutes. 2 Sagittal PD-weigthed TSE MRI. Erosion of the anteriomedial femur condyle is shown (arrow). Imaging findings Findings of severe haemarthrosis include clear synovial thickening and enhancement as a sign of intense prolif-common but also very unspecific clini- Sequence details eration of the synovia. Effusion containscal symptoms and can have different Examination was performed on a 3T also solid-appearing containments ascauses in childhood and adolescence open-bore MR system (MAGNETOM well as T1w iso- and slightly hyperin-(e.g. aseptic osteonecrosis). Verio), equipped with 18-channels (Tim tense areas. These findings are consis-The said patient presented with these [102 x 18] configuration) in combination tent with older haematoma. Erosions ofunspecific symptoms in the ambulance with a dedicated 15-channel knee coil. the cartilage can be found in both jointof our orthopedics department. Haemo- compartments including thinning of thephilia A was already known und multi- Imaging protocol included: tibial cartilage. In addition, erosion ofple events of haemarthrosis docu- ■ Sagittal PDw TSE without fat satura- the cartilage and bone can also be 3 A–C: Enhanced T1w axial MRI. 3B: Inverted. D: Transversal T2w TSE with spectral fat saturation. Arrows: Erosion of cartilage and bonemented. Conventional x-ray showed tion (TR 6090 ms, TE 88 ms, FOV found in the retropatellar joint. Epiphy- destructions, arrow heads: synovial thickening and synovialitis, asterisk: effusion with haematoma.effusion and discrete signs of arthrosis (186 x 220) mm2, matrix (346 x 512) seal fusion and bone marrow are age-with smallest lateral and medial osteo- px2, slice thickness 3 mm, parallel related and without suspicious findings.phytes. With the suspicion of a new imaging factor of 2, bandwidth 181 No signs of fracture are visible and liga-event of intraartricular bleeding, the Hz/px, two averages, TA 3:21 min). ments as well as menisci are within nor-patient was immediately referred to the ■ Coronal T2w TIRM (TR 6690 ms, mal range. However, as already sus-MRI department for further evaluation. TE 53 ms, TI 210 ms, FOV (218 x 220) pected through conventional x-ray, MRI mm2, matrix (400 x 448) px2, slice shows also small osteophytes as sign of thickness 3 mm, parallel imaging secondary arthrotic osseous changes.44 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 45
  • 25. Clinical Orthopedic Imaging Orthopedic Imaging Clinical4A 4B 4C 5A 5B 5 Arthroscopic images (courtesy of Tobias Gotterbarm, MD; Dept. of Ortho- pedics and Trauma Surgery, University Hospital Heidelberg, Germany). A: Multiple lesions of the femoral and tibial cartilage (arrowheads).4D 4E 4F B: Extensive synovialitis (arrow in Fig. 5A). uation of haemophilic knees and ankles of for fast and highly-resolved imaging haemophilic children. Expert MRI working group hampers the wide usage of MRI. So the of the international prophylaxis study group. implementation of a 3T open-bore Haemophilia. 2006 Sep;12(5):503-13. system in our department and as a con- 3 Lundin B, Berntorp E, Pettersson H, Wirestam R, sequence shorter scan times at higher Jonsson K, Ståhlberg F, Ljung R. Gadolinium contrast agent is of limited value for magnetic 4 A: Coronal T1w SE showing erosion of the femur condyles. B: Thinning of tibial cartilage (arrow). C: Coronal TIRM showing regular bone quality has significantly improved the resonance imaging assessment of synovial marrow and epiphyseal fusion within normal age-related range. D–F: Enhanced T1w with fat saturation revealing extensive synovialitis. acceptance of MR by patients and refer- hypertrophy in hemophiliacs. Acta Radiol. 2007 ring physicians. Jun;48(5):520-30. References Contact 1 Pergantou H, Matsinos G, Papadopoulos A, Pla- Marc-André Weber, M.D., M.Sc. Conclusion tokouki H, Aronis S. Comparative study of validity Heidelberg University of clinical, X-ray and magnetic resonance imaging In this case of haemarthrosis in a with superb image resolution, resulting However, the appropriate selection of scores in evaluation and management of haemo- Professor of Radiology patient with recurrent bleedings, MRI in most accurate assessment of joint MR imaging techniques as well as the Diagnostic and Interventional Radiology philic arthropathy in children. Haemophilia. 2006 Im Neuenheimer Feld 110 at high field-strength (3T) and in combi- damage and extension of synovialitis. appropriate translation of MRI findings May;12(3):241-7. 69120 Heidelberg nation with dedicated high-density coils It is already known that in cases of hae- into scoring systems are subject of 2 Doria AS, Babyn PS, Lundin B, Kilcoyne RF, Miller Germany S, Rivard GE, Moineddin R, Pettersson H; Expert is an invaluable tool for the evaluation mophilia implementing MRI for assess- ongoing debate [Doria et al., Lundin et MRI Working Group of the International Prophy- of joints in childhood and adolescence ment of joint involvement changes the al.]. In clinical routine the availability laxis Study Group. Reliability and construct validi- within a reasonable time-frame and patient management [Pergantou et al.]. of MR scan time and the requirements ty of the compatible MRI scoring system for eval- M.-A. Weber J. K. Kloth 46 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 47
  • 26. Clinical Orthopedic ImagingAdvantages of MSK Imaging 1Aat 3 Tesla with special focuson Spine and Tumor ImagingMarc-André Weber, M.D., M.Sc.Diagnostic and Interventional Radiology, University Hospital Heidelberg, GermanyBackgroundIn 2009, our institution, the Depart- of the SNR with the increase of the field compensated by new MR technologyment of Diagnostic and Interventional strength) and less prominent effect (e.g. adopting sequence techniques and 1 Patient with contractionsRadiology, had to decide for a replace- of B1 inhomogeneity on image quality application of parallel imaging tech- of the lower extremities.ment of an existing 1.0 Tesla MR system for most areas of interest in musculo- niques). Finally, we were convinced that MR-compatible wheelchair forwith conventional coil technology and a skeletal (MSK) imaging (knee, shoulder, the advantages of the 3T technology easy patient transport.bore-size of 60 cm at the Department of ankle, wrist etc.) results in clearly available with the new scanner genera- 1BOrthopedics with the main departments improved image quality (resolution tion do outweigh the disadvantages sig-Orthopedics and Traumatology as well wise) and / or faster scan times. How- nificantly. In spring 2009 we thereforeas Paraplegiology and Rehabilitation ever, for advanced spine imaging as decided for replacement of our old 1TMedicine. While the clinicians were sat- well as tumor staging, the “dielectric scanner by a 3T MAGNETOM Verio.isfied with the robustness of imaging in shading” effects would again have We would like to present below somecase of metal implants with the old limited the usability of the MRI scanner. interesting cases out of our daily clinicalscanner, compromises in image resolu- But with the development of anatomy routine which demonstrate the advan-tion and relatively long examination optimized amplitude and phase trans- tages of MSK imaging at 3T with specialtimes as well as the missing capabilities mission settings for homogenous B1 focus on spine and tumor imaging.of the old system for scanning multiple radio-frequency (RF) transmission andregions of interest within one examina- in combination with further optimiza- Case 1tion without the need for patient reposi- tions of the magnet and gradient design As a center dealing with a high numbertioning did limit the usage of MRI. In (TrueForm technology), local signal of patients with hemi-/ paraplegia,addition, due to the limited signal-to- drop out at 3T can be reduced signifi- cerebral palsy as well as scoliosis, thenoise ratio (SNR) as a result of the low cantly if not even eliminated practically. 70 cm open-bore system has the advan-field strength and old coil technology Another limitation of higher field tage of a very flexible patient position-implemented in this system, the increas- strength is the higher energy deposit ing. As demonstrated in figure 1B,ing clinical demand for widening the within tissue, resulting in higher specific especially severe contractions of theapplication of MRI to include, for exam- absorption rate (SAR). And finally, extremities often seen in these patientsple, molecular assessment of cartilage metallic implants will result also in do require sufficient space in the ante-repair or multi-region tumor staging in increased signal drop due to pro- rior-posterior direction. In figure 1A ourchildren and adults could not be fulfilled nounced susceptibility artifacts [Fries MR-compatible wheelchair is shown,sufficiently in a clinical environment. 2008, Baudendistel 2004]. But these which enables an easy and relative fastThe advantages of 3 Tesla especially for effects with negative impact on the patient transport into the scanner.orthopedic imaging are well known: image quality and examination time canincrease in SNR (proportional increase again significantly be reduced if not Flexible patient positioning in the 70 cm open-bore system.48 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 49
  • 27. 2A 2BClinical Cardiovascular Orthopedic Imgaging Clinical 2 A) T1w TSE Case 3 sagittal B) T2w TSE In case of malignancies or inflamma- 3A 3B 3C sagittal tion, however, we have to expand our clinical routine protocol. This case shows selected images of a 63-year-old male patient with known spinal astrocy- toma WHO grade III. This patient under- went chemo- and radiotherapy and pre- sented at our institution with clinically stable paraplegia at the level of Th5. A swollen myelon can be seen in this fol- low-up exam at the height of the irradi- ated tumor at the height of thoracic ver- tebra 6–8. On post-contrast T1w MRI, an inhomogeneous medullar enhance- ment can be seen (arrow). Note that the patient also underwent laminectomy and that a residual seroma can be detected. Enhancement within the ver- tebra was stable over a long period of time and based also on CT imaging, this finding has to be classified as a heman-2C 2D C) T1w TSE axial gioma of the 9th thoracic vertebra. (oblique) D) T2w TSE axial (oblique) 3D 3 A) T1w TSE sagittal B) T2w TSE sagittal C) ce T1w sagittal with fat-saturation D) ce T1w axial (oblique)Case 2This case demonstrates our standard T1w TSE axial (oblique): resolution multi-channel spine coil, also a rela-imaging strategy in case of lower back (0.7 x 0.7 x 3.0) mm3, TR 969 ms, tively high sub-millimeter in-planepain. We apply mainly turbo spin-echo TE 12 ms, TA 3:09 min (fig. 2C). resolution at slice thicknesses of 3 mm(TSE) sequences for this purpose. T2w TSE axial (oblique): resolution for sagittal and transversal planes isSequence parameters for the shown (0.7 x 0.7 x 4.0) mm3, TR 5060, achieved.images are: TE 115 ms, TA 2:59 min (fig. 2D). In this particular case, a medio-lateralT1w TSE sagittal: resolution (0.7 x 0.7 With a total scan time of less than 15 large hernia of the intervertebral discx 3.0) mm3, TR 684 ms, TE 12 ms, minutes, this protocol focuses on a fast of L5/S1 with compression of the leftTA 2:48 min (fig. 2A). assessment of the lumbar spine. How- nerve root is seen (arrows).T2w TSE sagittal: resolution (0.7 x 0.7 ever, because of the higher signal-to-x 3.0) mm3, TR 3650 ms, TE 113 ms, noise contribution of the 3 Tesla systemTA 3:00 min (fig. 2B). in combination with the integrated50 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 51
  • 28. 5A Clinical Orthopedic Imaging Case 4 Case 5 5 A) Coronal ce T1w with fat 43-year-old male patient, who under- in-plane resolution was low in the 1T Based on this MRI exam, the suspicion 66-year-old female patient with molecu- saturation. went a dorsal stabilization after trau- exam and a further evaluation of the of an arachnoidal cyst was supported lar pathology confirmed Ewing sarcoma matic fracture of vertebra Th10 and had tethering of the myelon was not pos- leading to a dorsal dislocation and com- of the right humerus. After initial tumor complete paraplegia below this seg- sible. The high SNR of the 3T scan pression of the myelon. Even the slight excision in 2009 and osteosynthesis, ment. On conventional x-ray, the spine allowed for a high in-plane resolution arachnoidal web could be detected the patient presented with an extensive fusion from Th9 to Th11 is shown (fig. (Fig. 4C, D) and also for T2w 3D imag- on the SPACE sequence (red arrow in recurrence of the tumor within four 4A). Figure 4B shows an MRI which was ing (syngo SPACE, Fig. 4E).The capabil- Fig. 4D). months. Figure 5A demonstrates the performed at our institution with our ity of evaluating the whole area of inter- Slice thickness for sagittal T2w images large tumor with infiltration also of the old 1 Tesla scanner. While artifacts est with the SPACE sequence at highest were 3 mm for both examinations at bone marrow. In addition, diffuse caused by metallic implants on the 1T resolution and contrast in any orienta- 1 and 3 Tesla, respectively. Resolution oedema is shown (arrowhead in 5A). exam with the chosen sequences are tion allowed further evaluation of the of the syngo SPACE exam was (0.7 x 0.7 Figure 5B also shows a large lymph node less prominent compared to imaging at reason for the dorsal dislocation of the x 0.7) mm3. metastasis (arrow). Therefore, before 5B B) Axial ce T1w 3T (compare Fig. 4C), SNR and therefore myelon starting at the height of Th6. again operating on the humerus, the with fat saturation. orthopaedic tumor surgeon wants to know whether more lesions are present.4A 4B 4C 4D Thus, a whole-body scan was added (Fig. 5C), demonstrating also multiple osseous filiae (arrows in 5C) of the pelvis and spine. No evidence of high risk or presence of a pathologic fracture was found. By selecting appropriate imaging tech- niques, imaging at 3T even with metal implants present and off-center posi- tioning can result in excellent image quality. The achievable superior resolu- tion clearly increases confidence about extension of a tumor and impairment of anatomical structures. In addition, the capability of scanning large areas of interest up to whole-body without 5C C) Coronal T2w compromise in image quality and within whole-body a clinical acceptable setting (time and with fat saturation. patient-comfort wise) is a prerequisite for any sufficient oncologic decision making and is highly esteemed by our tumor surgeons, especially to detect skip lesions that would distinctly influ- ence the therapeutic concept. The supe- rior capability of evaluating changes within the bone marrow including dif- fuse tumor infiltration is a particularly big advantage in our patient cohort. 4 A) Conventional x-ray B) T2w sagittal at 1T C) T2w sagittal at 3T D) T2w syngo SPACE at 3T 52 MAGNETOM Flash · 3/2010 ·
  • 29. Clinical Orthopedic Imaging Orthopedic Imgaging Clinical6A 6B 7A 7B 7C 6 A) Conven- tional x-ray B) T2w sagittal at 1T6C 6D C) T2w sagittal at 3T D) T2w syngo SPACE at 3T 7 A) T2w sagittal at 3T B) T1w sagittal at 3T C) T2w sagittal at 1T Case 6 Case 7 Complex congenital malformation of assessment of the meningomyelocele Exam of a 59-year-old male patient with the central nervous system, as well as (arrows). Especially T2w 3D imaging complete tetraplagia at the level of C5 the spine, requires also evaluation of allows for a detailed assessment of all and secondary syringobulbia starting the whole systemic aspect of disease. aspects of the impairment of the central at the vermis down to the 6th thoracic In this case, we show images from a nervous system including the myelon vertebra as a consequence of a bathing 15-year-old boy with Arnold Chiari II and nerve roots. Figure 6D shows the accident in 1968. The patient received malformation and lumbal meningomy- results of a syngo SPACE exam of the arachnolysis and dural plastic as specific elocele (closed by surgery after birth). whole spine. The meningomyelocele is therapy, as well as a wound examina- Because of severe and progedient com- resolved in detail (arrow) as well as the tion because of a liquor pad. The syngo plex scoliosis, this patient also underwent displacement of the cerebellum as part SPACE exam (Fig. 7A) shows multiple a dorsal spine fusion of Th9 downwards of the Arnold Chiari malformation. Also horizontal septae, which divide the to the pelvis with VEPTR instruments and tethering of the myelon, which is impor- syrinx and might hinder CSF exchange underwent multiple extensions (conven- tant for the orthopaedic surgeons to and thus might cause extension of the * tional x-ray Fig. 6A). Figures 6B and C do show the image know about because it must be resolved before any operation to the spine, is well syrinx. The 3 Tesla T2-weighted image (Fig. 7A) better delineates the septae quality difference between 1 and 3T depicted. Note also the displacement of than the 1 Tesla T2-weighted image exam (both 3 mm slice thickness). inner organs in this case (asterisk marks (Fig. 7C). In this case, a complete sup- Again, the superior SNR and in-plane one of the kidneys). pression of the liquor was seen on FLAIR resolution allows for a more detailed images (not shown), suggesting com- munication of the multiple cystic lesions and the subarachnoid space.54 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 55
  • 30. Orthopedic Imgaging Clinical8A 9A 9B Case 8 Intramedullar formation of cavities can often be found as a consequence of widening of the central canal (hydro myelia) or outside the central canal (syringomyelia) as result of traumatic events or space occupying lesions / tumors or as a malformation. T2w images of a 7-year-old boy are shown, showing a syringomyelia affecting the whole myelon (holocord syrinx). Case 9 10-year-old girl with meningomyelo- cele, paraparesis, spina bifida and rotation skoliosis is shown. In addition, partial fusion of the first and second lumbar vertebra is present as well as dysplasia of the 12th thoracic vertebra. Imaging was conducted for planning of specific therapy including instrumented dorsal spine fusion and decompression of the spinal canal. For optimal outcome 9C 9D and for best risk stratification of such a therapy, detailed information not only8B 8C about the complexity of the disorders of the spine but also of the myelon and nerve roots is essential. CT (volume ren- dering shown in Fig. 9A) as well as 3T MRI demonstrated in detail the known left convex rotation scoliosis of the thoraco-lumbal spine. Syrinx from level Th3 down to the conus is visualized by MRI (arrows in Figs. 9B–D). In addition, starting at the height of Th6, a T2w hypointense, T1w isointense to the myelon, linear and parallel to the myelon running structure can be delineated that might resemble a scarred cord. Most probably this structure represents split cord malformation e.g. diastemato- myelia. 8 A) Volume Rendering Technique (VRT) of a CT scan. B) Coronal, C) sagittal and D) oblique reconstructions based on 3D T2w imaging. 8 A) Coronal and B, C) sagittal reconstructions based on 3D T2w imaging.56 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 57
  • 31. Clinical Orthopedic Imaging10A 10B 10C Musculoskeletal Advisory Board Provides Protocols for 1.5 and 3T MAGNETOM systems We have launched the MSK Advisory 10 A) T2w sagittal with severe motion artifacts. B) T2w sagittal with syngo BLADE technique. C) ce T1w sagittal with fat saturation. Board website, providing proven MSK protocols (.edx files) for download.Case 10 To support Technologists there areResults of an MRI scan of an 87-year-old are significant, as shown with this case Referencesfemale patient with dementia and series. After approximately one year of 1 Fries P, Runge VM, Kirchin MA, Watkins DM, also coil positioning videos andsevere back pain are shown. Severe operation, the installation of the 3T Buecker A, Schneider G. Magnetic resonance imaging of the spine at 3 Tesla. Semin Musculo- tips & tricks.motion artifacts were present (Fig. 10A) open bore system with TrueForm tech- skelet Radiol. 2008 Sep;12(3):238-52.but could be compensated by applying nology has clearly improved our diag- 2 Baudendistel KT, Heverhagen JT, Knopp MV.motion-insensitive (syngo BLADE; Fig. nostic potential as well as widened the Clinical MR at 3 Tesla: current status. Radiologe 2004;44(1):11-8.10B) MR sequences and fast sequences indications for MRI and has lead to Board members are:with parallel imaging (post-contrast improved patient care. The system isT1w image; Fig. 10C). Spondylodiscitis therefore well received among our clini- ■ Christian Glaser, LMU Grosshadern, Germany Contactand complete destruction of the inter- cal colleagues, resulting also in a signifi- ■ Jürg Hodler, Balgrist University Hospital, Switzerland Marc-André Weber, M.D., M.Sc.vertebral space of L5/4 is seen. In addi- cant increase of referrals during the last Professor of Radiology ■ Young-Jo Kim, Harvard Medical School, Children’stion, multiple epidural abscesses can be year. In addition, the patient comfort Head of Musculoskeletal Radiology Hospital Boston, USAseen. The patient underwent surgery of the open bore system has resulted in Department of Diagnostic and Interven- ■ Tallal Charles Mamisch, Bern University, Switzerlandwith dorsal and ventral spine fusion, a higher acceptance of MRI by patients. tional Radiology ■ Michael Recht, New York University, USA University Hospital Heidelbergopen discectomy and laminectomy as ■ Siegfried Trattnig, AKH Wien, Austria Acknowledgements Im Neuenheimer Feld 110well as drainage. 69120 Heidelberg ■ Lawrence M. White, University of Toronto, Canada The excellent cooperation regarding GermanyConclusion brain and spine imaging with Prof. Dr. Phone: +49 6221-966601Although the adoption to the higher Stefan Hähnel and Dr. Leonie Jestaedt Fax: +49 6221-966640 MarcAndre.Weber@med.uni-heidelberg.defield strength of 3T, new coil technology from the Department of Neuroradiologyand multi-region exams were challenges at the University Hospital Heidelbergto radiologists, technologist and refer- (Head: Prof. Dr. Martin Bendszus) isring clinicians and do require a (short) gratefully acknowledged.transition phase, the clinical advantages Visit us at MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 59
  • 32. Technology TechnologyImage Quality Improvement 2 Application of a threshold andof Composed MR Images by Applying exclusion of transient pixels STEP Ia Modified Homomorphic FilterVladimir Jellus; Wilhelm Horger; Berthold KieferSiemens Healthcare, Erlangen, Germany The image is mirrored and an enlarged artifical image is generatedWith the development of MR machines regions, large fields-of-view (FOV) and formed including for small areas of inter- STEP II and filteredthat offer the capability to examine large multi-channel coils have to be applied est, negating the potential advantage of (homomorphicregions of the body without patient and/ [1, 5, 6]. Unfortunately, images with large FOV images for fast and easy access filter)or coil repositioning [1], MRI can now large FOV are often characterized by to pathologic findings. This problembe used for imaging systemic aspects of inhomogeneous illumination. At 1.5T will be aggravated regarding composeddiseases e.g. in oncology [1-6]. But this is caused mainly by local variations images.documentation of complex pathologies of coil sensitivities. This problem can be Therefore, a simple applicable and robustrequires a fast and easy assessment of pronounced at higher field strength post-processing approach is requiredall findings. For this purpose, image- by dielectric resonances, causing local to improve signal homogeneity for com- The filteredcomposing techniques may be helpful [1]. B1 inhomogeneities [7]. Consequently, posing large FOV MR images in clinical and unfiltered enlarged imagesTo acquire information from large body manual adjustments have to be per- routine. are compared1 STEP III ⁄ The resulting function is applied on the original MR image; an image 1 The filter as de- with improved scribed in this article can be applied easily STEP IV * signal intensity homogeneity is resulting within the syngo com- posing software without the demand of exten- sive computing time. 2 Overview of the basic steps of the filter. The modified homomorphic filter in 1.5T this is mainly caused by sensitivity mogeneity. Therefore, inhomogeneity the syngo composing software (Fig. 1) variations of the RF-coils. can be suppressed by a notch filter was initially developed to reduce arti- The method is based on the homomor- (removes low frequency components) facts caused by dielectric resonances phic filter as described in reference [9]. applied to the spectrum of the logarithm [8]. The purpose of the filter is to remove Homomorphic filters assume that the of the image. In comparison to a stan- signal inhomogeneities introduced into acquired image is a multiplication of the dard homomorphic filter, the developed the image by various phenomena, at ideal homogenous image and the inho- filter includes algorithms to exclude60 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 61
  • 33. Technology Technology3a 3b 3c 3A 3B 3C 3 This case demonstrates the improved signal uniformity in whole-body MRI, when the homomorphic filter is applied. 3 Filtered images are given in figures 3 (A), (B) and (C). Original composed T2-weighted STIR images are given in figures 3 a, b and c; filtered images are given in figures 3 (A), (B) and (C). While signal Case courtesy of Heinz-Peter Schlemmer and Matthias Lichy, University of Tuebingen, uniformity is clearly improved by the homomorphic filter especially for the brain, the metastases (marked by arrows) of the kidney cell cancer are Department of Diagnostic and Interventional Radiology, Tuebingen, Germany. well delineated without loss of contrast to their surrounding tissues. (Note: all images have the same window levels for contrast and brightness.)62 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 63
  • 34. Technologyinfluences of areas with very low signalintensity inside the object and in the border), the filter mirrors these parts to the outside. For this purpose, the of the signal homogeneity can be found in figure 3, in which it is also shown that Relevant clinical informationbackground. A “cepstrum” (spectrum of dimensions of the image are enlarged there is no compromise in the detectionthe logarithm of the image) is calculatedfrom this prepared image and a notch to avoid problems caused by circular convolutions at the borders, which can of suspicious lesions introduced by filter- ing. Further information about the influ- at your fingertipsfilter is applied on the cepstrum (Fig. 2). cause a leap in the sensitivity. Now the ence of the filter with special regardsThe filter can be applied on all kinds standard homomorphic filter algorithm to diagnostic safety and clinical value for From technology to clinical applications, you will find all the latest news on Siemens MR atof MR images, and is very valuable on is applied on this new and artificial whole-spine imaging in patients withcomposed images. It includes different image with low resolution (compare multiple myeloma can be found in [10]. Firstly, the image resolution is step 2, Fig. 2). The ratio of the filteredreduced. One effect is that the effective image and the input artificial image Don’t miss the talks of international experts onsignal-to-noise ratio (SNR) is increased provide the correction function (com- Magnetic Resonance Imaging. Contactin this new image and, additionally, pare step 3, Fig. 2). Finally, the filter Vladimir Jellus, Ph.D.computing performance is improved. interpolates this correction function Siemens Healthcare Go to EducationSecondly, areas with low signal intensity from the central part of the artificial, IM MR PLM AW Orthopedics > e-trainings & Presentationsare detected by setting of a threshold; low-resolution image to full resolution Allee am Roethelheimpark 2 91052 Erlangenisolated pixels in the background and (this area is corresponding to the non- Germanyinside the object are removed, including mirrored central part of the initial vladimir.jellus@siemens.compixels with possible partial volume image). After a multiplication with theeffects (via erosion). In the next step the values of the initial fully resolvedinitial signal intensities of the removed image, a corrected image with improvedpixels are replaced by the mean value signal uniformity is resulting (compareof N neighboring volume elements (with step 4, Fig. 2).N~10–100) (compare step 1, Fig. 2). To Further information about the functionminimize problems with extreme signal of the filter can be found in reference [8].changes (especially present at the image A clinical example of the improvement The centerpiece of the MAGNETOM World Internet platform consists of our users’ clinical results. Here you will find case reports and clinical methods. References 1 Schlemmer HP, Schafer J, Pfannenberg C, Suetsugu Y, Mikami M, Tamada T, Imai S, 7 Van de Moortele PF, Akgun C, Adriany G, Moeller S, Go to Clinical Corner > Case Studies Radny P, Korchidi S, Muller-Horvat C, Nagele T, Kajihara Y, Fukunaga M (2004). Detection of Ritter J, Collins CM, Smith MB, Vaughan JT, Tomaschko K, Fenchel M, Claussen CD (2005) bone marrow and extramedullary involvement Ugurbil K (2005). B(1) destructive interferences Fast whole-body assessment of metastatic dis- in patients with non-Hodgkin’s lymphoma by and spatial phase patterns at 7 T with a head ease using a novel magnetic resonance imaging whole-body MRI: comparison with bone and transceiver array coil. Magn Reson Med. system: initial experiences. Invest Radiol. 67Ga scintigraphies. Eur Radiol. 14(6):1074–81. 54(6):1503–18. 40(2):64–71. 5 Lichy MP, Wietek BM, Mugler JP 3rd, Horger W, 8 Jellúš V, Kiefer B (2005). New Modification of the 2 Ghanem N, Lohrmann C, Engelhardt M, Pache G, Menzel MI, Anastasiadis A, Siegmann K, Niemeyer Homomorphic Filter for Bias Field Correction. Uhl M, Saueressig U, Kotter E, Langer M (2006) T, Konigsrainer A, Kiefer B, Schick F, Claussen Proc. Intl. Soc. Mag. Reson. Med. 13: 2247 Whole-body MRI in the detection of bone marrow CD, Schlemmer HP (2005). Magnetic resonance 9 Gonzales RC, Woods RE (1992). Digital Image infiltration in patients with plasma cell neoplasms imaging of the body trunk using a single-slab, Processing, Reading, Addison-Wesley in comparison to the radiological skeletal survey. 3-dimensional, T2-weighted turbo-spin-echo 10 Lichy MP, Mueller-Horvat C, Jellus V, Horger W, Eur Radiol. 16(5):1005–14. sequence with high sampling efficiency (SPACE) Horger M, Pfannenberg C, Kiefer B, Claussen 3 Mentzel HJ, Kentouche K, Sauner D, Fleischmann for high spatial resolution imaging: initial clini- CD, Schlemmer HP (2008). Image quality im- C, Vogt S, Gottschild D, Zintl F, Kaiser WA cal experiences. Invest Radiol. 40(12):754–60. provement of composed whole-spine MR images (2004). Comparison of whole-body STIR-MRI 6 Rodegerdts EA, Boss A, Riemarzik K, Lichy M, by applying a modified homomorphic filter – and 99mTc-methylene-diphosphonate scinti- Schick F, Claussen CD, Schlemmer HP (2006) first results in cases of multiple myeloma. graphy in children with suspected multifocal 3D imaging of the whole spine at 3T compared Eur Radiol. 18(10):2274–82. Just a mouse click away you will find application videos bone lesions. Eur Radiol. 14(12):2297–302. to 1.5T: initial experiences. Acta Radiol. 47(5): and useful tips allowing you to optimize your daily MR 4 Iizuka-Mikami M, Nagai K, Yoshida K, Sugihara T, 488–93. examinations. Go to Clinical Corner > Application Tips For the whole range of clinical MR information visit us at64 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 65
  • 35. 2 1Clinical Abdomen / Pelvis Original 3D DCE MRI DATA Cardiovascular Abdomen / Pelvis ClinicalValue of Automated Retrospective Cor-rection of Contrast-Enhanced Dynamic * *Liver MRI. Initial Clinical Experience Original 3D DCE MRI DATA – subtracted images –H.-P. Schlemmer1,4; M.P. Lichy1,2; C. Plathow1; W. Horger2; B. Geiger3; B. Kiefer2; C. Chefdhotel3; C. D. Claussen1; U. Kramer1 # #1 University of Tübingen, Department of Diagnostic and Interventional Radiology, Tübingen, Germany # #2 Siemens Healthcare, Erlangen, Germany3 Siemens Corporate Research, Princeton, USA4 German Cancer Research Center (DKFZ) Heidelberg, GermanyIntroduction Corrected 3D DCE MRI DATA – subtracted images –Multiphase three-dimensional contrast- Not only because of the lesion size and MRI data requires an exact anatomicalenhanced dynamic liver scans (3D DCE the requirements for exact timing of the match of the 3D DCE MRI data sets.MRI) are of high diagnostic relevance arterial phase but also because these However, breathing artifacts are a com-in the characterization of liver lesions, nodules can already have bright native mon observation, resulting very often inespecially in the detection of primary signal intensity, and potential contrast- a clear anatomical offset of the differentliver malignancies, e.g. the hepato-cel- media enhancement is therefore not phases of liver 3D DCE MRI. In theory,lular carcinoma (HCC). But detection of easy to detect just by qualitative image a simple subtraction of images derivedsmaller HCC nodules within fibrotic liver reading. But precise (and in the clinical from different phases would highlighttissue is especially challenging [1–7]. routine also fast) assessment of 3D DCE pathologic enhancement including sig- native phase arterial phase portal venous phase late phase 2 Example of a patient with a small HCC (lesion marked by arrows). Caused by a mismatch of the arterial and p.v. as well as late phase, subtraction artifacts are clearly visible (marked by #) in the original data sets and subtracted images are of no diagnostic value. In the case of the subtraction of1A 1B the corrected images, these artifacts are not present and the lesion is well defined. PORTAL VEIN VENOUS CONFLUENCE LEFT A. HEPATICA relative SI RIIGHT A. HEP. 300 Patients and methods nal changes of smallest and already on For non-rigid image registration, for such a non-rigid image registration native images bright lesions. But this a newly developed algorithm was algorithm can be delivered by standard simple approach is not feasible anymore adapted to the special needs of liver hardware as implemented in today’s 200 if offsets between the different phases DCE MRI. This algorithm is based on MR scanner platforms. are present. Not only offset in cranio- maximization of statistical similarity For evaluation of this algorithm in a caudal direction can occur; under patho- criteria (global as well as local) in a vari- clinical setting, a prototype software logic conditions especially, e.g. presence ational framework. It uses correspond- platform was developed which is fully 100 of ascites or after liver segment resec- ing gradients to drive a flow of diffeo- integrated in a standard syngo based tion, one can observe deformations morphisms allowing large deformations. workstation (syngo MMWP). This imple- especially of the liver and as a conse- This flow is introduced through a tem- mented prototype allows the automated quence inplane shift of individual voxels plate propagation method, by composi- retrospective correction of multi-breath- 0 NATIVE ART. P.V. Late NATIVE ART. P.V. Late are present. To enable a fast and accu- tion of small displacements. Regulariza- hold DCE-MRI data sets. It is also capa- rate reading of liver DCE MRI, a non-rigid tion is performed using fast filtering ble of synchronizing the display of the correction algorithm has therefore to be techniques. This approach combines the native, arterial, portal-venous (p.v.) and 1 Relative changes of the signal intensities in patients with HCC measured by an ROI analysis. A) Uncorrected and B) corrected DCE liver data applied. The purpose of our study was robustness of statistical similarity mea- late liver phase. These data sets can sets. SI changes of the left/right hepatic artery were found to be significantly different in the corrected and uncorrected data sets and were the therefore to evaluate the clinical value sures with the flexibility of diffeomor- also be processed to obtain subtraction most sensitive quantitative parameter for evaluation of image mismatch and therefore the function of the correction algorithm. of a retrospective anatomical correction phic matching techniques [8]. In addi- images. In addition, corrected data of multi-breath hold 3D DCE MRI. tion, the required computational power derived from different phases can be66 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 67
  • 36. 3 1st examination 2nd examination 1st examination 2nd examination 1st examination 2nd examinationA * * *B *C * * original examination original DCE – subtraction corrected DCE – subtraction 3 Example of a patient with follow-up examination in case of a dysplastic nodule (lesion marked by arrows). The lesion is already hyperintense enhancement of the lesion at the follow-up MRI only visualized on the corrected, subtracted images consequently. on native T1w MRI. A slight mismatch is obvious especially for the DCE data sets at the second examination. The discrete contrast media A) Native T1w 3D VIBE B) post CM T1w FLASH 2D C) T2w 2D TSE *fold-in artifactsdisplayed as checker boxes for qualita- sis Child A / B was additionally reported. evaluation was performed by two expe- chyma and portal vein. The required cant mismatch of 3D DCE MRI data sets rected DCE MRI data sets in all cases.tive analysis of the proper functionality Additionally, 6 patients with focal nodu- rienced radiologists for the original and total time for assessment of all livers was only obvious in tumor patients This was most obvious in patients withof the algorithm. Corrected DCE MRI lar hyperplasia (FNH), 5 with an ade- corrected data sets (with and without lesions was documented, too. (HCC and metastases). No artificial HCC: 597 s (mean) for the report withdata can be stored as separate image noma and 5 with liver metastases of a subtraction). It included qualitative lesions were introduced by the correc- the original data sets and the conven-sequences and these images can than mamma carcinoma were evaluated. In (presence of artifacts, degree of ana- Results tion algorithm and no additional lesions tional clinically used image viewer;be analyzed further e.g. with the Mean all cases, at least one further MRI fol- tomical mismatch) and semi-qualitative In all cases, the retrospective correction were observed in the cases with FNH 231 s (mean) for the corrected and sub-Curve functionality the enhancement low-up examination was available for (number of lesions per liver segment, of 3D DCE MRI data sets was performed (lesions per patient: n = 1.3), adenoma tracted examinations.patterns were evaluated in more detail. further classification of additional suspi- lesions diameters) criterions. For quanti- successfully. Quality rating was signifi- (n = 1.4) and metastases (n = 1.8).A total of 22 patients were evaluated in cious lesions. All 3D DCE MRI were per- tative data analysis, changes of signal cantly higher for the corrected, sub- While not statistically different, how- Discussion and conclusionretrospect. In all cases, malignancies formed at 1.5 Tesla. For the acquisition intensities (SI) at the native, arterial, tracted images (statistically significant). ever, in patients with a HCC numbers of As shown in this clinical feasibilitywere proven by histology and at least of the dynamic data a T1w gradient- p.v. and late (equilibrium) phase were SI changes of the left/right hepatic detected lesions differed (original data study, the implementation of a non-one follow-up MRI was available as ref- echo (either a 3D FLASH or VIBE) evaluated by a region-of-interest (ROI) artery were found to be the most sensi- sets: n = 4.4; corrected and subtracted rigid liver registration for DCE MRI canerence. In 17 patients a HCC was pres- sequence was used. Acquisition time analysis. Therefore, ROIs were placed tive quantitative parameters to evaluate DCE MRI data: n = 4.7). The total report- clearly improve the overall quality ofent (mean age 66 years, range 55 to 65 was approximately 20 s, resulting reso- within the aorta, left / right hepatic the function of the correction algorithm ing time was significantly reduced by DCE liver MRI especially in patients withyears). In 12/17 patients, a liver cirrho- lution was (2.0 x 1.5 x 2.5) mm3. Data arteries, tumor lesions, liver paren- (compare graph 1). However, a signifi- the synchronous display of the cor- limited breathhold capabilities. Based68 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 69
  • 37. Clinical Abdomen / Pelvis Cardiovascular Clinical How-I-do-iton the evaluated patient cohort, a ten-dency towards a more accurate detec- robust procedure in the clinical work- flow. In addition, several consulting References 1 Van den Bos IC, Hussain SM, Dwarkasing RS, Hop WC, Zondervan PE, de Man RA, IJzermans JN, Non Rigid 3D-Registration for Accurate Subtrac-tion of liver lesions especially in case of radiologists requested that this func-HCC was observed. However, whether tionality should be available as an inline Walker CW, Krestin GP. MR imaging of hepato- cellular carcinoma: relationship between lesion tion of Dynamic Liver Images for Improved Visu-this fact can be reproduced in larger tool; the implementation of a liver reg- size and imaging findings, including signal in-patient groups is still a question to beanswered. In general, it should be men- istration based on dedicated postpro- cessing software would have limited its tensity and dynamic enhancement patterns. J Magn Reson Imaging. 2007 Dec;26(6):1548-55. alization of Liver Lesions with syngo dynaVIBE 2 Van den Bos IC, Hussain SM, Terkivatan T,tioned that the detection of suspicious wide clinical usage. Independent from Zondervan PE, de Man RA. Stepwise carcino- Matthias P. Lichy, M.D.; Wilhelm Horger; Berthold Kiefer, Ph.D.contrast media enhancement within the this request, however, retrospective genesis of hepatocellular carcinoma in the cir-liver tissue is not relying on the most non-rigid registration of dynamic data is rhotic liver: demonstration on serial MR imag- Siemens Healthcare, Magnetic Resonance, Erlangen, Germanyaccurate coregistration and image sub- required for multiple purposes and ing. J Magn Reson Imaging. 2006 Nov;24(5):1071-80.traction. Reading of inaccurately regis- already implemented for advanced 3 Terkivatan T, van den Bos IC, Hussain SM,tered DCE MRI is time-consuming and image reading software. Wielopolski PA, de Man RA, IJzermans JN. Focalcomplex but not the reason why lesions The non-rigid registration of a four- nodular hyperplasia: lesion characteristics on Backgroundwithin the liver tissue are missed. Opti- phase liver DCE MRI exam (syngo state-of-the-art MRI including dynamic gadolini-mal timing of image acquisition with dynaVIBE) is already available for all MR um-enhanced and superparamagnetic iron-ox- The arterial phase derived from T1w venous and equilibrium phase) which the liver in the craniocaudal direction; ide-uptake sequences in a prospective study. Jthe perfusion cycle of the liver, correct scanners equipped with the software contrast-enhanced liver dynamics (liver can result in a clear offset of the ana- under certain conditions e.g. severe Magn Reson Imaging. 2006 Oct;24(4):864-72.contrast media application as well as versions syngo MR B 15 and 17. As 4 Yu JS, Chung JJ, Kim JH, Kim KW. Hypervascular DCE) is perhaps one of the most impor- tomical position over the different ascites or liver resection, movementhigh resolution and optimal contrast described in “Non Rigid 3D-Registration focus in the nonhypervascular nodule (“nodule- tant diagnostic tools for the assessment phases. This has disadvantages for the within the plane including deformationbehavior of the selected DCE MRI for Accurate Subtraction of Dynamic in-nodule”) on dynamic computed tomography: of liver disease. However, true enhance- reading of liver DCE data: firstly, the of the tissue can also be observed. imaging evidence of aggressive progression insequences are the key elements towards Liver Images for Improved Visualization ment of liver lesions is hard to judge in position has to be aligned manually (in With syngo dynaVIBE, however, it is hepatocellular carcinoma. J Comput Assist To-highest detection rates*. Therefore, a of Liver Lesions with syngo dynaVIBE” mogr. 2009 Jan-Feb;33(1):131-5. several conditions such as liver fibroses the worst case three out of the four easy to set up liver DCE scans with retro-statistically significant difference in on page 71 of this issue, these imple- 5 Yu JS, Kim YH, Rofsky NM. Dynamic subtraction or tumor necroses. In addition, even data sets) and secondly, the subtraction spective non-rigid registration of thediagnostic accuracy between original mentations of syngo dynaVIBE require magnetic resonance imaging of cirrhotic liver: under optimal conditions, the patient of different phases will generate severe different liver phases (Figure 1) and alsoand registered as well as subtracted that the liver DCE MRI is set up as one assessment of high signal intensity lesions on might hold his breath in slightly differ- artifacts and may falsely hint to an to generate subtracted images which nonenhanced T1-weighted images. J Computimages was neither expected nor was it single sequence with four measure- ent respiratory phases during the multi- enhancement. But for a precise anatom- can be used for improved demonstra- Assist Tomogr. 2005 Jan-Feb;29(1):51-8.observed in our patient cohort. But ments (covering the four liver phases: 6 Hecht EM, Holland AE, Israel GM, Hahn WY, Kim ple breathholds of a multi-phase DCE ical alignment it is also insufficient to tion of contrast-enhancement of thewhat is most important is that by the native, arterial, (portal-)venous and late DC, West AB, Babb JS, Taouli B, Lee VS, Krinsky liver exam (native, arterial, portal- adjust just the mismatch over time for different phases without the need ofalgorithm no artificial lesions were (or equilibrium) phase). While this GA. Hepatocellular carcinoma in the cirrhoticintroduced into the registered DCE liver approach assures perfect match and liver: gadolinium-enhanced 3D T1-weighted MR imaging as a stand-alone sequence for diagno-MRI exams. However, in daily routine, correct assignment of the different 1 sis. Radiology. 2006 May;239(2):438-47. 1 Scheme of the function-one has to read large amount of image phases for the correction algorithm, in 7 Holland AE, Hecht EM, Hahn WY, Kim DC, Babb ality of a non-rigid liverdata and for this purpose the accurate clinical routine a more flexible handling JS, Lee VS, West AB, Krinsky GA. Importance of I. registration. In general, adisplay of findings over different phases may be required e.g. one could apply a small (< or = 20-mm) enhancing lesions seen dynamic liver scan consists only during the hepatic arterial phase at MR im- of four phases (nativeis required. Efficient reading (this single-shot HASTE MRCP between the aging of the cirrhotic liver: evaluation and com- (row I), arterial (row II),means accurate detection and classifica- (portal-) venous and late phase. parison with whole explanted liver. Radiology. venous (row III) and equi-tion of suspicious lesions within a short 2005 Dec;237(3):938-44. librium, row IV)). Columtime frame) of liver lesions relies on the 8 Chefd’hotel C, Hermosillo G, Faugeras O A displays the originalside-by-side display of the different Flow of Diffeomorphisms for Multimodal Image II. results from such a MR Registration Proc IEEE Int S Bio Im, 2002. exam. However, an anatom-phases and based on our experience, a ical mismatch between theclear profit by providing registered as different phases can bewell as subtracted DCE liver images is observed (reference scan isobvious. In addition, the usage of the shown in light grey). The Contact dynaVIBE algorithm analy-implemented algorithm is not limited to Ulrich Kramer, M.D. III. ses the deformation of theliver DCE MRI and in theory it is capable Diagnostic and Interventional Radiology tissue in all three dimen-of handling a theoretically unlimited University Hospital Tübingen sions and performs an elas-number of data points derived from any *See also Eric Hatfield et al. “Revisiting liver imaging Hoppe-Seyler-Str. 3 tic correction of the voxeldynamic MR exam. with VIBE” in MAGNETOM Flash #39, 2/2008 available 72076 Tübingen shift (columns B and C). online at Germany Resulting (column D) is anBased on the clinical experiences with exact match of the anatom-the above applied first implementation Further reading: Diego R. Martin et al. “Challenges IV. ical structures over space and clinical value of automated and patient-specificof the algorithm, the next step was to and time allowing a voxel- dynamically timed contrast-enhanced liver MRI exami-integrate it as an easy to handle and nation” in MAGNETOM Flash #42, 3/2009 available based analysis of the liver. online at A B C D70 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 71
  • 38. Clinical CardiovascularHow-I-do-it Cardiovascular Clinical How-I-do-it2 3A 3B 3C 3D * * 3 Example of an insufficient match between two phases (A and B) of a dynamic liver scan at identical z-axis position. In this example, no con- trast-media was applied. A subtraction of two completely identical data sets would therefore result in a black screen. 3C shows how a simple subtraction of these two data sets results in severe artifacts, either artificial enhancement (arrows) or signal void (asterisk). After applying the liver registration algorithm, a nearly perfect subtraction is achieved. However, this does not compensate for signal intensity changes introduced e.g. by pulsation / movement within one acquisition (arrows) or non contrast-media related signal changes as present in this example within 2 Easy set up of syngo dynaVIBE. the aorta (asterisk).further post-processing steps. saturation is used. It is important for the parameters. This parameter has to be activating the “Subtraction” feature. This also presented to the radiologist who is accessed with the right button menu willThis technology is available for all Inline calculation of the non-rigid liver set to “4”. By activating the “Liver regis- produces three series, showing the reporting the exam. In this case “Save not be integrated.MAGNETOM systems running on syngo registration and for the subtraction of tration” feature (simply check the box, arterial, (portal-) venous and equilib- original images” should be activated. In daily routine it may be useful to setMR B15, 17 and for the syngo MR D the different phases that the scanner cf. figure 2), the non-rigid liver registra- rium enhancement patterns. up a few variations of the liver DCE VIBEsoftware versions. can clearly identify the coherent mea- tion will be performed after the comple- In the past the computational require- Further considerations sequence with special regard to breath- surements which define the liver DCE. It tion of the liver DCE. ments for non-rigid registration algo- The liver registration algorithm is inde- hold capabilities of the patientsHow to set up a syngo is also a prerequisite for the algorithm By default, the second phase (which rithms clearly limited their usage in clini- pendent from the time intervals between (adopted resolution, scan duration anddynaVIBE liver DCE that the number of slices within the should represent the arterial phase) will cal routine. However, by optimizing the the different measurements. These slab thickness) and with the featuresA syngo dynaVIBE liver DCE examination slab, FOV and matrix are not changed be used as reference for the liver regis- algorithm and applying the computer pauses between the different phases can described above activated. This wouldrequires four phases: for the separate phases of a liver DCE tration and the other three measure- power available with Siemens MR scan- be defined by fixed values but it is also further reduce the required interactiona) Native exam. Therefore all the above four mea- ments will be adjusted accordingly to ners, the final results of a syngo dynaVIBE possible to start a measurement manu- for the Radiographer in adopting theb) Arterial surements must be linked. This can eas- the position and shape of the liver as exam will be available very quickly. It is ally (Inline display feature). However, it is liver DCE and also avoid the risk of for-c) (Portal-) Venous ily be achieved by selecting “multiple present in the reference phase. Based also important to note that the MR exam not possible to combine independent 3D getting to activate the syngo dynaVIBEd) Equilibrium phase. measurements” in the “Inline” menu on this registration one can easily can be continued without need for paus- VIBE scans, and additional scans added features.As MR sequence, a T1w 3D VIBE with fat when adjusting the 3D VIBE sequence generate subtracted images by simply ing. Original data sets can be stored and for example with the “append” command Figure 3 shows an insufficient match of72 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 73
  • 39. 4A 4BClinical Cardiovascular I. II. Market your MAGNETOM system > Your MAGNETOM > MAGNETOM Marketing Tool Kit * * This webpage provides you with Marketing Tools to promote your MAGNETOM system. Multimedia The future belongs to multimedia communications! In this section you will find4C 4D specific powerpoint presentations and trailers helping to promote your system and its offerings to your customer. > PowerPoint Presentation > Trailers (Product Trailer, MRI Safety Video, Understanding MRI, MR Kids Cartoon) Print media Effective print media continues to play a key role in successful communications. The contents in this section will help you to create professionally designed print pieces for promoting your new MR system. > Advertisements > Mailing > Logbook 4 The liver registration algorithm also corrects other anatomical structures within the 3D data sets. In all images shown, the native phase was subtracted from the arterial enhancement with 4A/4C for original and 4B/4D for registered data. 4A shows blooming of the renal cortex (arrowhead) without correction. Even under nearly perfect conditions, a slight mismatch can be observed in most liver scans. Rimming at the organ boarders is often a good indicator (arrows). The asterisk indicates artificial enhancement On-site material of the bone marrow for uncorrected subtracted phases (arterial minus native liver phase shown). 4C and 4D show magnified areas from the Take a number of quite different marketing steps. This section contains valuable left liver lobe. In this patient with severe fibrosis and hepatocellular carcinoma, an overemphasis of the arterial enhancement is obvious (same window level for both images). tips and checklists that will support you in all these individual activities. > Appointment Calendar > Posters > Patient Information and Safety Guidesthe subtracted two phases of a liver After completion of a liver DCE, the These artifacts may very often be easily > Event ChecklistDCE. This can be recognized by the quality and contrast-media timing of separated from a potential malfunction > Material for kidshyperintense rims of anatomical struc- the individual phases as well as the of the non-rigid liver registration.tures. However, areas with complete results of the Inline calculation should In conclusion, a clear improvement of Image galleryloss of signal can also be seen. “Blur- be checked. While the liver registration the results of liver DCE scans can be A picture is worth a thousand words! Here are some sample images that say aring” of anatomical structures compared algorithm does not compensate for achieved with syngo dynaVIBE without great deal, and you can use them for many the original, unsubtracted images can noise bands, pulsations and breathing the need of further post-processing.also be an indicator for an insufficient the artifacts may be present within the > Product imagesanatomical match. individual measurement of a liver DCE. > Mood images > Clinical images Contact k Tips how to optimize the sequence parame- Matthias Lichy, M.D. ters of 3D VIBE for liver DCE can be found in Siemens Healthcare Eric Hatfield et al. “Revisiting Liver Imaging PR basics Magnetic Resonance Karl-Schall-Str. 6 with VIBE” published in MAGNETOM Flash Revolutionary technology is news worthy! Your local news media can help you to D-91052 Erlangen 2/2008 (page 11), which is available online at publicize your MAGNETOM system. This press release makes it easy for you – and Germany for them – to spread the exciting word. > Press Release74 MAGNETOM Flash · 3/2010 ·
  • 40. Product News Product NewsVIBE for Liver Imaging K-space reordering scheme A new k-space reordering scheme was introduced to improve image quality: Fat suppression Linear k-space reordering is used in con- junction with the Q-Fatsat option avail- long enough to allow a symmetric echo, and the echo optimization (on thewith syngo MR B17 Linear reordering in the slice (3D / parti- tion) direction produces clean image quality, as it is less susceptible to able in the Contrast UI tab card. Inter- nally, the flip angle of the fat saturation pulse is adjusted for nulling the fat sig- Sequence – Part 1 UI tab card) must be None. Symmetric echo also produces uniform fat suppression with linear reor- artifacts and motion due to its smooth nal at the center of k-space. This scheme dering scheme.Agus Priatna, Ph.D.1; Stephan Kannengiesser, Ph.D.2 magnetization trajectory. It also allows produces uniform fat suppression for the for shortening the scan time as it does liver. If the condition of zero fat signal at Reconstruction with Projection1 MR R&D Collaborations, Siemens Medical Solutions, St Louis, MO, USA not require ‘dummy’ pulses to drive the the center of k-space cannot be met, the Onto Convex Sets (POCS)2 MR Applications Development, Siemens Healthcare, Erlangen, Germany signal into the steady state condition. reordering reverts to centric reordering A new option to enhance image recon- The linear reordering acquisition is still in the slice direction, which was the struction is also available in the syngo ‘single-shot’ to maintain the short scan standard setting up to now. This condi- MR B17 software: Projection Onto time. Furthermore, the linear reordering tion is dependent on the resolution Convex Sets or POCS can be selected on scheme reduces artificial enhancement parameters in the slice direction, on TR, the Resolution – Filter UI tab card whenVolume Interpolated Breathhold Exami- arterial, portal venous, early equilibrium the most critical requirements for VIBE: of the liver edges. and on the imaging flip angle. It is rec- using partial Fourier in the phase and/ornation (VIBE) [1] is a well known tech- and 5 minutes delayed equilibrium uniform fat suppression, excellent tissue ommended that opposed phase TE is read directions. POCS reconstructionnique for imaging of the liver. VIBE phases of enhancement. This allows contrast, image sharpness, few artifacts, used for dark fat suppression when will sharpen the image by reducing theoffers three-dimensional multi-phase more accurate characterization than and short scan time. The new function- using asymmetric echo. It is also possi- blurring induced by partial Fourieracquisition before and following con- static pre or post-contrast analysis. alities include a new k-space reordering ble to use a reversed echo asymmetry acquisition.trast administration under breathhold In the syngo MR B17 software, new scheme, a new fat suppression scheme, to shorten the scan time by manuallyconditions. The dynamic behavior of the functionalities have been added to the and a new reconstruction functionality. reducing the TR while maintaining theliver lesions and structures is typically VIBE sequence to better meet the TE constant. For this, the TE has to beanalyzed by scanning pre-contrast, clinical requirements. The following are 1 2 1 The linear 2 The POCS reordering option as it scheme as appears on seen in the the resolution user interface tab. (UI).76 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 77
  • 41. Product News Product News3A 3B 3 Typical VIBE 3 (B) Portal venous images obtained at phase. (Images 3T MAGNETOM Trio, courtesy of Washing- A Tim system ton University in (A) Arterial phase. St Louis.)Examples of protocolsThe followings are recommendations to ■ 10 degree excitation flip angle at 1.5T ■ Phase partial Fourier = Off for image Figure 3 shows the typical image quality asymmetry Off, phase partial Fourieracquire good image quality of VIBE for system and 9 degree at 3T system for sharpness. of the arterial phase (A) and the por- Off, TE 1.9 ms, TR 4.1 ms, 72 partitions,liver imaging: uniform fat suppression. ■ If further scan time reduction is neces- tal venous phase (B) acquired at 3T Prescan normalized, total acquisition■ Q-Fatsat with linear reordering. ■ Symmetric echo for image sharpness. sary, select 7/8 phase partial Fourier. MAGNETOM Trio Tim with the following time 19.72 seconds. These images show■ 320 base resolution to increase image ■ Opposed phase TE if using asymmetric Using POCS will reduce blurring. parameters: Q-Fatsat with linear reorder- good fat suppression and good contrast sharpness. echo for uniform fat suppression. ■ Prescan Normalize filter. ing, BW 446 Hz/pixel, base resolution enhancement. ■ Slice partial Fourier = 6/8. 320, slice thickness 3 mm, echo78 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 79
  • 42. Product News Product News4A 4B 5A 5B 4 A portal venous phase as seen in a patient with colorec- tal cancer metastasis obtained at 3T MAGNETOM Trio with Tim system. (Images courtesy of Washington University in St Louis.)4C 4D Pre-contrast Arterial phase 5C 5D4E 4F Portal venous phase Early equilibrium 5E 5 Dynamic contrast-enhanced images of a patient with metastases from a colon cancer obtained at 1.5T open-bore MAGNETOM Espree system. (Images courtesy of Washington University in St Louis.) ConclusionsFigure 4 shows another example of clini- Figure 5 is an example of a multi-phase New functionality of the VIBE sequencecal cases obtained from 3T MAGNETOM contrast-enhanced VIBE scan on a 1.5T in the syngo MR B17 software allowsTrio, A Tim system. Images shown are open-bore MAGNETOM Espree system improvements in fat suppression, tissue 5 min delaythe portal venous phase of a patient of a patient with metastases from colon contrast, image sharpness, residual arti-with metastases from a colon cancer cancer with the following protocol: fact, and scan time. The improvementsobtained with the same 3T protocol Q-Fatsat with linear reordering, BW 390 in image quality are shown on both 3Tmentioned above. Image sharpness and Hz/pixel, Base resolution 320, slice thick- and 1.5T systems. References Contact 1 Rofsky NM, Lee VS, et al. Abdominal MR Imagingcontrast enhancement are seen in this ness 3 mm, echo asymmetry Off, phase Agus Priatna with a Volume Interpolated Breath-hold Exami-example. partial Fourier Off, TE 2.2 ms, TR 4.4 ms, nation. Radiology. 1999 Sept; 212(3):876-84. Siemens Medical Solutions USA, Inc. 72 partitions, acquisition time 24 sec- MR Research Collaborations 51 Valley Stream Parkway onds. These images show sharpness, Malvern, PA 19355-1406 good contrast enhancement, uniform USA fat suppression and reduced artifacts on an open-bore system.80 MAGNETOM Flash · 3/2010 · MAGNETOM Flash · 3/2010 · 81
  • 43. SubscriptionSiemens Healthcare PublicationsOur publications offer the latest information and background for every healthcarefield. From the hospital director to the radiological assistant – here, you can quickly findinformation relevant to your needs. Medical Solutions Innovations and trends eNews in healthcare. The Register for the magazine is designed global Siemens especially for members Healthcare News- of hospital manage- letter at ment, administration personnel, and heads healthcare-eNews of medical depart- to receive monthly ments. updates on topics that interest you. AXIOM Innovations MAGNETOM Flash SOMATOM Sessions Everything from the worlds Everything from the world Everything from the world of interventional radiology, of magnetic resonance of computed tomography. cardiology, fluoroscopy, imaging. The magazine With its innovations, clinical and radiography. This semi- presents case reports, applications, and visions, annual magazine is primar- technology, product news, this semiannual magazine ily designed for physicians, and application tips. It is is primarily designed for physicists, researchers, and primarily designed for physicians, physicists, medical technical personnel. physicians, physicists, and researchers, and medical medical technical personnel. technical personnel. For current and past issues and to order the magazines, please visit MAGNETOM Flash · 3/2010 ·
  • 44. ImprintAmong Europe’s BestSiemens Healthcare Publications received the Silver Award experts from the areas of journalism, design, marketing, cor-in the category “Best Crossmedia Solution” at the BCP Best of porate/internal communication, print, and direct marketing.Corporate Publishing Congress in Hamburg, Germany. Under Obtaining the BCP Silver Award places Siemens Healthcarethe topic “Healthcare Publications,” Siemens Healthcare sub- among the top corporate crossmedia publishers in Europe.mitted its crossmedia publications portfolio, which consists The jury of the largest corporate publishing contest in Europeof the business-to-business magazine Medical Solutions, the honored the best publications out of more than 600 entriesexpert magazines AXIOM Innovations (angiography, radiography, in 29 permanent and four special categories. 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