This document summarizes new abdominal MR imaging protocols using fast 3D gradients and breath hold techniques. It discusses T1, T2, diffusion weighted sequences and the use of liver specific contrast agents for evaluating conditions like cirrhosis, HCC and cholangiocarcinoma. Protocols for liver lesions include pre and post contrast T1 weighted sequences in arterial, portal venous and hepatobiliary phases. Diffusion imaging and hepatobiliary phase are valuable for small HCC detection. Multiphase kidney protocols evaluate corticomedullary, nephrographic and excretory phases for renal tumors. New protocols combining diffusion and hepatobiliary imaging improve HCC detection over single sequences.

1. ABDOMINAL
MR IMAGING
Evolving protocols
DR.MANOJ.K.S MD,DNB RD
METRO SCANS,TRIVANDRUM

2. INTRODUCTION
With the advent of fast 3D gradients it was
possible to image Liver and abdominal
organs with high speed and resolution .
The breath hold and single shot techniques
helped in fighting the problem of motion in
abdominal imaging
Diffusion imaging has added another valuable
dimension
Perfusion and MRS now coming up

3. BODY MR PULSE SEQUENCES
T2 WEIGHTED IMAGING
FSE - FRFSE +_ Fat suppression
SSFSE
IR
• STIR
BALANCED SEQUENCES
FIESTA +/-fat sat

4. BODY MR PULSE SEQUENCES
T1 WEIGHTED IMAGING
LAVA
FSPGR
DUAL ECHO

5. DIFFUSION IMAGING - BODY DIFFUSION
• "DW MR imaging should be considered in evaluation of
cancer patients when there is a need to minimize radiation
exposure (children and pregnant women) , cases where
contrast-enhanced body CT evaluations are of inadequate
quality (patients with renal failure, poor venous access,
contrast medium allergies), or cases when there is a need
to survey the entire bone marrow
Anwar R. Padhani, Dow-Mu Koh, and David J. Collins
• Whole-Body Diffusion-weighted MR Imaging in Cancer: Current Status and Research
DirectionsRadiology December 2011 261:3 700-718; doi:10.1148/radiol.11110474

6. BODY DIFFUSION /PET-CT
Newly Diagnosed Lymphoma: Initial Results With Whole-Body T1-Weighted, STIR, and Diffusion-Weighted MRI Compared
With 18F-FDG PET/CTAJR March 2011 vol. 196no. 3 662-669

7. Enhanced DWI1
Improved ADC quantification "In our facility, we have found
that the high image quality of
Improved SNR and contrast … the IR-prep DWI sequence is
applicable for a broad range of
Reduced scan time … smart oncology studies and
averaging treatment monitoring“
Dr T. La Folie,
Improved spatial resolution … 3-
in-1 mode HIA Laveran
1 Compared to conventional DWI technique Ste Anne Hospital, Paris,
Flexible fat suppression France
b=50 b=600
b=200 b=1000
Respiratory Triggered eDWI Liver mets 3in1 , b=500, 4 NEX
at 3.0T Breath-hold
Courtesy: Keio University, Japan; Sharp & Children, USA; St. Joseph, France

8. Enhanced DWI1
Improved ADC quantification
Improved SNR and contrast …
Reduced scan time … smart
averaging
Improved spatial resolution … 3-in-1
mode eDWI control panel
1 Compared to conventional DWI technique
Flexible fat suppression
3in1 192 x 224 in 30 s Increased confidence in lesion detection
b20 1NEX b500 3NEX T1w T2w DWI
b800 3NEX
Courtesy of Sharp and Childrens, USA; CCN, France

9. eDWI PROPELLER 3.0 WBI eDWI at
1.5T
eDWI b1000
8 mm, 128x192,
1:04 min Resp
Trig. 3 in 1
ADC Map
MR 450 1.5T: Colorectal tumor
b-value 1300, 3.5 mm slice
DWI/T2w fusion overlay Prostate cancer at Bone metastases
3.0T
Courtesy of Hospital Vera Cruz, Brazil, Yokohama Sakae Kyosai Hospital, Japan, Sharp and Children San

10. DIFFUSION IMAGING : BODY DIFFUSION
“Whole-body diffusion-weighted MRI can be used
for tumor staging and assessment of treatment
response. Meticulous technique and knowledge of
potential interpretive pitfalls will help to avoid
mistakes and establish this modality in radiologic
practice”
Whole-Body Diffusion-Weighted MRI: Tips, Tricks, and Pitfalls
Dow-Mu Koh, Matthew Blackledge, Anwar R. Padhani ,Taro Takahara, Thomas C.
Kwee,
Martin O. Leach and David J. Collins
10.2214/AJR.11.7866AJR August 2012 vol. 199no. 2 252-262

11. “Virtual Biopsy”
• Prof. Diego R. Martin, M.D., Ph.D. The Cosden
Professor and Chair Department of Radiology University of Arizona College of Medicine Tucson
• Has termed the current MR sequences and contrast
studies as equivalent to doing a virtual biopsy since by
MR imaging many benign and malignant lesions could
be diagnosed without any additional pathologic proof.

12. LIVER SPECIFIC CONTRAST
MULTIHANCE - Gadobenate dimeglumine
PRIMOVIST - Gadoxetic acid

13. LIVER
CHRONIC LIVER DISEASES - CIRRHOSIS
DIFFUSE LIVER DISEASES
BENIGN FOCAL LESIONS
MALIGNANT LESIONS

14. CLD – FIESTA Fatsat images

15. LAVA

16. Cirrhosis

17. Cirrhosis

19. PROTOCOL FOR HCC
• FRFSE fat sat
• DWI
• LAVA MULTIPHASIC CONTRAST
 Arterial phase -early/late 30 s
 Portal Venous phase 70s
 Immediate delayed 180s
 Equilibrium phase 5-7 mt
 Hepato-biliary phase 20 mt (primovist)
60-120mt with Multihance

20. Consensus guidelines of the APASL &AASLD on the
definition of imaging features of classical HCC.
The presence of arterial hypervascularity and washout are generally
considered to be highly specific for the diagnosis of HCC -referred to
as “classical imaging features”
Arterial hypervascularity is defined as increased enhancement of the
lesion in the hepatic arterial phase of imaging relative to the
background liver.
Since HCC receives predominant vascular supply via the hepatic artery
Washout” of the lesion is based on the fact that HCC contains
predominantly arterial blood and so, by the time portal venous and
delayed images are acquired, the lesion is observed to be
hypoattenuating on CT (or in the case of MRI, “hypointense”) to the
surrounding liver at the portal venous or equilibrium phase.

21. MR Protocol
Contrast-enhanced dynamic MRI, 0.025mmol kilogram 21 of body weight
of gadoxetic acid disodium (Primovist; )
injection rate of 2 ml s21 as a rapid bolus followed by a saline flush of 20
ml.
3D spoiled gradient-recalled-echo sequence with chemically selective
fat suppression during suspended respiration
30–35 s (arterial phase),
60–70 s (portal phase),
90–100 s (hepatic venous phase)
120–150 s (equilibrium phase)
after the intravenous injection of the contrast agent.
Additional hepato-biliary phase images were obtained at 20 min after
injection
Differentiation of early hepatocellular carcinoma from benign hepatocellular nodules on gadoxetic
acid-enhanced MRI H RHEE, MD, 1,2M-J KIM, MD, PhD, 1,2M-S PARK, MD, PhD and 1K A KIM, MD
1Department of Radiology, Yonsei University Severance Hospital, Seoul, Republic of Korea, and
2Research Institute of Radiologic Science, Yonsei University Severance Hospital, Seoul, Republic of
Korea May 2, 2012 BJR

22. MR Protocol
Gadoxetic acid-enhanced MRI,
Unenhanced, arterial phase (20–35 s; via a bolus triggered
technique under fluoroscopic guidance),
Portal phase (60 s),
Late phase (3 min),
20-min delayed Hepato-biliary phase
Small (<2 cm) hepatocellular carcinoma in patients with chronic liver disease: comparison
of gadoxetic acid-enhanced 3.0 T MRI and multiphasic 64-multirow detector CT
J HWANG, MD, S H KIM, MD, M W LEE, MD and J Y LEE, MD
Department of Radiology and Center for Imaging Science, Samsung Medical Center,
Sungkyunkwan University School of
Medicine, Seoul, Republic of Korea The British Journal of Radiology, 85 (2012), e314–
e322BJR July 1, 2012 vol. 85 no. 1015 e314-e322

23. MR Protocol
Dynamic fat-saturated T1-weighted gradient-echo images with 3D LAVA
Non Contrast phase
20–30 seconds (arterial phase, fluoroscopic triggering technique),
60 seconds (portal venous phase),
2 minutes (late phase),
5, 10, and 20 minutes (hepatocyte phase)
Gadoxetic acid administration bolus (0.025 mmol per kilogram body
weight) rate of 1 mL/sec flushed with 20 mL of saline
Imaging Study of EarlyHepatocellular Carcinoma: Usefulness of Gadoxetic Acid–enhanced MR
Imaging Katsuhiro Sano, MD, PhD, etal
December 2011 Radiology, 261, 834-844.
From the Departments of Radiology (K.S., T.I., U.M., H.S., A.M.M., T.A.), Surgery 1 (M.M., M.A., H.F.),
Pathology (T.N.), and Internal Medicine 1 (T.K., N.E..), University of Yamanashi, 1110 Shimokato,
Chuo-shi, Yamanashi 409-3898, Japan; Department of Diagnostic Pathology, Tokyo Women’s Medical
College Yachiyo Medical Center, Yachiyo, Japan (M.N.); and Department of Pathology, Keio
University, Tokyo, Japan (M.S.).

24. Small HCC
Hypervascular Hepatocellular Carcinoma 1 cm or Smaller in Patients With Chronic Liver
Disease: Characterization With Gadoxetic Acid–Enhanced MRI That Includes Diffusion-
Weighted Imaging
1. Department of Radiology and Center for Imaging Science, Sungkyunkwan University School of Medicine, Samsung
Medical Center, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea.
AJR June 2011 vol. 196 no. 6W758-W765
Hypovascular Hypointense Nodules on Hepatobiliary Phase Gadoxetic Acid–enhanced MR
Images in Patients with Cirrhosis: Potential of DW Imaging in Predicting Progression to
Hypervascular HCC
Radiology October 2012 265:1 104-114;
Small (≤2 cm) hepatocellular carcinoma in patients with chronic liver disease: comparison of
gadoxetic acid-enhanced 3.0 T MRI and multiphasic 64-multirow detector CT
BJR July 1, 2012 vol. 85 no. 1015 e314-e322
• Small Hepatocellular Carcinomas: Improved Sensitivity by Combining Gadoxetic Acid–enhanced and
Diffusion-weighted MR Imaging PatternsRadiology September 2012 264:3 761-770
• Min Jung Park, Young Kon Kim, Min Woo Lee, Won Jae Lee, Young-Sun Kim, Seong Hyun Kim, Dongil Choi, and Hyunchul Rhim

25. Rationale for the new MR protocols
“Hepatocarcinogenesis is a multifactorial process
that includes changes in architecture, cellular
density, hepatocyte function, and Kupffer cell
numbers or function . Accordingly, combining
gadoxetic acid and DW imaging has the potential
to be robust liver MR protocol in that it is targeting
three processes of hepatic carcinogenesis:
hemodynamic changes, hepatocyte function, and
tissue diffusivity”
Imaging Study of Early Hepatocellular Carcinoma: Usefulness of Gadoxetic Acid–
enhanced MR Imaging Katsuhiro Sano, MD, PhD, etal
December 2011 Radiology, 261, 834-844 .

26. MR Diagnostic criteria
A size cut-off value (>/=1.5cm diameter)
MRI findings of T1 hypointensity,
T2 hyperintensity, DWI hyperintensity on both low and high b-value
images (b550 and 800 s mm22, respectively), arterial enhancement,
late washout and hepato-biliary
hypointensity
Differentiation of early hepatocellular carcinoma from benign
hepatocellular nodules on gadoxetic acid-enhanced MRI H RHEE, MD,
1,2M-J KIM, MD, PhD, 1,2M-S PARK, MD, PhD and 1K A KIM, MD
1Department of Radiology, Yonsei University Severance Hospital,
Seoul, Republic of Korea, and 2Research Institute of Radiologic
Science, Yonsei University Severance Hospital, Seoul, Republic of
Korea May 2, 2012 BJR

27. Cholangiocarcinoma
• FRFSE fat sat
• DWI
• MRCP
• MR CONTRAST ANGIOGRAPHY
• LAVA CONTRAST
 Venous phase 70s
 Immediate delayed 120s
 Hepato-biliary phase 20 mt (primovist)
60/120mt with Multihance

28. Choangiocarcinoma

29. HBP phase enhancement

30. Infiltration by metastases

31. DWI in metastases

32. MR Protocol for FNH
• FRFSE fat sat
• DUAL ECHO SPGR
• LAVA MULTIPHASIC CONTRAST
 Arterial phase -early/late 30 s
 Portal Venous phase 70s
 Immediate delayed 180s
 Equilibrium phase 5-7 mt
 Hepato-biliary phase 20 mt (primovist)
60-120mt with Multihance

33. FNH

34. FNH

35. FNH

36. FNH

37. KIDNEY – MULTIPHASIC MR
ANGIOGRAPHIC/ CORTICOMEDULLARY
NEPHROGRAPHIC
UROGRAPHIC PHASE
Renal Cortical Tumors: Use of Multiphasic Contrast-enhanced MR
Imaging to Differentiate Benign and Malignant Histologic
Subtypes Radiology September 2012 264:3 779-788; Published
online July 24, 2012,doi:10.1148/radiol.12110746

38. Multiphasic contrast-enhanced MR
imaging protocol
precontrast, corticomedullary phase, nephrographic phase,
and excretory phase.
(SmartPrep; GE Medical Systems) to synchronize the
contrast material administration with the image acquisition.
The first postcontrast sequence 5 seconds after peak
arterial enhancement,
followed by 70 seconds after contrast material
administration
and 3–4 minutes after contrast material administration.
Subtraction of the precontrast images from the postcontrast
images was performed at the console.

39. 50 yr male pt with severe UTI

40. pt with UTI

41. LAVA CONTRAST

42. LAVA Delayed excretion phase

43. Thank You All
Thanks to Dr.SureshBabu,
Metro scans