Body MR in the Emergency Setting Lloyd Stambaugh, M.D.
CT and Cancer Risk <ul><li>CT scans/year </li></ul><ul><ul><li>1980 3 million </li></ul></ul><ul><ul><li>2007 62 million (...
CT and Cancer Risk <ul><li>Recent NEJM article estimates that as much as 1.5 – 2 % of all cancers in the U.S. may be the r...
MR Small Bowel <ul><li>Development of rapid breath-hold sequences  </li></ul><ul><li>High T2 signal of water </li></ul><ul...
3T MR—normal small bowel
3T MR—MR enterography
Normal post-contrast small bowel
3T MR—Normal multiphase post-Gd small bowel
MRI Appendicitis <ul><li>In a study of 51 pregnant patients, MRI was 100% sens and 94% specific in diagnosing appendicitis...
MR Appendicitis <ul><li>Dilated fluid-filled appendix </li></ul><ul><li>Peri-appendiceal edema </li></ul><ul><li>Thickened...
Normal appendix
Normal Appendix
Normal Appendix
Copyright ©Radiological Society of North America, 2006 Appendiceal phlegmon in 29-year-old pregnant woman
Copyright ©Radiological Society of North America, 2007 Patel, S. J. et al. Radiographics 2007;27:1705-1722 Acute appendici...
Copyright ©Radiological Society of North America, 2007 Acute appendicitis in a nonpregnant patient
Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Acute appendicitis...
Copyright ©Radiological Society of North America, 2006 Pedrosa, I. et al. Radiology 2006;238:891-899 Appendiceal phlegmon ...
Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Perforating append...
Copyright ©Radiological Society of North America, 2006 Pedrosa, I. et al. Radiology 2006;238:891-899 Mild acute appendicit...
Copyright ©Radiological Society of North America, 2006 Pedrosa, I. et al. Radiology 2006;238:891-899 MR images in 33-year-...
Copyright ©Radiological Society of North America, 2007 Acute appendicitis in a 20-year-old pregnant patient
Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Gangrenous appendi...
MRI Crohn’s <ul><li>MRI’s inherent tissue contrast allows effective imaging of bowel and inflammation </li></ul><ul><li>Cr...
MRI Crohn’s <ul><li>59 Crohn’s patients were evaluated with MR </li></ul><ul><li>T2 and post-Gd T1 had 98% sens and 78% sp...
Copyright ©Radiological Society of North America, 2005 Maccioni, F. et al. Radiology 2005;238:517-530 28-year-old man with...
Copyright ©Radiological Society of North America, 2005 Maccioni, F. et al. Radiology 2005;238:517-530 Recurrence of Crohn ...
Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Crohn disease
Crohn’s with Ileo-ileo fistula
Crohns with reactive lymph nodes—3T image
3T MR—Crohns disease Comb sign—engorged vasa recta
3T MR—Crohns disease Neo-terminal ileum with ulceration
Diverticulitis with colovesicle fistula
3T MR Colonography Cecal cancer
Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Acute epiploic app...
Post-adhesiolysis for SBO; mild resolving ileus
MR GU Pathology <ul><li>High T2 water signal gives MR an advantage in imaging the renal collecting systems </li></ul><ul><...
3T MR—Normal renal collecting systems
MR Urography <ul><li>MR urography is similar in accuracy to CT in assessing renal obstruction </li></ul><ul><li>MR is supe...
Hydronephrosis & Pregnancy <ul><li>Hydro of pregnancy </li></ul><ul><li>Usually mild </li></ul><ul><li>Right > Left </li><...
NF Mild hyronephrosis of pregnancy
Mild hydronephrosis of pregnancy
Distal left ureter obstruction
Distal right ureter obstruction
3T MR—partial obstructing mid L ureter stone
3T MR—distal R ureter susceptibility artifact… Not ureter stone
3T MR—renal pelvis stone
Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Adnexal torsion
Ovarian torsion
Ovarian fibroma
3T MR—tubo-ovarian abscess
Smoker with index finger ulcer
 
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Body MR imaging in the emergenecy setting. Focus on application where MRI provides diagnostic information for patient management in the emergency department, without radiation exposure.

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  1. 1. Body MR in the Emergency Setting Lloyd Stambaugh, M.D.
  2. 2. CT and Cancer Risk <ul><li>CT scans/year </li></ul><ul><ul><li>1980 3 million </li></ul></ul><ul><ul><li>2007 62 million (4M in children) </li></ul></ul><ul><li>Radiation dose estimate </li></ul><ul><ul><li>CT 10-20 mSv (per scan) </li></ul></ul><ul><ul><li>30-60 mSv for multi-phase </li></ul></ul><ul><ul><li>CXR 0.2 mSv </li></ul></ul>
  3. 3. CT and Cancer Risk <ul><li>Recent NEJM article estimates that as much as 1.5 – 2 % of all cancers in the U.S. may be the result of radiation from CT scans. </li></ul><ul><li>There is NO ionizing radiation exposure from MRI </li></ul>
  4. 4. MR Small Bowel <ul><li>Development of rapid breath-hold sequences </li></ul><ul><li>High T2 signal of water </li></ul><ul><li>Intrinsic MR tissue contrast </li></ul><ul><li>Multi-planar imaging </li></ul>
  5. 5. 3T MR—normal small bowel
  6. 6. 3T MR—MR enterography
  7. 7. Normal post-contrast small bowel
  8. 8. 3T MR—Normal multiphase post-Gd small bowel
  9. 9. MRI Appendicitis <ul><li>In a study of 51 pregnant patients, MRI was 100% sens and 94% specific in diagnosing appendicitis </li></ul><ul><li>Additional studies report ranges of 97-100 % sensitivity and 92-94% specificity. </li></ul>
  10. 10. MR Appendicitis <ul><li>Dilated fluid-filled appendix </li></ul><ul><li>Peri-appendiceal edema </li></ul><ul><li>Thickened wall </li></ul><ul><li>Enhancement (if Gd is given) </li></ul>
  11. 11. Normal appendix
  12. 12. Normal Appendix
  13. 13. Normal Appendix
  14. 14. Copyright ©Radiological Society of North America, 2006 Appendiceal phlegmon in 29-year-old pregnant woman
  15. 15. Copyright ©Radiological Society of North America, 2007 Patel, S. J. et al. Radiographics 2007;27:1705-1722 Acute appendicitis in a pregnant woman with right lower quadrant pain
  16. 16. Copyright ©Radiological Society of North America, 2007 Acute appendicitis in a nonpregnant patient
  17. 17. Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Acute appendicitis in a 21-year-old pregnant patient
  18. 18. Copyright ©Radiological Society of North America, 2006 Pedrosa, I. et al. Radiology 2006;238:891-899 Appendiceal phlegmon in pregnant woman
  19. 19. Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Perforating appendicitis in a 16-year-old girl
  20. 20. Copyright ©Radiological Society of North America, 2006 Pedrosa, I. et al. Radiology 2006;238:891-899 Mild acute appendicitis in a 27-year-old pregnant woman (gestational age, 13 weeks)
  21. 21. Copyright ©Radiological Society of North America, 2006 Pedrosa, I. et al. Radiology 2006;238:891-899 MR images in 33-year-old pregnant woman (gestational age, 20 weeks) with acute appendicitis
  22. 22. Copyright ©Radiological Society of North America, 2007 Acute appendicitis in a 20-year-old pregnant patient
  23. 23. Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Gangrenous appendicitis in a pregnant patient
  24. 24. MRI Crohn’s <ul><li>MRI’s inherent tissue contrast allows effective imaging of bowel and inflammation </li></ul><ul><li>Crohn’s patients tend to be young and will often have multiple imaging studies, making radiation exposure from CT an issue </li></ul>
  25. 25. MRI Crohn’s <ul><li>59 Crohn’s patients were evaluated with MR </li></ul><ul><li>T2 and post-Gd T1 had 98% sens and 78% spec for ileal lesions </li></ul><ul><li>T2 images found: </li></ul><ul><ul><li>90% of severe strictures </li></ul></ul><ul><ul><li>71% of entero-enteric fistulas </li></ul></ul><ul><ul><li>all abscesses </li></ul></ul>
  26. 26. Copyright ©Radiological Society of North America, 2005 Maccioni, F. et al. Radiology 2005;238:517-530 28-year-old man with known Crohn disease
  27. 27. Copyright ©Radiological Society of North America, 2005 Maccioni, F. et al. Radiology 2005;238:517-530 Recurrence of Crohn disease in a 52-year-old man
  28. 28. Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Crohn disease
  29. 29. Crohn’s with Ileo-ileo fistula
  30. 30. Crohns with reactive lymph nodes—3T image
  31. 31. 3T MR—Crohns disease Comb sign—engorged vasa recta
  32. 32. 3T MR—Crohns disease Neo-terminal ileum with ulceration
  33. 33. Diverticulitis with colovesicle fistula
  34. 34. 3T MR Colonography Cecal cancer
  35. 35. Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Acute epiploic appendagitis
  36. 36. Post-adhesiolysis for SBO; mild resolving ileus
  37. 37. MR GU Pathology <ul><li>High T2 water signal gives MR an advantage in imaging the renal collecting systems </li></ul><ul><li>Intrinsic MR tissue contrast provides detailed imaging of the uterus and ovaries </li></ul>
  38. 38. 3T MR—Normal renal collecting systems
  39. 39. MR Urography <ul><li>MR urography is similar in accuracy to CT in assessing renal obstruction </li></ul><ul><li>MR is superior in showing peri-renal edema </li></ul><ul><li>Post-Gd MR better at showing urinary calculi (filling void) than T2-urography </li></ul><ul><li>MR of 23 high-risk patients found 5 renal & 8 ureteral TCC’s; remaining patients negative on F/U for 1 year. </li></ul>
  40. 40. Hydronephrosis & Pregnancy <ul><li>Hydro of pregnancy </li></ul><ul><li>Usually mild </li></ul><ul><li>Right > Left </li></ul><ul><li>ureter tapers between uterus and psoas </li></ul><ul><li>No perinephric edema </li></ul><ul><li>Ureteral obstruction </li></ul><ul><li>Perinephric edema </li></ul><ul><li>Ureter cutoff below or above uterus </li></ul><ul><li>May see filling defect </li></ul><ul><li>Don’t be fooled by flow artifact on HASTE/SSFSE </li></ul>
  41. 41. NF Mild hyronephrosis of pregnancy
  42. 42. Mild hydronephrosis of pregnancy
  43. 43. Distal left ureter obstruction
  44. 44. Distal right ureter obstruction
  45. 45. 3T MR—partial obstructing mid L ureter stone
  46. 46. 3T MR—distal R ureter susceptibility artifact… Not ureter stone
  47. 47. 3T MR—renal pelvis stone
  48. 48. Copyright ©Radiological Society of North America, 2007 Singh, A. et al. Radiographics 2007;27:1419-1431 Adnexal torsion
  49. 49. Ovarian torsion
  50. 50. Ovarian fibroma
  51. 51. 3T MR—tubo-ovarian abscess
  52. 52. Smoker with index finger ulcer

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