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MRI Protocols

QUICK FACTS

  • Weight Limit Max ~300 lbs, as tolerated by body habitus
  • Generally, pregnant women should not be administered gadolinium
  • Okay to administer gadolinium to breastfeeding mothers


MRI HOURS



ST. LUKE’S:
Weekdays: 7:30 am-11:00 pm
Weekends: 8:00 am-4:00 pm
Holidays: 8:00 am-4:00 pm
ON CALL pager: 5310


WEST:
Weekdays: 7:00 am-11:00 pm
Weekends: 8:00 am-11:00 pm
Holidays: 8:00 am-4:00 pm
ON CALL pager: 2194


CALLING IN A TECH OVERNIGHT

  • Check indication per our SLR policy
  • ONLY CALL IN MR TECH OVERNIGHT IF PATIENT HAS NEUROLOGIC DEFICITS!!!

  • All other studies must be directly requested by an Attending as below, use discretion
  • Check requester
    • Must be requested by a Neurosurgery, Orthopedics, Emergency Attending
  • Check patient
    • MRN, name, age
    • Weight limit > 300 lbs
    • Safety screen = metal, pacemaker? stent < 2 wks old?
    • Claustrophobia, need for sedation
    • Contact isolation
  • MRI techs will no longer be cross covering (effective 1/1/2017)
    • MSSL staff will cover on call for MSSL
    • SL MRI pager 3-5310
    • MSW will cover only MSW
    • West pager 3-2194
    • MRI staff on site from 8-4 ONLY on all 8 hospital celebrated holidays


MEDICAL DEVICES/FOREIGN BODIES

  • Searchable Database from Institute for Magnetic Resonance Safety, Education, & Research
  • If available, always look up the manufacturer’s online package insert for MRI compatibility!
 

EMERGENCY MRI PROTCOLS

STROKE RULE OUT
First check CT Head, if negative
Brain MRI C-
Brain MRA C-
Neck MRA C-



DISSECTION RULE OUT 
   
Brain MRI C-
Brain MRA C-
Neck MRA C- with Fat Sat T1





NEURORADIOLOGY MRI PROTOCOLS

Brain Routine
     Appropriate FOV and spacing per patient head size
    Axial T1 FLAIR (T1 for patients under 3)
    Axial T2
    Axial FLAIR
    Axial DWI
    Sagittal T1
    Axial Gradient Echo (include for hemorrhage or trauma)

optional sequences
    Sagittal FLAIR (include for MS)
    Coronal T1 (include for AVM)
    Coronal T2 high res (include for epilepsy)
    Coronal FLAIR (include for epilepsy)
    Coronal 3D T1 IR (optional for epilepsy, do for pediatric patients)
    Axial FIESTA IAC (Ax T2 hi res IAC if no FIESTA) (optional for vertigo/dizziness)
    Use Propeller for patients who cannot hold still if you have it

 
Brain with and without Gadolinium
    Appropriate FOV and spacing per patient head size
    Axial T1 (not T1 FLAIR)
    Axial T2
    Axial FLAIR
    Axial DWI
    3 planes post T1
    Optional sequences from Brain Routine as needed
    Coronal with 3D recons per Seizure Protocol

MRA COW (Circle of Willis) Routine
    3D TOF 3 or 4 slab depending on patient size and anatomy
    MIP anterior separate from posterior with side to side rotations and SI rotations
    Magnify MIPS so that they fit most of the FOV
    Axial T2 brain
    Axial DWI brain

MRA Neck Routine
    2D Time of Flight aortic arch to sella
    3D Time of Flight carotid bifurcations
    Axial T1 fat sat sella to C6 (include for rule out dissection)
    MIP Carotid and Vertebral arteries together from each side with rotational views
        *If Gadolinium requested, add dynamic study (with fluoro-triggering if available, 
            timing run if not

MRV head Routine
    2D Time of Flight Coronal acquisition, MIP Rotations and SI
        *If done as part of a noncontrast study, do non contrast
        *If done in conjunction with a contrast brain MRI, do post contrast
        Dynamic Gadolinium (Optional with timing run for sites that have it)

Cervical Spine Routine
    3 Plane Scout
    Sagittal T1 FLAIR 3x1 frequency AP 22 FOV (May decrease FOV for smaller people)
    Sagittal T2 3x1 frequency AP 24 FOV 
    Sagittal STIR optional if marrow abnormalities (fractures, infxn, neoplasm)
    Axial T1 4x1 C2-T1 18 FOV
    Axial T2 4x1 C2-T1 18 FOV
    Axial GE 4x1 C2-T1 18 FOV

Thoracic Spine Routine
    Scout to count from C2
    Sagittal T1 FLAIR or T1 (whichever looks better on your system) 3x1 Frequency AP 
        T1- bottom of L1 include conus
    Sagittal T2 3x1 Frequency AP T1- bottom of L1 include conus
    Sagittal STIR optional if marrow abnormalities ((fractures, infxn, neoplasm)
    Axial T1 5x5 T1-L1 18 FOV
    Axial T2 5x5 T1-L1 18 FOV
 
Lumbar Spine Routine 
    Sagittal T1 4x1 Frequency AP 28 FOV
    Sagittal T2 4x1 Frequency AP 28 FOV
    Sagittal STIR optional if marrow abnormalities
    Axial T1 4x1 S1-L1 18 FOV
    Axial T2 4x1 S1-L1 18 FOV
    Axials can be done multioblique or in blocks depending on patient but must cover 
        discs levels at least pedicle to pedicle.  Watch out for cross talk (dark bands) if doing multiobliques

Total Spine Routine
    Scout entire spine and split into 2 halves so that the sagittals overlap by 1-2 vert bodies
    Upper Half Sagittal T1 3x1 Frequency AP 
    Upper Half Sagittal T2 3x1 Frequency AP
    Lower Half Sagittal T1 3x1 Frequency AP
    Lower Half Sagittal T2 3x1 Frequency AP
    Axial T1 and T2 entire spine 5x5 18 FOV
    Sagittal STIR (optional, should be used for trauma or metastatic disease)
 
Cervical, Thoracic, or Lumbar Spine with and without Gadolinium
    Pre Sagittal T1
    Pre Sagittal T2
    Post Sagittal T1 without fat sat
    Sagittal Proton Density should be done if Hx MS (C or T Spine)
    Axial T1 post and Axial T2, thickness and spacing per appropriate spine level
    Optional Axial Gradient Echo for C-spine

Pituitary with and without Gad
    Sagittal T1 Brain pre
    Coronal T1 Pituitary 3 x .3 16 FOV
    Coronal T2 Pituitary 3 x .3 16 FOV
    Coronal T1 Post 3 x .3 16 FOV
    Sagittal T1 Post 3 x .3 16 FOV
    Post Axial T1 Brain
    Axial T2 Brain
    Axial DWI
    If Pituitary and Brain requested, add Axial T2 FLAIR Brain
       *If noncontrast Pituitary - Cut Post Coronal T1 Pituitary and Post Sagittal T1 Brain.  
        Do Sagittal T1 Pituitary Pre.  Run all other sequences

Neuro Orbit (or Cavernous Sinus) (ie: for non-ENT cases)
    Coronal T1 Pre 4x1 16 FOV from behind sella through globe
    Coronal STIR to match thickness and spacing
    Coronal T1 Post gadolinium with Fat Suppression to match thickness and spacing
    Axial T1 Post gadolinium Fat Sat 3 x 0.3 orbits and sella 18 FOV
    Axial T1 post brain
    Axial T2 brain
    Axial DWI
        *If noncontrast orbit - Cut coronal post T1 orbit.  Add Axial T2 orbit 3x .3.  
        Do axial T1 orbit pre without fat suppression.  Run all other sequences.

Neuro Orbits and Brain double study (for non-ENT cases)
    Coronal T1 4x1 16 FOV from behind sella through globe
    Coronal STIR to match thickness and spacing
    Coronal T1 Post gadolinium with Fat Suppression to match thickness and spacing
    Axial T1 Post gadolinium Fat Sat 3 x .3 orbits and sella 18 FOV
    Axial T1 post brain
    Axial T2 brain
    Axial DWI
    Axial FLAIR
    Sagittal FLAIR
    Sagittal T1 Post
 
Preop Brain Lab (stereotactic study)
    Pre contrast Axial T1
    Post Contrast SPGR volume axial acquisition 256 x 192, 25 FOV including whole 
        nose, head and ears. Reformat 3 planes 5x0
    Post contrast Axial T1
    Axial T2
    Axial DWI
    Optional STRAIGHT AXIAL T2 brain lab 3 x 0 whole head 25 FOV
    Optional STRAIGHT AXIAL FLAIR brain lab 3 x 0 whole head 25 FOV

IAC Routine
    Axial T1 pre posterior fossa 18 FOV 3 x .3
    Axial FIESTA
    Axial T2 high res to match T1 if FIESTA not available
    Axial T1 post gadolinium with fat sat to match pre T1 coverage
    Coronal T1 post IAC 3 x .3 18 FOV
    Axial T2 Brain
    Axial T1 post Brain
    Axial FLAIR Brain
    Axial DWI Brain
        *if noncontrast IAC cut post axial T1 fat sat and add coronal thin T2 IAC if no FIESTA. 
        Run all other sequences.

CSF Flow study
    Sagittal T1 Brain
    Axial T2 Brain
    Axial DWI Brain
    Sagittal T2 High Resolution 16 FOV, 9 slices 4mm thick centered and angled so that 
        middle slice is midline through floor of third ventricle.  No flow comp.
    Axial T2 High Resolution 16 FOV 9 slices 4mm thick centered at optic chiasm and
        covering through the cerebral aqueduct. No flow comp.
    Midline Sagittal Phase Contrast cardiac gated CSF flow study



BODY MRI PROTOCOLS

MR Abdomen: Routine

- “+/- Gad”


R/O APPENDICITIS 

Non-pregnant patients: “Appendicitis protocol, with Gad”. 

Pregnant patients write “Appendicitis protocol, without Gad”. Make sure to include axial + coronal diffusion and extra set of axial + coronal SSFSE T2 series to assess RLQ at a separate time point and garner the benefits of peristalsis. A Fiesta Axial and/or Coronal might be helpful to further delineate fat planes and organ margins. 



MR Abdomen: Kidneys

-“+/- Gad”

- With Gadavist for renal lesions, pyelonephritis



MR ABDOMEN: r/o renal artery stenosis

- Routine abdomen

- add Axial PC 3D sequence through kidneys




MR abdomen: Adrenal gland

-“Adrenal gland protocol w/o Gad”

- For straightforward cases (ex. adenomas) without contrast is fine. If patient may have a pheochromocytoma or ACC, contrast is helpful to more fully assess. One could review any prior CT imaging to get a sense if this is a simple appearing nodule or a more complicated case.


MR Abdomen: Liver

-With Eovist to evaluate for liver malignancy (patients with cirrhosis, hepatitis, etc), first timers with risk factors, metastasis, equivocal liver lesions, s/p TACE to evaluate NEW lesions.

-“Liver protocol w/ Eovist

-With Gadavist to evaluate hemangiomas, immediately s/p TACE. 

-“Liver protocol w/ Gad”

-No contrast to evaluate Iron quantification

-“Hemochromatosis protocol”


MR Abdomen: Pancreas

- “MR Abdomen: Pancreas w/ gad” (MRCP images may be added as per attending)

- With Gadavist for pancreatic cystic lesions +/- PD involvement. 

-CT better for adenocarcinoma.  


MR abdomen: MRCP

-“MRCP w/o gad”

-Usually NO CONTRAST (although sometimes ordered WITH contrast; if there is suspicion of tumor contrast very helpful) to assess biliary tree, assessment of pancreatic duct, cholelithiasis, choledocholithiasis, biliary strictures, pancreatic divisum


MR Pelvis: Ovarian mass/fibroid

-“+/- Gad, subs, add T2 FS axial”

- With Gadavist for ovarian lesions, uterine fibroids, uterine masses


MR Pelvis: Routine

-“+/- Gad”


MR Pelvis: Fistula

-“+/- Gad”

- This protocol can be utilized for MRI Pelvis: Testicular Mass (remind techs to image supine as this will not compress the scrotal region making the case more challenging to read).

- This protocol is also similar to what you can employ for a high-resolution PENILE TRAUMA MRI WITHOUT CONTRAST. Note, if there is priapism, consider recommending angiography +/- ultrasound.  http://pubs.rsna.org/doi/full/10.1148/rg.333125158


MR pelvis: Prostate

-“+/- Gad”

-With Gadavist for prostate cancer, spermatic cord lesions

-No contrast s/p seed implantation


MR pelvis: Rectum

-“+/- Gad, Focused high resolution rectal CA protocol”

-With gadavist to evaluate for rectal cancer


MR Enterography:

-“+/- Gad”

- To exclude Crohn's disease, assess disease activity in Crohn's.