Less is Moreor is it?

Whitney Bowen, BS, NMTCB, RT(MR)

University of Cincinnati
College of Allied Health Sciences
Advanced Medical Imaging Technology Program

Objectives
Define MRI imaging pulse sequences and their
parameters.
Demonstrate the value of using additional MRI
imaging sequences to benefit patient diagnosis.
Demonstrate the value of multiple imaging
modality utilization to benefit patient diagnosis.

Overview
MRI Pulse Sequences
STIR, FLAIR, & DWI

Uses for additional MRI pulse sequences

Anatomy Overview
Spine, shoulder, knee & ankle

Uses for additional MRI sequences

Multiple imaging modalities combined
Ultrasound, Nuclear Medicine, & X-ray

MRI Pulse Sequence Overview

STIR
FLAIR
DWI

STIR Pulse Sequence

STIR = Short Tau Inversion Recovery
Fat suppression technique
TI = Inversion time (also known as tau)
Corresponds to the time it takes fat to recover
from full inversion to the transverse plane
Known as the null point

Fat = dark signal; Fluid = bright signal

STIR Pulse Sequence

Parameters:
TR = 4000+ ms
TE = 50+ ms
TI (tau) = 100-175 ms (varies by field
strength)
Average scan time = 5-15 minutes

http://slideplayer.com/slide/3280943/

Westbrook, Catherine, Roth, Carolyn, & Talbot, John. MRI in Practice, 3 rd Edition. Blackwell Publishing Ltd., 2005.

STIR Pulse Sequence

*Should only be used pre-contrast
Can be used to evaluate:
Bone tumors
Bone bruising
Soft tissue tumors

STIR Pulse Sequence

https://mrimaster.com/characterise%20image%20stir.html

FLAIR Pulse Sequence

FLAIR = Fluid Attenuation Inversion
Recovery
CSF suppression technique
TI = time of recovery of CSF from 180 to
the transverse plane
CSF = dark signal

FLAIR Pulse Sequence

Parameters:
TR = 6000+ ms
TE = 70+ ms
TI = 1700-2200 ms
Average Scan Time = 13-20 minutes

http://slideplayer.com/slide/3280943/

FLAIR Pulse Sequence

Can be used for:
Brain periventricular lesions (meningitis, subarachnoid
hemorrhage)
Spine cord lesions (MS plaques)

FLAIR parameter modification:

TI = ~300 ms
Nulls brain white matter

FLAIR Pulse Sequence

http://casemed.case.edu/clerkships/neurology/Web%20Neurorad/MRI%20Basics.htm

FLAIR Pulse Sequence

https://www.mypacs.net/cases/63348420.html
http://konez.com/Protocol_head_contrast.htm

DWI Pulse Sequences

DWI = Diffusion Weighted Imaging
Measures random thermal motion of water
molecules within a voxel of tissue

ADC = Apparent Diffusion Coefficient

Net displacement of molecules

Acquired by applying 2 gradient pulses to

either side of the 180 RF pulse

Bammer, Roland. Basic Principles of Diffusion Imaging. European Journal of Radiology, 45, 2003, 169-184.

DWI Pulse Sequences

Trace Images = damaged tissue has
restricted diffusion (bright signal low
ADC), normal tissue has free diffusion (less
bright signal high ADC).
ADC maps = post-processing to find the
ADC for each voxel and allocate its signal
intensity

DWI

https://openi.nlm.nih.gov/detailedresult.php?img=PMC2678695_ymj-50-211-g001&req=4

ADC

DWI Pulse Sequences

Stationary spins have no net phase
Moving spins have signal loss
Normal Tissue = lower signal intensity
than abnormal tissue

DWI Pulse Sequences

Parameters:
TR = 8000 ms
TE = 84 ms
B Value = varies based on pathology
Average scan time = seconds
Able to void flow and other motion

DWI Pulse Sequences

Can be used to evaluate:
Edema vs. Infarct
Brain ischemia/Stroke

Benign vs. Malignant lesion

Breast lesions
Prostate lesions
Liver lesions

DWI Pulse Sequences

b=500

https://mrimaster.com/characterise%20image%20stir.html
https://bodymri.stanford.edu/brucedaniel

Examples of Extra Sequences

STIR
Demyelinating disease full spine survey

FLAIR
Seizure foci & damaged tissue

DWI
Lesion assessment Breast & prostate

STIR Demyelinating Disease

Demyelinating Disease Evaluation
MS Journal, 2013 both spinal cord volume and
spinal cord lesions impact physical disability in
MS patients
International Spinal Cord Society, 2015
Thoracic cord lesions are influenced by degree of
cervical cord involvement (independent of brain
findings)

T2 vs. STIR
ACTA Neurologica
Scandinaviac,
2014 STIR allows
for better contrast
and visualization of
MS lesions. STIR
should be within
routine protocol.

T2 Image

Nayak, NB et all. A comparison of sagittal short T1 inversion recover and T2-weighted FSE
sequences for detection of multiple sclerosis spinal cord lesions. ACTA Neurologica
Scandinavica, 2014, 129, 198-203. doi: 10.11 11/ane.12168.

STIR

STIR Demyelinating Disease

Sagittal Plane Imaging
Cervical, Thoracic and Lumbar

Scanned on all rule out MS Brain

orders
Pre-Contrast
Parameters:

TR = 2888 ms
TE = 60 ms
TI = 110 ms
Slices: 3, gap 0

Burghart, Geraldine. Handbook of MRI Scanning. Elsevier Mosby, 2011.

Full Spine STIR Imaging

http://radiopaedia.org/images/16069297

FLAIR Seizure Foci & Damage

Epilepsy Foci Detection & Hippocampal
Damage
Investigative Radiology, 1999 FLAIR can
provide increased yield of Mesial Temporal
Sclerosis.

Figure 3. (A) The left hippocampus has an increased signal intensity on

this proton density-weighted image (0.5 Tesla system). The adjacent
collateral white matter in the parahippocampal (arrow) and fusiform gyri
(arrowhead) has clearly diminished. (B) The T2-weighted image confirms
the findings seen on the proton density image; however, the smaller
hippocampal size and enlargement of the ipsilateral temporal horn are
better appreciated. (C) All features described in A and B are as clearly
seen on the FLAIR image, except for the enlargement of the temporal
horn.
Meiners, L. et all. Fast Fluid-Attenuated Inversion Recovery (FLAIR) Compared with T2weighted Spin-Echo in the Magnetic Resonance Diagnosis of Mesial Temporal Sclerosis.
Investigative Radiology, 1999, 34(2), 134-142. ISSN: 00004424-199902000-00006

Epilepsia, 2011 FLAIR can detect

hippocampal damage after prolonged febrile
seizure.

Takuya, T. et all. Hippocampal damage after prolonged febrile seizure: One case in a
consecutive prospective series. Epilepsia, 2011, 52(4), 837-840. doi: 10.1111/j.15281167.2010.02958.x

FLAIR Seizure Foci & Damage

Temporal lobe imaging
Uses a Coronal Thin Slice Sequence
Parameters:

TR = 8800 ms
TE = 120 ms
TI = 2200 ms
Slices: 5, 0 gap

Burghart, Geraldine. Handbook of MRI Scanning. Elsevier Mosby, 2011.

Breast Diffusion Imaging

Breast Lesion Detection
Diagnosis
More Precise biopsy
Treatment planning and staging

Benefits:
Fast scan time
Non-contrast imaging

Breast Diffusion Imaging

Frontiers in Oncology, 2016 Low ADC
values = malignancy; Medium ADC values
= benign; High ADC value = normal tissue
(1.02 0.17 103 mm2/s) malignant
(1.57 0.26 103 mm2/s) benigh
(1.78 0.13 103 mm2/s) healthy

Breast Diffusion Imaging

Axial Plane Imaging
B value varies with
each scanner, protocol
and pathology.

Burghart, Geraldine. Handbook of MRI Scanning. Elsevier Mosby, 2011.

Abdulghaffar, W., Tag-Aldeen, M. Role of diffusion-weighted imaging (DWI) and

apparent diffusion coefficient (ADC) in differentiating between benign and malignant
breast lesions. Egyptian Society of Radiology and Nuclear Medicine, 2013, 44, 945951. doi: 10.1016/j.ejrnm.2013.09.009.

Prostate Diffusion Imaging

Prostate Lesion Identification
Diagnosis
More precise biopsy
Treatment planning and staging

Benefit - fast acquisition time, less artifacts

Prostate Diffusion Imaging

European Radiology, 2011 Early study
determined DWI was useful in prostate
diagnosis, biopsy and treatment.
Magnetic Resonance in Medicine (ISMRM
publication), 2016 Use of 3D HighResolution DWI with 3T scanners is better
for low-risk, low-volume assessment

Tan, C., Wang, J., Kundra, V. Diffusion weighted imaging in prostat cancer.
European Radiology, 2011, 21, 593-603. doi: 10.1007/s00330-010-1960-y

Prostate Diffusion Imaging

Axial Imaging Plane
B value varies with each scanner,
protocol, and pathology
0, 300 and 600 (most common)

Burghart, Geraldine. Handbook of MRI Scanning. Elsevier Mosby, 2011.

Uses for Additional Sequences

Spine Obliques
Shoulder Aber View
Knee & Ankle T2 Mapping

Spine Anatomy

http://www.uscspine.com/spine-health-education/spinal-anatomy.cfm

Spine Anatomy

http://nw-mc.com/lateral-recessforaminal-stenosis/
http://www.mayfieldclinic.com/PE-STEN.htm

Spine Sagittal Obliques

Can be used to specifically diagnose:
Foraminal Stenosis

~45 Oblique Sagittal

Radiologist then us a grading scale to evaluate
the stenosis present

Spine Sagittal Obliques

http://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B80dc5496-8b14-4770-89c4b439201fb92d%7D/study-shows-oblique-mri-may-aid-precise-lumbar-foraminal-stenosis-diagnosis

Shoulder Anatomy

http://www.kaliper.com.au/shoulder-anatomy.html
http://sportsrehabcoach.com/shoulder-rehabilitation-labral-tear-repairs/

Shoulder Aber View

ABER = Abduction External
Rotation
Can be used to specifically
diagnose:
SLAP tear = Superior labral tear
from anterior to posterior
Subtle soft tissue pathology
Other rotator cuff tears

http://www.healio.com/orthopedics/journals/ortho/2010-8-33-8/%7B24a09a5f-9cb2-46fb8048-fa1afe352fd4%7D/the-abduction-external-rotation-aber-view-for-mri-of-the-shoulder

http://www.healio.com/orthopedics/journals/ortho/2010-8-33-8/%7B24a09a5f-9cb2-46fb8048-fa1afe352fd4%7D/the-abduction-external-rotation-aber-view-for-mri-of-the-shoulder

Knee & Ankle Anatomy

http://www.santiforestmonastery.com/anatomy-of-the-knee-lateral-collateral-ligamentmuscles-joint-illustrated/muscle-tendon-articular-cartilage-anatomy-of-the-knee-linecushions-bone-in-your-joint-cruciate-ligament-medial-collateral-ligament-mcl-meniscalcartilage/
http://www.tsaog.com/our-specialties/joint-replacement/san-antonio-ankle-replacement/

T2 Mapping Sequence
Functional cartilage mapping
Detects cartilage breakdown by evaluating
cartilage hydration
Increased hydration = increased cartilage damage

Can be used to evaluate:

Cartilage damage
Cartilage treatment monitoring

T2 Mapping Sequence
T2 Map Cartigram
Color Scale
Blue --- Green =
Damaged cartilage
Yellow ---- Red =
Normal cartilage

Breaking New Ground in Detecting Early Cartilage Degeneration. SignaPULSE, a GE

Healthcare MR Publication. Autumn 2008, 29-30.

T2 Mapping Sequence
Sagittal, Axial or Coronal Planes

Burghart, Geraldine. Handbook of MRI Scanning. Elsevier Mosby, 2011.

T2 Mapping Sequence

http://www.auntminnie.com/index.aspx?sec=rca&sub=ecr_2012&pag=dis&itemId=98513

Multiple Imaging Modalities

Ultrasound & MRI
HIFU

X-ray & MRI

CT & MRI
Nuclear Medicine & MRI
PET/MR

Conclusion
Take the time needed to acquire the
images your patient needs for proper
diagnosis!
It is up to you as the technologist to use
proper imaging sequences!

Resources

Abdulghaffar, W., Tag-Aldeen, M. Role of diffusion-weighted imaging (DWI)

and apparent diffusion coefficient (ADC) in differentiating between benign
and malignant breast lesions. Egyptian Society of Radiology and Nuclear
Medicine, 2013, 44, 945-951. doi: 10.1016/j.ejrnm.2013.09.009.
Bammer, Roland. Basic Principles of Diffusion Imaging. European Journal
of Radiology, 45, 2003, 169-184.
Breaking New Ground in Detecting Early Cartilage Degeneration.
SignaPULSE, a GE Healthcare MR Publication. Autumn 2008, 29-30.
Burghart, Geraldine. Handbook of MRI Scanning. Elsevier Mosby, 2011.
Hua, LH et all. Thoracic spinal cord lesions are influenced by the degree of
cervical spine involvement in multiple sclerosis. Spinal Cord, 2015, 53(7),
520-525. doi: 10.1038/sc.2014.238.

Resources

Meiners, L. et all. Fast Fluid-Attenuated Inversion Recovery (FLAIR)

Compared with T2-weighted Spin-Echo in the Magnetic Resonance
Diagnosis of Mesial Temporal Sclerosis. Investigative Radiology, 1999,
34(2), 134-142. ISSN: 00004424-199902000-00006
Nayak, NB et all. A comparison of sagittal short T1 inversion recover and
T2-weighted FSE sequences for detection of multiple sclerosis spinal cord
lesions. ACTA Neurologica Scandinavica, 2014, 129, 198-203. doi: 10.11
11/ane.12168.
Nguyen, et all. 3D High-Resolution Diffusion-Weighted MRI at 3T:
Preliminary Application in Prostate Cancer Patients Undergoing Active
Surveillance Protocol for Low-Risk Prostate Cancer. Magnetic Resonance
in Medicine, 2016, 75, 616-626. doi: 10.1002/mrm.25609

Resources

Sharma, U. et all. Potential of Diffusion-Weighted Imaging in the

Characterization of Malignant, Benign, and Health Breast Tissues and
Molecular Subtypes of Breast Cancer. Frontiers in Oncology, 2016, 6
(126). Doi: 10.3389/fonc.2016.00126.
Takuya, T. et all. Hippocampal damage after prolonged febrile seizure: One
case in a consecutive prospective series. Epilepsia, 2011, 52(4), 837-840.
doi: 10.1111/j.1528-1167.2010.02958.x
Tan, C., Wang, J., Kundra, V. Diffusion weighted imaging in prostat
cancer. European Radiology, 2011, 21, 593-603. doi: 10.1007/s00330010-1960-y
Westbrook, Catherine, Roth, Carolyn, & Talbot, John. MRI in Practice, 3rd
Edition. Blackwell Publishing Ltd., 2005.