12 Introduction to medical imaging

FDG Figure 1.15 Annihilation. A positron (e+) emitted by an

FDG molecule encounters an electron (e−). The two particles
annihilate converting their mass into energy in the form of
two 511 keV gamma rays, which are emitted in opposite
directions.

e+
511 keV 511 keV

• Cardiac: Non-invasive assessment of myocardial modern practice. At the time of writing, PET–MR
viability in patients with coronary artery disease scanners are also becoming available in research
• Central nervous system and tertiary institutions.
• Characterization of dementia disorders
• Localization of seizure focus in epilepsy. 1.5.4 Limitations and disadvantages of
As with other types of scintigraphy, a problem scintigraphy
with PET is its non-specificity. Put another way, • Use of ionizing radiation
‘hot spots’ on PET may have multiple causes, with • Cost of equipment
false positive findings commonly encountered. • Extra care required in handling radioactive
The specificity of PET may be increased by the use materials
of scanners that fuse PET with CT or MRI. PET– • The main disadvantage of scintigraphy is its
CT fusion imaging combines the functional and nonspecificity; as described above, this may be
metabolic information of PET with the precise cross- reduced by combining scintigraphy with CT or
sectional anatomy of CT (Fig. 1.16). Advantages of MRI.
combining PET with CT include:
• Reduced incidence of false positive findings in
primary tumour staging 1.6 MRI
• Increased accuracy of follow-up of malignancy
during and following treatment. 1.6.1 MRI physics and terminology
PET–CT scanners are now widely available and MRI uses the magnetic properties of spinning
have largely replaced stand alone PET scanners in hydrogen atoms to produce images. The first step

Figure 1.16 Positron emission tomography–CT (PET–CT): Hodgkin’s lymphoma. CT image on the left shows neoplastic
lymphadenopathy, collapsed lung and pleural effusion. Corresponding FDG-PET image on the right shows areas of increased
activity corresponding to neoplastic lymphadenopathy. Collapsed lung and pleural effusion do not show increased activity, thus
differentiating neoplastic from non-neoplastic tissue.
 MRI 13

in MRI is the application of a strong, external • Larger coils are required for imaging the
magnetic field. For this purpose, the patient is chest and abdomen, whereas smaller
placed within a large powerful magnet. Most extremity coils are used for small parts such
current medical MRI machines have field strengths as the wrist or ankle.
of 1.5 or 3.0 tesla (1.5T or 3T). The hydrogen atoms
within the patient align in a direction either parallel 1.6.2 Tissue contrast and imaging
or antiparallel to the strong external field. A greater sequences
proportion aligns in the parallel direction so that
the net vector of their alignment, and therefore Much of the complexity of MRI arises from the
the net magnetic vector, will be in the direction of fact that the MR signal depends on many varied
the external field. This is known as longitudinal properties of the tissues and structures being
magnetization. examined, including:
A second magnetic field is applied at right angles • Number of hydrogen atoms present in tissue
to the original external field. This second magnetic (proton density)
field is known as the radiofrequency pulse (RF • Chemical environment of the hydrogen atoms,
pulse), because it is applied at a frequency in the e.g. whether in free water or bound by fat
same part of the electromagnetic spectrum as • Flow: blood vessels or CSF
radio waves. A magnetic coil, known as the RF • Magnetic susceptibility
coil, applies the RF pulse. The RF pulse causes the • T1 relaxation time
net magnetization vector of the hydrogen atoms • T2 relaxation time.
to turn towards the transverse plane, i.e. a plane By altering the duration and amplitude of the
at right angles to the direction of the original, RF pulse, as well as the timing and repetition of
strong external field. The component of the net its application, various imaging sequences use
magnetization vector in the transverse plane these properties to produce image contrast. Terms
induces an electrical current in the RF coil. This used to describe the different types of MR imaging
current is known as the MR signal and is the basis sequences include spin echo, inversion recovery
for formation of an image. Computer analysis of and gradient-recalled echo (gradient echo).
the complex MR signal from the RF receiver coils is
used to produce an MR image. 1.6.2.1 Spin echo
Note that in viewing MRI images, white or light
Spin echo sequences include T1-weighted, T2-
grey areas are referred to as ‘high signal’; dark grey
weighted and proton density. The following is a
or black areas are referred to as ‘low signal’. On
brief explanation of the terms ‘T1’ and ‘T2’.
certain sequences, flowing blood is seen as a black
Following the application of a 90° RF pulse, the
area referred to as a ‘flow void’.
net magnetization vector lies in the transverse plane.
Each medical MRI machine consists of a number
Also, all of the hydrogen protons are ‘in phase’, i.e.
of magnetic coils:
spinning at the same rate. Upon cessation of the RF
• 1.5T or 3T superconducting magnet
pulse, two things begin to happen:
• Gradient coils, contained in the bore of the
superconducting magnet, used to produce
• Net magnetization vector rotates back to the
longitudinal direction: longitudinal or T1
variations to the magnetic field that allow image
relaxation
formation
• Rapid switching of these gradients causes the
• Hydrogen atoms dephase (spin at slightly
varying rates): transverse or T2 relaxation
loud noises associated with MRI scanning
(decay).
• RF coils are applied to, or around, the area of
interest and are used to transmit the RF pulse The rates at which T1 and T2 relaxation occur are
and to receive the RF signal inherent properties of the various tissues. Sequences
• RF coils come in varying shapes and sizes that primarily use differences in T1 relaxation rates
depending on the part of the body to be produce T1-weighted images. Tissues with long T1
examined values are shown as low signal while those with
14 Introduction to medical imaging

shorter T1 values are displayed as higher signal. are extremely sensitive to the presence of substances
Gadolinium produces T1 shortening; tissues or that cause local alterations in magnetic properties.
structures that enhance with gadolinium-based Examples of such substances include iron-containing
contrast materials show increased signal on T1- haemosiderin and ferritin found in chronic blood.
weighted images. GRE sequences are used in neuroimaging to
T2-weighted images reflect differences in T2 look for chronic blood in patients with suspected
relaxation rates. Tissues whose protons dephase vascular tumours, previous trauma or angiopathy.
slowly have a long T2 and are displayed as high An extension of GRE sequences in the brain
signal on T2-weighted images. Tissues with shorter known as susceptibility-weighted imaging (SWI)
T2 values are shown as lower signal (Fig. 1.17). uses subtraction techniques to remove unwanted
Proton density images are produced by sequences information and thereby increase sensitivity. GRE
that accentuate neither T1 nor T2 differences. The sequences also allow extremely rapid imaging and
signal strength of proton density images mostly are used for imaging the heart and abdomen.
reflects the density of hydrogen atoms (protons)
in the different tissues. Proton density images are 1.6.2.3 Inversion recovery
particularly useful in musculoskeletal imaging for
Inversion recovery sequences are used to suppress
the demonstration of small structures, as well as
unwanted signals that may obscure pathology. The
articular cartilage (Fig. 1.18).
two most common inversion recovery sequences
are used to suppress fat (STIR) and water (FLAIR).
1.6.2.2 Gradient-recalled echo (gradient echo) Fat suppression sequences such as STIR (short TI-
Gradient-recalled echo (GRE) sequences are widely inversion recovery) are used for demonstrating
used in a variety of MRI applications. GRE sequences pathology in areas containing a lot of fat, such as

Figure 1.17 MRI of the lower lumbar spine and sacrum. (a) Sagittal T1-weighted image. Note: dark cerebral spinal fluid (CSF).
(b) Sagittal T2-weighted image. Note: bright CSF; nerve roots (NR).
 MRI 15

Figure 1.18 Proton density (PD) sequence. Sagittal PD MRI

of the knee shows a cartilage fragment detached from the
articular surface of the lateral femoral condyle (arrow).

Figure 1.19 Short tau inversion recovery (STIR) sequence.

the orbits and bone marrow. STIR sequences allow Sagittal STIR MRI of the lumbar spine shows a crush fracture
the delineation of bone marrow disorders such as of L2. Increased signal within L2 on STIR (arrows) indicates
oedema, bruising and infiltration (Fig. 1.19). FLAIR bone marrow oedema in a recent fracture.
(fluid-attenuated inversion recovery) sequences
suppress signals from CSF and are used to image
the brain. FLAIR sequences are particularly useful 1.6.3.2 Perfusion-weighted imaging
for diagnosing white matter disorders such as In perfusion-weighted imaging (PWI) the brain is
multiple sclerosis. rapidly scanned following injection of a bolus of
contrast material (gadolinium). The data obtained
may be represented in a number of ways including
1.6.3 Functional MRI sequences maps of regional cerebral blood volume, cerebral
1.6.3.1 Diffusion-weighted imaging blood flow, and mean transit time of the contrast
bolus. PWI may be used in patients with cerebral
Diffusion-weighted imaging (DWI) is sensitive to
infarct to map out areas of brain at risk of ischaemia
the random Brownian motion (diffusion) of water
that may be salvageable with thrombolysis.
molecules within tissue. The greater the amount of
diffusion, the greater the signal loss on DWI. Areas
of reduced water molecule diffusion show on DWI 1.6.3.3 Magnetic resonance spectroscopy
as relatively high signal. Magnetic resonance spectroscopy (MRS) uses
Diffusion-weighted imaging is the most sensitive different frequencies to identify certain molecules
imaging test available for the diagnosis of acute in a selected volume of tissue, known as a voxel.
cerebral infarction. With the onset of acute ischaemia Following data analysis, a spectrographic graph of
and cell death there is increased intracellular water certain metabolites is drawn. Metabolites of interest
(cytotoxic oedema) with restricted diffusion of include lipid, lactate, NAA (N-acetylaspartate),
water molecules. An acute infarct therefore shows choline, creatinine, citrate and myoinositol. Uses
on DWI as an area of relatively high signal. of MRS include characterization of metabolic
16 Introduction to medical imaging

brain disorders in children, imaging of dementias, reconstruction techniques allow the display of
differentiation of recurrent cerebral tumour from blood vessels in 3D as well as rotation and viewing
radiation necrosis, and diagnosis of prostatic of these blood vessels from multiple angles. MRA
carcinoma. is most commonly used to image the arteries of the
brain, although is also finding wider application in
1.6.3.4 Blood oxygen level-dependent imaging the imaging of renal and peripheral arteries.
MRI of veins is known as magnetic resonance
Blood oxygen level-dependent (BOLD) imaging is a
venography (MRV). MRV is most commonly used
non-invasive functional MRI (fMRI) technique used
in neuroimaging to demonstrate the venous sinuses
for localizing regional brain signal intensity changes
of the brain. For certain applications, the accuracy of
in response to task performance. BOLD imaging
MRA and MRV is increased by contrast enhancement
depends on regional changes in concentration
with intravenous injection of Gd-DTPA.
of deoxyhaemoglobin, and is therefore a tool to
investigate regional cerebral physiology in response
to a variety of stimuli. BOLD fMRI may be used 1.6.5 Contrast material in MRI
prior to surgery for brain tumour or arteriovenous Gadolinium (Gd) is a paramagnetic substance that
malformation (AVM), as a prognostic indicator of causes T1 shortening and therefore increased signal
the degree of postsurgical deficit. on T1-weighted images. Unbound Gd is highly toxic
and binding agents, such as diethylenetriamine
1.6.4 Magnetic resonance angiography pentaacetic acid (DTPA), are required for in vivo
use. Gd-DTPA is non-toxic and used in a dose of
and magnetic resonance venography
0.1 mmol per kilogram.
Flowing blood can be shown with different Indications for the use of Gd enhancement in
sequences as either signal void (black) or increased MRI include:
signal (white). Magnetic resonance angiography • Brain
(MRA) refers to the use of these sequences to • Inflammation: meningitis, encephalitis
display arterial anatomy and pathology. Computer • Tumours: primary (Fig. 1.20), metastases

Figure 1.20 Intravenous contrast in MRI: vestibular schwannoma. (a) Transverse T1-weighted image of the posterior fossa
shows a right-sided mass. (b) Following injection of gadolinium the mass shows intense enhancement, typical of vestibular
schwannoma (VS). (See also Fig. 11.10.)
 Hazards associated with medical imaging 17

• Tumour residuum/recurrence following • Young children and infants usually require

treatment general anaesthesia
• Spine • Patients experiencing pain may require
• Postoperative to differentiate fibrosis from intravenous pain relief
recurrent disc protrusion • For examination of the abdomen, an
• Infection: discitis, epidural abscess antispasmodic, such as intravenous hyoscine,
• Tumours: primary, metastases may be required to reduce movement of the
• Musculoskeletal system bowel
• Soft tissue tumours • Safety issues related to ferromagnetic materials
• Intra-articular Gd-DTPA: MR arthrography within the patient, e.g. surgical clips, or electrical
• Abdomen devices such as pacemakers (see below)
• Characterization of tumours of liver, kidney • High auditory noise levels: earplugs should
and pancreas. be provided to all patients undergoing MRI
examinations
1.6.6 Applications and advantages of MRI • Claustrophobia
• Modern scanners have a wider bore and
Widely accepted applications of MRI include: claustrophobia is less of a problem than in
• Imaging modality of choice for most brain and the past; intravenous conscious sedation may
spine disorders occasionally be required
• Musculoskeletal disorders, including internal • Problems with gadolinium: allergy (extremely
derangements of joints and staging of rare) and nephrogenic systemic fibrosis (see
musculoskeletal tumours below).
• Cardiac MR is an established technique in
specific applications including assessment of
congenital heart disease and aortic disorders 1.7 HAZARDS ASSOCIATED WITH
• MR of the abdomen is used in adults for
visualization of the biliary system, and for MEDICAL IMAGING
characterization of hepatic, renal, adrenal and Hazards associated with modern medical imaging
pancreatic tumours are outlined below, and include:
• In children, MR of the abdomen is increasingly • Exposure to ionizing radiation
replacing CT for the diagnosis and staging of • Anaphylactoid reactions to iodinated contrast
abdominal tumours media
• MRA is widely used in the imaging of the • Contrast-induced nephropathy (CIN)
cerebral circulation and in some centres is • MRI safety issues
the initial angiographic method of choice for • Nephrogenic systemic sclerosis (NSF) due to
other areas including the renal and peripheral Gd-containing contrast media.
circulations.

Particular advantages of MRI in clinical practice 1.7.1 Exposure to ionizing radiation

include:
1.7.1.1 Radiation effects and effective dose
• Excellent soft tissue contrast and
characterization Radiography, scintigraphy and CT use ionizing
• Lack of artefact from adjacent bones, e.g. radiation. Numerous studies, including those on
pituitary fossa survivors of the atomic bomb attacks in Japan in
• Multiplanar capabilities 1945, have shown that ionizing radiation in large
• Lack of ionizing radiation. doses is harmful. The risks of harm from medical
radiation are low, and are usually expressed as the
increased risk of developing cancer as a result of
1.6.7 Disadvantages and limitations of MRI exposure. Public awareness of the possible hazards
• Time taken to complete examination of medical radiation is growing and it is important