Tips and Tricks of State of the art MRA

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1 Tips and Tricks of State of the art MRA Mayil Krishnam, MD,MBA, MRCP,FRCR(UK) Professor of Radiology Director, Cardiovascular and Thoracic Imaging University of California, Irvine

2 Objectives Technical and clinical challenges Technical advancement CE-MRA, Time-resolved MRA Clinical Indications and Cases Non-contrast MRA, alternative MR contrast agent

3 Technical and Clinical Challenges SNR and CNR Timing of the contrast Venous contamination Spatial resolution Temporal resolution Scan time Motion Breathing, and body movements Sick patients Small vascular details Hemodynamic status Body habitus Renal impairment

4 Technical Developments 3T- Intrinsic high SNR, High T1 relaxivity of Gd Higher gradient systems-ultra short TR/TE View sharing- better temporal resolution Partial Fourier- Acquire partial K space data Parallel Imaging- 1D-2D- K space undersampling Multicoil array/coil geometry- Higher acceleration factors Compressed sensing- to use unsampled data to generate images

5 Technical: Parallel Imaging Reduces scan time Increase speed in filling K space Acceleration factors, 2-3 is common Higher acceleration factors are doabledepends on coils Multi-direction parallel imaging Avoid fold over artifact by increasing FOV

6 Technical: Contrast Injection Test-Bolus method Very reliable Extra 3 ml of contrast to assess the timing with a low resolution free breathing time resolved MRA Scan delay(time from injection to contrast arrival at target region) is calculated or readily available Then CE_MRA is performed using the calculated scan delay Fluoroscopic Triggering Continuous monitoring with low resolution real time MR after IV contrast Trigger the CEMRA when manually see the contrast at the target region similar to Bolus triggering method in CTA May not be reliable in some patients

7 Contrast Enhanced-MRA Ultra-short TR/TE 3D spoiled gradient-echo sequence Low TR, such that k-space filling may be achieved during first-pass Gad bolus Centric ordering

8 Time resolved MRA: Technique Rapid sequential 3D T1 W ultrafast GRE imaging of the selected FOV during a tight contrast bolus injection It is a high temporal resolution dynamic contrast MRA which depicts real time contrast flow pattern in a vascular tree at different time points 4ml contrast at 3 cc /sec followed by saline chaser, 15 ml at 3 cc/sec Center (A) for contrast Periphery (B) for details A is always sampled B is undersampled K space is acquired in random but strategic fashion Courtesy: Gerhard Laub SMS

9 TR MRA vs CE MRA TR MRA CE-MRA High temporal resolution Very low contrast dose Low in spatial resolution Functional information obtained Limited in evaluation for fine details May not need breathhold High spatial resolution Very low temporal resolution(20sec) Vascular details are best evaluated Stenosis is better assessed More contrast Breathhold

10 Chest MRA: Congenital Heart Disease- Extracardiac anatomy Protocol: 1. Multiplanar Steady State Free Precession or Haste 2. Precontrast Axial T1 FS GRE 3. Test Bolus for timing 4. Time-Resolved MRA 5. Contrast Enhanced MR Angiography- 2 passes. 6. Axial post contrast T1 FS 3D GRE (VIBE ; volumetric interpolated breath-hold examination). Post processing: MIPs and Rotation MIP ( Maximum Intensity Projection). CE-MRA L-TGA with RV t PA conduit

11 Parameters MRA CE-MRA/MRV VIBE Time Resolved TR (ms): TE (ms): Flip angle: Slice thickness (mm): Voxel size (mm 3 ): 1.1 x 0.9 x x 1 x x 1 x 3 Matrix: 368 x x x 512 GRAPPA Factor: 3 2 3

12 Pediatric-CV Under GA for less than yrs Inherent high SNR Parallel Imaging Increase resolution Can go upto triple dose if needed Rapid clearance of contrast from body Dilute contrast if needed to increase total volume- max 70% saline 30 % contrast Test bolus method preferred Time resolved and High spatial resolution MRA key CE-MRA DTGA TR-MRA shows patent bilateral Glenn shunt

13 Vasculitis Pre contrast T1 FS GE TE-MRA- steal, pulmonary perfusion CE-MRA- 2 passes Post Contrast T1 FS GRE CE-MRA Focal stenosis of pulmonary arteries Aortic wall vasculitis

14 Large Vessel Vasculitis with Subclavian Steal TR-MRA CE-MRA Reverse flow in left vertebral artery Aortic aneurysm, carotid aneurysms and stenosis, and left subclavian artery occlusion Phase Contrast MRA confirms reverse flow left vertebral artery

15 Pulmonary Embolism Tru fisp TEMRA CEMRA-key High Res Vibe Ability to breath hold is key CE-MRA central filling defects--pe

16 Aortic Aneurysms CE-MRA Multiple aneurysms CE-MRA Different patient with Marfan s and aortic root aneurysm

17 Takayasu s: Abdominal Aortitis CE-MRA abdomen Thin MIP TR-MRA of the same patient with s/p aortic bypass graft(arrow) CE-MRA Chest and Neck of the same patient: Rotation Thin MIP Chronic occlusion of LT subclavian artery

18 MRA Abdomen: Renal Artery 1mm isotropic high spatial CE- MRA Distal right main renal artery aneurysm TR-MRA RT renal artery FMD is depicted

19 Median Arcuate Ligament Syndrome Free breathing cine SSFP shows real time compression of celiac artery Inspiration phase CE MRA: Moderate CA stenosis with poststenotic dilation Expiration Phase CE-MRA: Severe stenosis of the CA

20 SMA Aneurysm TR-MRA depicts prompt filling of aneurysm via PDA collaterals CE-MRA MIP showing aneurysm

21 Pelvic MRA: Fibroid Preembolization TR-MRA CE-MRA Dilated tortuous bilateral uterine arteries Absent ovarian artery

22 Peripheral MRA- Claudication Hybrid technique-three station run off Two timing runs 1st bolus injection: CEMRA Calf station 2 nd : Abdomen/Pelvis then move table to Thighs Overlap stations by 5-10cm Masks of all stations prior to bolus injection

23 Peripheral Arterial Disease Right proximal SFA and left popliteal artery occlusion

24 Vascular Malformation Axial STIR Timing run Time resolved MRA CE MRA- multiple passes- 4 Post contrast VIBE

25 Hand MRA: Ulnar Artery thrombosis TRMRA CE-MRA Delayed CE- MRA shows thrombus in the ulnar artery CE-MRA Rotation MIP Post T1 GRE shows thrombus

26 Popliteal Entrapment syndrome Single station LE MRA Precon T2 Timing run- Neutral TE MRA at stress- extreme Dorsiflexion CEMRA- at stress-extreme DF Post C VIBE- Neutral and Stress

27 TOS: Neutral and Stress MRA -Neutral- Arms by the side Timing run Axial and Sag Haste/Tru fisp -Stress-Arms Up Time resolved MRA CE MRA 2-3 passes High Res VIBE axial coronal -Neutral- High Res VIBE Axial and Coronal Stress TE MRA and CEMRA- RT Subclavian artery stenosis Stress VIBE >70% RT SV-RT Neutral VIBE 50% stenosisi

28 Pitfalls and Artifacts CE-MRA Inadequate contrast bolus timing may result in non diagnostic studies. K-space filling artifacts. Ringing or modulation artifactblurring of vessels Venous contamination Wrap artifact Motion and pulsatility artifact TR-MRA- Limited spatial resolution or SNR as a compromise for advanced temporal resolution. Limited through-plane resolution.

29 Non Contrast MRA Techniques Subtractive techniques Arterial spin labeling with SSFP or FSE readout (taggeduntagged) EKG gated FSE imaging (systole-diastole) Non Subtractive methods- better 3D SSFP MRA-thoracic IR-SSFP-renal Standard methods 2d or 3d Tof Other: phase contrast MRA, pulsatility MRA ToF MRA IR-SSFP

30 3D SSFP Non contrast MRA Steady state Free precession technique (SSFP) has high T2/T1 signal Fat, fluid and blood appear as bright signal SSFP MRA should ideally be performed on 1.5 Ability to obtain 3D images compared to 2d SSFP Significantly less off resonance artifacts compared to 2d SSFP Free breathing navigator gated Prospective EKG triggering Data acquired in diastole End expiratory data collected Inspiratory date rejected Non selective RF excitation

31 Alternative Contrast Agent: USPIO- Ferumoxytol Dose 4mg/kg USPIO Dilute with saline total volume of 25-60ml Slow infusion-.1-.2mg/kg/sec Acute anaphylaxis can occur High SNR of cardiovascular structures Can be imaged until 8hrs from injection Difficult evaluation of small arteries due to venous contamination

32 Conclusion State of the art CEMRA can be widely achievable for various clinical indications Higher gradients, high SNR and high T1 relaxivity of Gd chelate contrast at 3T, centric ordering filling of K-space, accelerated data acquisition by parallel imaging, multiple coil array and coil geometry for 2D parallel imaging with higher acceleration and view sharing technique facilitate to acquire state of the art MRA High temporal resolution TEMRA depicts real time contrast flow dynamics in vessels and it is a complimentary technique to CE MRA in assessing various cardiovascular pathologies Non contrast MRA, and alternative contrast agent such as USPIO may be useful in CKD patients

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