Page 1 NEURO PROTOCOLS Brain Stroke Brain Brain with contrast Brain for seizures Brain for MS Brain for Pineal gland Sella FAST Scan for hydrocephalus MRA/MRV Brain MRA carotids 8 th nerve Cranial nerves Skull base Orbits TMJ s Soft tissue neck Nasopharynx/Face Sinus Glomus Tumor Brachial Plexus Cervical spine Thoracic spine Lumbar spine Sacrum Spine screen MRI NEURO PROTOCOLS (SIEMENS SCANNERS)
Page 2 SIEMENS--Please uncheck the MTC box on T1 pre and post contrast brain imaging 06/07/17 MRI Brain without contrast for stroke (Use in the workup for stroke or TIA) FOV-230 5mm DWI/ADC axial FOV-230 5mm DWI/ADC coronal FOV-230 5mm T2 AX FOV-230 5mm T2 COR FOV-230 5mm FLAIR AX FS FOV-230 5mm GRAD HEMO FOV-230 5mm MRI Brain without contrast FOV-230 5mm DWI/ADC FOV-230 5mm T2 AX FOV-230 5mm T2 COR FOV-230 5mm FLAIR AX FS FOV-230 5mm GRAD HEMO FOV-230 5mm MRI Brain with/without contrast FOV-230 5mm DWI/ADC axial FOV-230 5mm Add Coronal DWI/ADC coronal if for stroke FOV-230 5mm DWI/ADC for GRAD HEMO FOV-230 5mm stroke/tia workup T2 COR FOV-230 5mm FLAIR AX FS FOV-230 5mm T1 AX FOV-230 5mm MPRAGE SAG POST (Do COR MPR) FOV-230 use water excitation keep isotropic 0.9 mm T2 AX FOV-230 5mm T1 AX POST FOV-230 5mm **IF YOU SEE A TUMOR, run the MPRAGE in the axial plane instead of the sagittal plane MRI Brain for seizures-preferred w/wo contrast
Page 3 MPRAGE SAG pre FOV-230 0.9mm DWI/ADC FOV-230 5mm 3D SAG T2 SPACE (dark fluid) (through mid-line) FOV-230 1mm ***perform axial and coronal MPR 3x1 T2 COR THIN (perpendicular to temporal lobe) FOV-230 3mm GRAD HEMO FOV-230 5mm T1 AX FOV-230 5mm MPRAGE SAG POST (Do COR MPR) 0.9 mm use water excitation keep isotropic T2 AX FOV-230 5mm T1 AX POST 5mm **IF you see a tumor, run the MPRAGE in the axial plane instead of the sagittal plane MRI Brain for MS-preferred w/wo contrast FOV-230 5mm DWI/ADC FOV-230 5mm 3D SAG T2 SPACE (dark fluid) (through mid-line) FOV-230 1mm GRAD HEMO FOV-230 5mm T1 AX FOV-230 3mm MPRAGE SAG POST (Do COR MPR) 0.9mm keep isotropic! use water excitation FOV 230 T2 AX FOV-230 5mm T1 AX POST FOV-230 3mm ***Do AX and COR MPR from SAG SPACE 3mm X 1mm **IF you see a tumor, run the MPRAGE in the axial plane instead of the sagittal plane MRI Brain for Pineal Gland-preferred w/wo contrast DWI/ADC (Whole brain) FOV-230 5mm FLAIR AX FS (whole brain) FOV-230 5mm GRAD HEMO (Whole brain) FOV-230 5mm
Page 4 THIN (MID LINE STRUCTURES) FOV-200 3mm T2 SAG THIN (MID LINE STRUCTURES) FOV-200 3mm T1 AX (Whole brain) FOV-230 5mm MPRAGE SAG POST (Do COR MPR) FOV-230 0.9mm keep isotropic! Use water excitation T2 AX (Whole brain) FOV-230 5mm T1 AX POST (Whole brain) FOV-230 5mm *****IF you see a tumor, run the MPRAGE in the axial plane instead of the sagittal plane MRI Sella-preferred w/wo contrast THIN FOV-150 3mm T1 COR THIN FOV-150 3mm T2 COR THIN FOV 160 3mm T1 COR PRE 30 sec long 256x192 FOV 160 3mm ETL-3 HALF DOSE FOLLOWED BY SALINE BOLUS T1 COR DYNAMIC POST COPIED TO T1 COR PRE T1 COR DYNAMIC POST T1 COR DYNAMIC POST T1 COR DYNAMIC POST T1 COR DYNAMIC POST COPIED TO T1 COR PRE COPIED TO T1 COR PRE COPIED TO T1 COR PRE COPIED TO T1 COR PRE T1 COR THIN POST FOV-150 3mm MPRAGE SAG POST (Do COR MPR 5x5 and 3x3) FOV 230 keep isotropic! use water excitation THIN POST FOV-150 **** START SCAN IMMEDIATELY FOLLOWING INJECTION-use injector when possible ***You do not need to run the dynamic sequences if there is a obvious mass arising from the sella or if the patient has had previous pituitary surgery ***IF the referring orders a brain as well please add in the following sequences at no charge T2 AX FLAIR AX FS DIFFUSION *****IF you see a tumor, run the MPRAGE in the axial plane instead of the sagittal plane MRI FAST Scan for Hydrocephalus Single Shot TSE T2 Imaging (HASTE) in the axial, sagittal, and coronal planes matrix size, 256 205; FOV 24; TR/TE/turbo factor, 1500 ms/120 ms/76; 5-mm section thickness;
Page 5 approximately 25 sections Total imaging time, approximately 90 seconds MRA/MRV MRA Brain only 3D TOF AX MRA Brain with and without contrast (Dr. Heck's follow up aneurysm coil) 3D TOF AX FL3D PRE FL3D POST ***We should only be giving contrast on MRA brain for Dr. Heck or Dr. Brown UNLESS the referring physician or the insurance company insist on doing the exam w/wo contrast MRV Brain-preferred with and without contrast 2D TOF (oblique Sagittal) PHASE SAG PHASE AX PHASE COR 3D SAG MPRAGE (Do COR MPR) FOV-230 0.9mm keep isotropic use water excitation ****IF THE PATIENT IS NOT SCHEDULED FOR AN MRI BRAIN AS WELL please include the following T2 AXIAL MRA brain with contrast only THE FOLLOWING EXAM WILL BE RARE AND IS ONLY TO BE USED WHEN THE REFERRING PHYSICIAN
Page 6 OR THE INSURANCE COMPANY INSISTS ON BEING SPECIFIC WITH REGARDS TO MRA Brain with contrast only FL3D PRE Administer 1 ml contrast 3D TOF AX Administer remaining contrast to equal weight based dose FL3D POST MRA Carotids with and without contrast 3D TOF (MIP right and left carotid together, rotate R/L) FL3D PRE T1 AX FS (COVER FROM 1 inch ABOVE SKULL BASE TO TOP OF STERNUM) FL3D POST (MIP right and left carotid together and separately, rotate R/L)
Page 7 ***Coverage on contrast enhanced sequence is from aortic arch to include COW MRA carotids without contrast 2D TOF (MIP right and left carotid together) 3D TOF (MIP right and left carotid together and separately) T1 AX FS (COVER FROM 1 inch ABOVE SKULL BASE TO TOP OF STERNUM) MRI 8th Nerve-preferred w/wo contrast DWI/ADC (Whole brain) FOV-230 5mm FLAIR AX FS (Whole brain) FOV-230 5mm 3D T2 AX (Post Fossa) FOV-180 0.8mm max REPLACE THE ABOVE SEQUENCE WITH THE FOLLOWING IF ABLE 3D CISS (Post Fossa) FOV 180 0.8 max T1 AX THIN (Post Fossa) FOV-180 3mm MPRAGE SAG POST (Do COR MPR 5x5 & 3x3) FOV-230 0.9mm keep isotropic! Use water excitation T2 AX (Whole brain) FOV-230 5mm T1 AX FS POST (Post Fossa) FOV-180 3mm **Perform a COR MPR (2X1) on 3D sequence after cutting down to the IAC's **IF you see a tumor, run the MPRAGE in the axial plane instead of the sagittal plane MRI Cranial Nerves-preferred w/wo contrast (Whole brain) FOV-230 5mm T1 AX (Whole brain) FOV-230 5mm FLAIR AX FS (Whole brain) FOV-230 5mm DWI/ADC (Whole brain) FOV-230 5mm
Page 8 T1 COR coverage below FOV-230 3mm 3D T2 AX (Post Fossa) FOV-180 0.8mm max REPLACE THE ABOVE SEQUENCE WITH THE FOLLOWING IF ABLE 3D CISS (Post Fossa) FOV 180 0.8mm max MPRAGE SAG POST (Do COR MPR 5x5 & 3x3) FOV-230 0.9mm keep isotropic! Use water excitation T2 AX (Whole brain) FOV-230 5mm T1 COR FS THIN (Post Fossa) FOV-180 3mm COVERAGE FOR CRANIAL NERVES 1st-6th--nerve cover from above optic chiasm through pons 7th nerve--cover 8th nerve region through parotid gland 9th-12th nerve--cover lower pons through tongue base INDICATIONS FOR CRANIAL NERVES Nerves 1-6 visual/pupillary problems facial/jaw pain orbital numbness Nerve 7 Ramsey Hunt Syndrome Bell's Palsy Nerve 8 Hearing loss dizziness Tinnitus Nerves 9-12 Swallowing difficulty **IF you see a tumor, run the MPRAGE in the axial plane instead of the sagittal plane MRI PARANASAL SINUS-Use for anosmia (whole brain) FOV 230 5 mm T2 AX (whole brain) FOV 230 5 mm T1 AX THIN (Sinus) FOV 180-200 3 mm T1 COR THIN (Sinus) FOV 180-200 3 mm T2 COR FS THIN (Sinus) FOV 180-200 3 mm T2 AX FS THIN (Sinus) FOV 180-200 3 mm
Page 9 MPRAGE SAG POST FOV 230 0.9mm keep isotropic! use water excitation T1 AX FS THIN POST (sinus) FOV 180-200 3 mm T1 COR FS THIN POST (sinus) FOV 180-200 3 mm Cover from tip of nose to the brain stem and superior border of frontal sinus to the level of the lower lip Cover all sinuses including a cut above the frontal sinuses on axials MRI Skull Base (Whole brain) FOV-230 5mm T1 AX (Whole brain) FOV-230 5mm STIR AX (through skull base) FOV-200 3mm MPRAGE SAG POST (Do COR MPR) FOV-230 0.9mm keep isotropic! use water excitation T1 AX (Whole brain) FOV-230 5mm T1 COR FS (through skull base) FOV-200 3mm T1 AX FS (through skull base) FOV-200 3mm ******Axials--cover mandible through top of frontal sinus ******Coronals--cover dorsal pons through mid maxilary sinus MRI Orbits-preferred w/wo contrast DWI/ADC (Whole brain) FOV-230 5mm FLAIR AX FS (Whole brain) FOV-230 5mm T1 AX THIN FOV-180 3mm T1 COR THIN FOV-180 3mm T2 COR FS THIN FOV-180 3mm T2 AX FS THIN FOV-200 3mm MPRAGE SAG POST (Do COR MPR) FOV-230 0.9mm keep isotropic use water excitation T1 AX FS THIN POST FOV-180 3mm
Page 10 T1 COR FS THIN POST FOV-180 3mm ***If referring physician orders a MRI brain also, you will perform the entire brain protocol and charge an additional study MRI TMJ'S T1 COR (mouth closed) 120 FOV 3mm PD/T2 SAG (mouth closed) 120 FOV 3mm ***open mouth to comfortable position PD/T2 SAG (mouth open) 120 FOV 3mm GRE SAG (one slice each side) 120 FOV 3mm ***repeat gradient at various degrees while patient closes mouth *****Create CINE file from gradient sequences to show ROM *****If using dual echo sequences separate PD and T2 into individual folders MRI Soft Tissue Neck (USE FOR PAROTID GLAND) preferred w/wo contrast T1 AX FOV-220 5mm T2 AX FOV-220 5mm T1 COR FOV-220 5mm T2 SAG FS FOV-220 5mm Midline to include both sides of tongue STIR COR FOV-250 5mm T1 AX POST FOV-220 5mm T1 COR FS POST FOV-220 5mm MRI Nasopharynx/Face FOV-220 5mm T1 AX FOV-220 3mm STIR AX FOV-220 5mm T2 COR THIN FOV-200 3mm cover anterior face through floor of anterior skull base MPRAGE SAG POST (Do COR MPR) keep isotropic! FOV-230 0.9mm use water excitation T1 AX FS FOV-220 3mm T1 COR FS FOV-220 3mm ******Axials--cover mandible through top of frontal sinus ******Coronals--cover dorsal pons through mid maxillary sinus
Page 11 MRI Glomus Tumor (Use for pulsitile tinnitus) FLAIR AX FS (whole brain) FOV-230 5mm T2 AX FS (whole brain) FOV-200 5mm DWI/ADC (whole brain) FOV-230 5mm T1 AX THIN (Post Fossa-include down to C2) FOV-180 3mm 3D TOF AX (COW-include down to C2) MPRAGE SAG POST (Do COR MPR 5x5 and 3x3) FOV 230 0.9mm keep isotropic! Use water excitation T1 AX THIN POST(Post Fossa-include down to C2) FOV-180 3mm ***The carotids have been dropped from the glomus tumor protocol-only do carotids if referring physician specifically asks for them MRI Brachial Plexus-prefered w/wo contrast T1 AX (scan bilaterally) T1 COR STIR AX T1 AX POST T1 COR FS POST FS POST *****scan unilaterally except for T1 AX *****AX coverage-c5 through level of axilla *****SAG coverage-glenoid of affected side through opposite side of spine MRI Cervical Spine T2 SAG SPACE SAG 0.9mm TE->120 ***Do axial MPR at 2mmX2mm from base of skull through T2 GRE AX **** see comments below ****If giving contrast add T1 AX PRE (copy to T2 AX) FS POST T1 AX POST ******* Axial coverage is C2-T1 ******** Add T2 AX if myelopathy or if you see abnormal signal in the cord
Page 12 ***Run T2 axial INSTEAD of MEDIC if there is a large amount of metal artifact from surgery MRI Thoracic Spine COUNTER 3mm slices T2 SAG 3mm slices 3mm slices SPACE SAG **Do axial MPR 3mmx3mm entire thoracic spine TE>120 0.9mm T2 AX ("stack" through entire thoracic spine) 5mm-6mm **If giving contrast add T1 AX PRE (copy to T2 AX) FS POST 3mm slices T1 AX POST ******Counter must include C1 (without distortion) and Thoracic marker MRI Lumbar Spine-radiologists preference to perform w/wo if patient has has surgery within 10 years SPACE SAG TE->120 0.9mm ***** Do AX MPR 3mmx3mm entire lumbar spine-also do 4mmx4mm SAG MPR T1 AX (scan L3-4, L4-5, L5-S1 disc spaces) T2 AX (scan L3-4, L4-5, L5-S1 disc spaces) FS POST T1 AX POST ***If you do NOT have the ability to do a 3D sagittal sequence (SPACE) you must scan L2-L3, L3-L4, L4-L5, L5-S1 disc spaces axially MRI Spine for MS ***When scanning multiple studies for Multiple Sclerosis you can OMIT the SPACE sequence. Be certain to run the following in each ordered spinal exam. DO NOT forget to add the T2 sagittal in the lumbar region since we do not routinely perform the T2 sagittal. T2 SAG T1 AX T2 AX FS POST T1 AX POST
Page 13 MRI Sacrum T1 COR (parallel to sacrum) TE 20-30 STIR COR (parallel to sacrum) PD FS SAG TE 45 T1 AX (perpendicular to sacrum) TE 20-30 T2 FS AX MRI Sacrum w/wo T1 COR (parallel to sacrum) TE 20-30 STIR COR (parallel to sacrum) T1 AX (perpendicular to sacrum) TE 20-30 T2 FS AX FS FS (perpendicular to sacrum) T1 AX FS MRI Lumbosacral plexus-charge pelvis w/wo T1 AX STIR AX T2 COR SPACE T1 COR T2 SAG STIR COR T1 AX FS T1 COR FS ***Axials are straight, coronals are parallel to the sacrum ***COVERAGE IS BILATERAL FROM L3 TO TOP OF HIPS MRI Spine Screen Cervical spine
Page 14 T2 SAG Thoracic spine T2 SAG Lumbar spine T2 SAG ****You do NOT need to scan axials except in RARE cases of signifigant cord compression ****You do not need to do the SPACE sequence