Advances Ib Ob/Gyn Advances Ib Ob/Gyn Cross Sectional ImagingCross Sectional Imaging

DR. SONAL GARG

JASLOK HOSPITAL AND RESEARCH CENTRE,MUMBAI

DR. SONAL GARGJASLOK HOSPITAL AND RESEARCH CENTRE,

MUMBAI

MRI evaluation of Pelvic floor disordersMRI evaluation of Pelvic floor disorders Urinary and anal incontinence affects a large Urinary and anal incontinence affects a large

proportion of the female populationproportion of the female population

MRI is now the modality of choice for preop planning MRI is now the modality of choice for preop planning of pelvic floor repairsof pelvic floor repairs

Superior soft tissue evaluation of viscera, pelvic Superior soft tissue evaluation of viscera, pelvic musculature and fascial investmentsmusculature and fascial investments

Guides detailed evaluation of repair in cases that do Guides detailed evaluation of repair in cases that do not resolve with conservative Rx.not resolve with conservative Rx.

Normal position of the Normal position of the bladder base, vaginal bladder base, vaginal vault and ano- rectal vault and ano- rectal junction at restjunction at rest

Normal position of the Normal position of the bladder base, vaginal vault bladder base, vaginal vault and ano- rectal junction and ano- rectal junction with Valsalvawith Valsalva

ANAL SPHINCTER INJURIESANAL SPHINCTER INJURIES

Internal and External Sphincter trauma seen Internal and External Sphincter trauma seen in obstetric injuries leads to fecal in obstetric injuries leads to fecal incontinence.incontinence.

Pelvic floor denervation secondary to vaginal Pelvic floor denervation secondary to vaginal delivery may lead to perineal descent and delivery may lead to perineal descent and posterior compartment deficits.posterior compartment deficits.

MRI of the ANAL SPHINCTERSMRI of the ANAL SPHINCTERS

Recent advances in MRI technologies using Recent advances in MRI technologies using the endoanal coil, rapid sequencing, and the endoanal coil, rapid sequencing, and cinematic display have enabled dynamic cinematic display have enabled dynamic defecography.defecography.

Used to evaluate both muscular and Used to evaluate both muscular and connective tissue supports of the pelvis. connective tissue supports of the pelvis.

Muscular defects along with POP and Muscular defects along with POP and perineal descent can be assessed. perineal descent can be assessed.

At rest, the bladder base and At rest, the bladder base and Cervix is normal.Cervix is normal.The anal sphincter is open The anal sphincter is open with an abnormally low with an abnormally low placed anorectal junctionplaced anorectal junction

The evacuation phase shows The evacuation phase shows a large descending cystocele a large descending cystocele and Severe descending and Severe descending perineal syndromeperineal syndrome

Dynamic MRI in Dynamic MRI in Stress Urinary IncontinenceStress Urinary Incontinence

Used to asses the functional and anatomic Used to asses the functional and anatomic changes that occur during stress changes that occur during stress incontinenceincontinence

Dynamic MRI guides management options- Dynamic MRI guides management options- response with pessary or need for surgeryresponse with pessary or need for surgery

Dynamic MRIDynamic MRI

A- MRI without pessary A- MRI without pessary

B- MRI with pessaryB- MRI with pessary

(line represents the pubococcygeal line)(line represents the pubococcygeal line)

Fast MRI with and without pessary Fast MRI with and without pessary while performing Valsalva while performing Valsalva

A- Valsalva with pessary A- Valsalva with pessary

B- Valsalva without pessaryB- Valsalva without pessary

(line represents posterior urethro-vesical angle)(line represents posterior urethro-vesical angle)

FETAL MRI- FETAL MRI- A Developing technique for the A Developing technique for the

Developing patientDeveloping patient

What does it provide?What does it provide?

Offers complete evaluation of the fetus even in Offers complete evaluation of the fetus even in difficult situations like oligohydramnios, difficult situations like oligohydramnios, maternal obesity, limitations of fetal position etc.maternal obesity, limitations of fetal position etc.

Overcomes the problems of Calvarial and bone Overcomes the problems of Calvarial and bone calcification which may obscure detail.calcification which may obscure detail.

Gives more information to guide management Gives more information to guide management and counselling when an abnormality is and counselling when an abnormality is detected on ultrasounddetected on ultrasound

FETAL MRI- AdvantagesFETAL MRI- Advantages

Excellent spatial soft tissue resolutionExcellent spatial soft tissue resolution

Large field of view-Detailed evaluation of Large field of view-Detailed evaluation of fetal and extra-fetal structures.fetal and extra-fetal structures.

Three dimensional information with Three dimensional information with multiplanar imaging.multiplanar imaging.

Established safety in second trimesterEstablished safety in second trimester

Limitations of fetal movement has been Limitations of fetal movement has been overcome by using HASTE sequences overcome by using HASTE sequences

CASE 1- RECURRENT PREGNANCY LOSSCASE 1- RECURRENT PREGNANCY LOSS

FETAL MRI- ApplicationsFETAL MRI- Applications Central nervous system and spine pathologies:Central nervous system and spine pathologies: Evaluation of ColpocephalyEvaluation of Colpocephaly Agenesis of the Corpus CallosumAgenesis of the Corpus Callosum Posterior fossa anomalies- is there Dandy Walker Posterior fossa anomalies- is there Dandy Walker

malformation?malformation? Intra-axial and extra-axial mass lesions and fluid collectionsIntra-axial and extra-axial mass lesions and fluid collections Destructive brain lesions and haemorrhageDestructive brain lesions and haemorrhage Spinal dysraphism- delineates the extent and levelSpinal dysraphism- delineates the extent and level Sacrococcygeal teratoma- Intrapelvic and abdominal extent Sacrococcygeal teratoma- Intrapelvic and abdominal extent

of tumor, mass effect on adjacent organsof tumor, mass effect on adjacent organs

CASE 1- PERSISTENT COLPOCEPHALYCASE 1- PERSISTENT COLPOCEPHALY

CASE 2- PROMINENT POSTERIOR CISTERNA MAGNACASE 2- PROMINENT POSTERIOR CISTERNA MAGNA

CASE 3- PRECIOUS PREGNANCY WITH CASE 3- PRECIOUS PREGNANCY WITH SUSPECTED ARNOLD CHIARI MALFORMATIONSUSPECTED ARNOLD CHIARI MALFORMATION

FETAL MRI- ApplicationsFETAL MRI- Applications

Intrathoracic lesions:Intrathoracic lesions:

CCAM- cystic nature, differentiates it from CCAM- cystic nature, differentiates it from Congenital diaphragmatic hrenia containing Congenital diaphragmatic hrenia containing bowel loopsbowel loops

Pulmonary sequestrationPulmonary sequestration

Congenital diaphragmatic hernia- extent, Congenital diaphragmatic hernia- extent, severity scores such as lung volumetryseverity scores such as lung volumetry

FETAL MRI- The futureFETAL MRI- The future

Diffusion tensor imaging and Perfusion Diffusion tensor imaging and Perfusion studies:studies:

Extremely sensitive and specific sequences Extremely sensitive and specific sequences to detect cerebral ischemiato detect cerebral ischemia

Can determine the onset of ischemia and Can determine the onset of ischemia and detailed extent of neural damage for detailed extent of neural damage for prognosis and guiding managementprognosis and guiding management

MRI guided High Intensity Focused MRI guided High Intensity Focused Ultrasound- Ultrasound-

The New Kid on the BlockThe New Kid on the Block

What is HIFU?What is HIFU?

Thermal ablation techniqueThermal ablation technique

Sound waves focused to deliver heatSound waves focused to deliver heat

Results in tissue necrosis and cell Results in tissue necrosis and cell deathdeath

What does the MR What does the MR guidance provide?guidance provide?

3D multiplanar imaging of the fibroid3D multiplanar imaging of the fibroid

Clearly identifies the position and extent of Clearly identifies the position and extent of the fibroid, what portion has to be treatedthe fibroid, what portion has to be treated

Provides real time information about Provides real time information about temperature changes of the treated fibroid to temperature changes of the treated fibroid to ensure ablation.ensure ablation.

MrgFUS- What are the advantages?MrgFUS- What are the advantages?

Non-invasive, does not require hospital stayNon-invasive, does not require hospital stay

Uterus conservingUterus conserving

Offers good symptom relief and excellent Offers good symptom relief and excellent quality of life quality of life

MrgFUS- Inclusion CriteriaMrgFUS- Inclusion Criteria

Women between 18 and 59 yearsWomen between 18 and 59 years

Weight less than 140 kgWeight less than 140 kg

Uterine size less than 24 weeksUterine size less than 24 weeks

Symptomatic fibroids- bleeding, pressure, Symptomatic fibroids- bleeding, pressure, pain, urinary symptoms etc.pain, urinary symptoms etc.

MrgFUS- Exclusion CriteriaMrgFUS- Exclusion Criteria

Extensive scarring along the lower Extensive scarring along the lower abdominal wall or surgical clips in the direct abdominal wall or surgical clips in the direct path of the beam.path of the beam.

Not yet approved for women seeking fertilityNot yet approved for women seeking fertility

Pregnant patientsPregnant patients

THANK YOU THANK YOU