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Christian Lienerth, Ph.D.
Bayer Vital GmbH / Germany
Head of CT-/MR-Application Service
Business Unit Radiology & Interventional
2BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Liver-ImagingDemand
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3BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Desirable: 4 criterions
• strong T1w
• high spacial resolution
• fast scanning (< 20s)
• whole coverage of the liver
further wishes:
• good fat-saturation
• 3D-scan for MPR / MIP
Liver-ImagingDemand
4BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
1. Alpha Phase = vascular Phase, t1/2 = 2 - 3 min.
2. Beta Phase = vaskular and interstitial distribution: t1/2 ~ 60 - 90 min.
PharmacokineticECM (Extracellular Contrast Media)
For good tumor enhancement you have to scan in the -Phase.
Waiting period of 2-3 min. after CM-injection are recommended.
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5BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
PharmacokineticECM (Extracellular Conrast Media)
Gadovist® - 1 min vs. 3 min after CM
GV® - 1 min. after CM GV® - 6 min. after CM
6BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
1. Localizer
2. T1w_tra_(T)SE_nativ
3. T2w_sag_FLAIR
4. ___ CM-Injection ___
5. T2w_tra_(T)SE
6. T1w_tra_(T)SE_CM_1
7. T1w_cor_(T)SE_CM_2
8. …..
~ 2 min.
1. Localizer
2. T1w_tra_(T)SE_nativ
3. ___ CM-Injection ___
4. T2w_sag_FLAIR
5. T2w_tra_(T)SE
6. DWI
7. T1w_tra_(T)SE_CM_1
8. T1w_cor_(T)SE_CM_2
~ 5 min.
Workflow RecommendationsSequences and Waiting Period
Tip: Arrange your sequences in a clever order It´s a pharmacokinetic property.
For excellent enhancement in -phase you have to wait !
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7BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Pharmacokineticof Primovist® - Liver Specific
Modified Gd-Complex
lipophilic side-chain(Ethoxybenzylgruppe)
• Dosage: 0.025 mmol/kg 0,1ml/kg BW
intravenous Bolus–Injection
Protein-Binding: ~ 10 %
Relaxivity 6,9 l/mmol/ s(in Blood-Plasma, bei 37°C, und 1,5T)*
Uptake into Hepatocytes
T1w Images
[*Rohrer et al., Investigative Radiology 2005, 40 (11): 715-724]
8BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Pharmacokineticof Primovist® - Liver Specific
excretion via Gallbladder: ~ 50%
excretion via kidney: ~ 50%
excretion via kidney or biliarycould be supplemented in both ways
plasma t1/2: ~ 60 min.
complete elimination: 24 h
[Hamm et al., Radiology 1995, 195:785-792]
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9BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Primovist®
intelligent MR sequencen ordering
Stand 07/2010
Tip: For a “ time optimized workflow” it is important, that Primovist®
will be given very early in the liver examination procedure.
Product Information
10BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Optimized Workflow
Example for a Primovist® Procedure
Pre Contrast Post Contrast
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11BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Workflow
Closer Look to the Details
t1_fl2d_inop_tra_mbh_2
12BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Localizer
fast coronal scout, to estimate the size of the liver (HASTE / SSH / SS-FSE or TruFisp / b-FFE / FIESTA)
Expansion of the Liver
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13BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
In-Out-Phase
T1w-Sequence
different precession frequencies of „H“ in the CHx in the H2O molecule(3,5 ppm shifted, @ 1,5 T 217 Hz)
possibility of fat-quantification
Primovist® will influence the T1-relaxation t ime, „ In-Opp-Seq“ must be run before CM
all other sequences could be run after CM
Scan before Contrast Media
14BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Workflow
Tip: A separated pre T1w sequence (3) could be skipped, as
• the In-Out Phase (4) contains the pre T1w information and
• the dynamic series (5,6,7,8) includes a pre T1w scan as well
34
5
T1w before Contrast Media
Different scans with the same radiological information.
t1_fl2d_inop_tra_mbh_2
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15BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
MRCP: T2w
• MRCP is an alternative to ERCP (Endoscopic retrograde cholangiopancreatography)
• Primovist® will be excreted via the biliray system
• the beginning of Primovist®
excretion will be accelerate the T2* dephasing• T2w-MRCP must be run before Primovist®,
to avoid signal dropout in the biliary system
E c h o A m p l i t u d e ( S I )
TE (ms)T2w-MRCP before Primovist® T2*-dephasing
16BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
MRCP: T2w
Opinion of the Literature ?
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17BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Primovist® Injection
• T1w-dynamic with fat-saturation (3D: VIBE / THRIVE / LAVA)
• Dosage:
0,1ml / kg BW 1 ml / 10 kg KG
• Injection:
Flow rate: ~ 1 – 2 ml/s
followed by 30 – 40 ml NaCl
Tip: Injection of Primovist®
• slow flow rate of 1 ml/s
• inject sufficient NaCl
be aware of dead volume in the transfer-line
18BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Injection and Scan-Delay
Tip: Each patient has different circulation time
individual timing is necessary
goal: arterial phase of the “liver lesion”
Test-Bolus oder Fluroscopic Method
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19BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Injection and Scan-Delay
Tip: Each patient has a different circulation time
individual timing is necessary
goal: arterial phase of the „ liver-lesion”
MIP MIP with wrong liver-timing
Arterial or Venous Phase ?
20BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
0,1 ml /kg BW
Gadobutrol
(Gadovist® 1.0)
0,2 ml/kg BW
Gd-DTPA (Magnevist®)
Gd-BOPTA (MultiHance®)
Gadodiamide (Omniscan®)
Gadoteridol (ProHance®)
Gadoterate meglumine (Dotarem®)
Injection StrategiesSmall Volume
0,1 ml/kg BW
Gd-EOB-DTPA
(Primovist® )
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21BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Tip: Be aware of anatomy and physiology the small amount of CM should be transferred to the heart,
by an appropriate amount of saline-chaser (NaCl)
better better
Injection of Small Volume
22BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Injection ProtocolSaline Chaser
The transfer line can hold alone a volume of 7 ml.
Sometimes additional extensions are used.
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23BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Dynamic Phases
the arterial Phase should be measuredwith fluroscopic control
the portal-venous Phase should be measured 15-20 sec.
after the end of the arterial phase
the dynamic late Phase should be measured 2-3 min.
after the injection of Primovist®
[Ringe, et al . AJR 195:13-28 (2010)]
Dynamic Liver Imaging
24BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Individual Timing is
important
different lesions shows
different enhancement
pattern
important information for
tdetection and
characterisation
Dynamic Liver Imaging
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25BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Signal-Variation
Autor: Dr Akihi ro Tanimoto (Diagnostic Radiology, Keio University School of Medicine, Japan
Typical signal-variation of liver lesion with Primovist®
26BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Signal-Variation
Autor: Dr Akihi ro Tanimoto (Diagnostic Radiology, Keio University School of Medicine, Japan
Typical signal-variation of liver lesion with Primovist®
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27BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Diffusion (DWI)
* 2 Talks ECR 2009, Choi 2009
28BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
DWI: ADC and Primovist®
Comparison of ADC-Werte
BEFORE and AFTER Primovist®
Choei e.a.: „ Diffu sion-weighted MR imaging of liver on 3.0-Tesla system:effect of intr avenous administration of gadoxetic acid disodium“ , Eur Radiol 2009
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29BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Reasonable Worklist
• uptake of Primovist® in the hepatocytes needs 10 – 20 minutes
• to avoid, that the patient has to be a second time on the table, T2w
and possible DWI scans should be performed after theadministration of Primovist®
30BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
T2w after Primovist®
• in general: Gadolinium will influence T1- as well T2-time
• higher concentration of CM will be more seen on the images
• the influence of PV onto T2w is not disturbing,it will sometimes increase the tissue-lesion contrast
E c h o A m p l i t u d e ( S I )
TR
MZ
E c h o A m p l i t u d e ( S I )
TE
MXY
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31BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
T2w after Primovist®
Example: T2w - HASTE / SSH / SS-FSE
pre CM ~3 min after Primovist®
32BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
T2w after Primovist®
Basically you have different sequences for T2w
T2w-Single-Shot
HASTE / SSH / SS-FSE
T2w- triggered TSE
free breathing/ navigator / respiratory triggered
T2w-motion correction
BLADE® / ROPELLER® / MultiVANE®
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33BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
„Breath hold“ respiratory triggering
T2w after Primovist®
Breath hold vs. Respiratory triggering
34BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Increase of image quality with
Gating- or Triggering
breath hold T2w fs gating
T2w after Primovist®
Breath hold vs. Respiratory triggering
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35BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Improvement of liver vessels and reduction of pulsation artifacts
Tip: use the waiting period in an reasonable manner
• run T2w respiratory triggered scans or motion corrected scans
after Primovist® this is convenient for the patient
T2w after Primovist®
Respiratory Triggering vs. Motion-Correction
36BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
T2w & DWI after Primovist®
Voice of the Literatur?
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37BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Late ImagesHepatobiliary Phase
Tipp: In the late phase it should be
• no or less CM visual in the vessels
• the hepatobiliary excretion should be visible
FNH
38BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Hepatobiliary Phase10 min. vs 20 min.
Uptake in the hepatocytes reaches a plateau after 20 min. which holds about 120 min.
At the time of approval: late phases after 20 min.was investigated and approved
Recent studies has shown that: After 10-15 min. no significant less lesions are
visible and the signal enhancement will not change
Tip: the late phase could be started after 10 – 15 min.
exception: Liver Cirrhosis here wait 20 min.
Hepatobiliäre Phase 10 min p.i.
Hepatobiliary Phase 20 min p.i.
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39BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Hepatobiliary Phase10 min. vs 20 min.
Tip: the late phase could be started 10 – 15 min.
exception: Liver Cirrhosis here wait 20 min.
[Suh Y, et al. AJR 2011;197:W44-W52]
Hyperintense HCCs
40BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Late ImagesHepatobiliary Phase
3D-Scan
breathhold
time: 1 x bh ca. 20 s
MPR possible
but: limited resolution
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41BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Late ImagesHepatobiliary Phase
Alternativ #1
2D Scan in „ multi breath hold“ Technique
higher spacial resolution (in-plane) possible
42BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Some General Remarks
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43BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
General Remarks
Patient Prepatarion
• good instruction about the procedure
• comfortable position• train the breathhold commands
Breathhold Capacity
• determine the time interval of breath hold capacitybefore start the examination
• adapt the scan duration to this capacity
Control• respiratory belt for visual control of the movement
44BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Breathhold Capaity
Avoid „ Movement“ -Artifacts
Adapt the scan duration to the breath hold capacity of the patient
too long, movement artefacts adopted scan duration
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45BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Oxygen & Breathhold Capacity
Preparation:
offering Oxygen (if possible)
• prolongation of the breath hold capacity
46BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Breath hold Position
Exspiration
• position is more defined and robust
• liver is more stretched maybe more slices, scan longer
Inspiration
• perception is more convenient
• position sometimes deep, sometimes notso deep
• compressed liver
less sl ices, shorter scan
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47BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Breath hold Position
Exspiration
• heart close to the liver
• sometimes artefacts in the leftliver lobe
Inspiration
• heart more away from the liver
• less artefacts
48BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Breath hold PositionInspiration
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49BHC Radiology ■ Dr. Chris tian Lienerth ■ Bangkok October 2012
Artefacts
Tip: Avoid Artefacts
be sure that the coils are well positioned on the patient
explain and train the breath hold commands before the procedure determine the individual breath hold capacity before start
adapt the scan duration to the patient
don’t hurry, give breath hold command in a calm manner
respiratory belt for visual control
better and reproducible results in expiration
short delay between breath hold command and start of the sequence patient must really finished the breathing
if necessary, give antispasmodic drugs (Buscopan©, Glukagon©)to calm down the bowel activity
S i F A B tt Lif