Aneurysm Clips Made of Titanium: Magnetic Characteristics andArtifacts in MR

Werner Wichmann, Klaus Von Ammon, Ulrich Fink, Thomas Weik, and Gazi M. Yas"argil

PURPOSE: To evaluate the magnetic characteristics, artifact formation, and implant safety oftitanium aneurysm clips for use in MR imaging. METHODS: Aneurysm clips made of titanium alloyTiAl6V4 were tested in a magnetometer to determine their magnetic susceptibility and in a 1.5-TMR imager using both a geometric phantom and an animal model. A commercially availablea-Phynox clip served as the reference standard. RESULTS: We found minimal magnetization anda significant reduction in image artifacts with the titanium clip as compared with the Phynox clip.CONCLUSION: The titanium clips improve image quality, biocompatibility, and patient safety inmedical MR applications.

Index terms: Aneurysm, therapeutic blockade; Interventional instruments, clamps

AJNR Am J Neuroradiol 18:939–944, May 1997

Neurosurgical treatment of intracranial aneu-rysms by permanent closure with “spring clips”placed over the neck of the aneurysm was in-troduced more than 20 years ago and has sincebecome a standard procedure (1–3). The springaneurysm clip is a refinement of the ductilesilver clip introduced by Cushing in 1910, mak-ing it technically possible to close blood vesselslocated in difficult-to-reach intracranial regions(4). Construction requirements of the springclips include such mechanical characteristicsas strength, elasticity, resistance to corrosion,and biological compatibility (5).

With the introduction of magnetic resonance(MR) imaging in the neurologic and neurosurgi-cal examination of patients, magnetic compat-ibility has become another essential require-ment (6, 7). At first, theoretical considerationsresulted in a general hesitation to use MR imag-

Received May 23, 1996; accepted after revision December 12.From the Institute of Neuroradiology (W.W.) and the Department of

Neurosurgery (K.V.A., G.M.Y.), University Hospital, Zurich, Switzerland;and Aesculap AG, Tuttlingen, Germany (U.F., T.W.).

Address reprint requests to Werner Wichmann, MD, Institute of Neuro-radiology, University Hospital of Zurich, Frauenklinikstrasse 10, Nord I,C-200, CH-8091 Zurich, Switzerland.

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© American Society of Neuroradiology

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ers operating at 0.5 to 1.5 T for the examinationof patients in whom metallic aneurysm clipshad been implanted (8). Indeed, a fatal out-come stemming from torque and displacementof a ferromagnetic clip in an MR imager hasbeen reported (9).

However, metallurgical and physical testingof commercially available clips has proved theMR compatibility of clips manufactured fromnonferromagnetic materials. Clinical use of MRimaging has demonstrated that the theoreticalpossibility of clip warming is negligible (10).Thus, it is possible to use MR imaging to exam-ine patients with nonferromagnetic aneurysmclips without risk (8, 10–13). These investiga-tions, however, disclosed considerable imagingartifacts surrounding the clips, which concealcontrast in their vicinity (11, 13–16). Therefore,it is necessary to find materials that produceminimal artifacts on MR images while still en-suring the aforementioned mechanical charac-teristics and biocompatibility.

It is known that a reduction in MR artifactscan be achieved by using titanium alloys (17–19). Our study investigated the magnetic char-acteristics and MR behavior of a Yas"argil tita-nium clip (TiAl6V4). Our purpose was todetermine the extent of MR artifacts as well asMR compatibility and implant safety of theseclips.

Fig 1. Photograph (A) and corre-sponding MR proton density–weighted im-age (2000/20/4) (B) of the phantom inwhich two identical a clips are placed 7.5cm apart on a nylon thread (z-axis is par-allel and frequency-encoding gradient isvertical to the section). The Co-basedPhynox clip is labeled 1 and the titaniumclip 2. A considerable reduction in artifactsis clearly visible around the titanium clip.(Incomplete imaging of the grid on the leftside of the MR image is caused by slighttilting of the imaging plane.)

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Materials and MethodsA generation of clips made of the titanium alloy TiAl6V4

has been invented. The basis for the design of the clips wasthe model FE Aesculap Yas"argil, with slightly bent bladesbelonging to the so-called a class (Figs 1A, 2, and 3A),which has been used successfully for years. This implantwas manufactured with an alloy called Phynox, specifiedin the International Organization for Standardization (ISO)ISO 5832–7 for implant applications and composed of thefollowing constituents: cobalt (Co) (40%), chrome (20%),nickel (16%), molybdenum (7%), and iron. The Co-basedPhynox, known for its good spring characteristics, hasoutstanding mechanical advantages, which has madePhynox the material of choice for several clip manufactur-ers.

The new clip, which is identical to the Yas"argil Phynoxin design, is made of TiAl6V4, which is specified ISO5832–3. It is composed primarily of titanium (Ti) and alsocontains aluminum (Al; 6%) and vanadium (V; 4%). Un-questionably, this material is superior in its biocompatibil-ity and hypoallergenicity as compared with the above-mentioned Co-based Phynox (20).

Fig 2. MR longitudinal view (clip orientation same as in theinset photo; proton density–weighted image 2000/20/4; z-axis ishorizontal and frequency-encoding gradient is vertical to the sec-tion); the artifact on left is located next to the Phynox clip, the oneon right is next to the titanium clip.

Both materials are nonferromagnetic alloys, so the ba-sic requirement for MR compatibility is met. However, inprinciple, any material, even nonferromagnetic, may be-come polarized in an external magnetic field. The less thematerial in question is polarized, the fewer artifacts areseen on MR images. To determine the so-called suscepti-bility, the magnetic polarization of the materials underinvestigation were measured at the Institute of Physics atthe University of Karlsruhe, Germany. Magnetic polariza-tion was measured as a function of the external magneticfield on a SQUID (superconducting quantum interferencedevice) magnetometer up to a field strength of 2.5 T. Thismethod is sensitive and reliable for measuring the mag-netic behavior of solid bodies. The SQUID was calibratedbeforehand using standards provided by the US NationalBureau of Standards.

After determining basic physical variables, clips thatwere identical in design but made of the two differentmaterials were examined in a conventional 1.5-T clinicalMR imager. Unlike the purely physical values measured,the results of these in vitro tests were specific to the MRequipment used (Philips S-15; 1.5 T).

The in vitro examination used a phantom composed ofa plastic ring strung with nylon threads crossing at rightangles, much like the strings of a tennis racket, in a 6.5-Lwater bath. The two clips made of different materials wereplaced in the phantom longitudinally 7.5 cm apart (Figs1A and B and 2). The clips were oriented parallel to themain axis (z-axis) of the MR unit and examined in threeplanes using spin-echo T1- and T2-weighted sequences.Imaging parameters were 600/23/8 (repetition time/echotime/excitations) and 2000/20,90/4, respectively; sectionthickness at full width at half maximum of 4 mm and 5mm, respectively, matrix size of 256 3 256, and field ofview of 16 cm.

In vivo MR studies were performed only with the tita-nium clip, in a 1.5-T magnet (Signa, General Electric,Milwaukee, Wis). A lateral aneurysm measuring approxi-mately 4 mm in diameter was created, using a vein patchon the right common carotid artery of a 250-g rat (breed,SIV; Zurich Veterinary Hospital) using a previously re-

Fig 3. Intraoperative photograph (A)and corresponding coronal T1-weightedspin-echo MR image (600/15/4) (B) showsite of the titanium clip implanted in a rat.The MR artifact (asterisk) can only be dis-cerned around the spring, because theblades extend out of the thin section, ow-ing to their curvature. (The esophagus,which contains air, appears in the middleas a wide, hypointense band.)

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ported technique (21). Eight hours after preparation, theaneurysm was clipped at the neck using the titanium clip(see Fig 3A). Fourteen days later, an MR examination wasperformed with the animal under anesthesia (intramuscu-lar neuroleptanesthesia, according to the Swiss Act onPrevention of Cruelty to Animals). Coronal spin-echo T1-weighted (600/15/4, section thickness at full width at halfmaximum of 3 mm, matrix of 256 3 192, field of view of16 cm) (Fig 3B) and coronal fast spin-echo T2-weighted(3500/23,115/4, echo train length of 8, section thicknessat full width at half maximum of 3 mm, matrix of 256 3192, field of view of 12 cm) images were obtained.

Results

The two clips belonging to the a class (modelFE Aesculap Yas"argil with slightly bent blades)had dimensions of 15 3 5 mm, with a wirethickness of 1.2 mm. Design and dimensions ofthe two clips were identical. The Phynox clipweighed 126.5 3 1023 g and the one madefrom titanium alloy weighed 74.6 3 1023 g.

Using the SQUID magnetometer, we deter-mined the magnetic susceptibilities (x) as x 514.6 3 1026 for the titanium alloy and x 5181 3 1026 for the Co-based alloy (Phynox).The susceptibilities are stated according to theCGS (centimeter-gram-second) system. Thisphysical quantity has no unit.

The in vitro MR investigation revealed that theclip composed of TiAl6V4 caused considerably

fewer artifacts in terms of signal alteration andimage distortion (Figs 1B and 2). On the T2-weighted sequences, the ellipsoid artifact con-cealing the surrounding area measured 15 3 9mm for the Phynox clip, diminishing to 10 3 5mm for the titanium clip.

T1-weighted MR images are, in general, notas greatly impaired by susceptibility artifacts asare T2-weighted images (24, 26). Comparingthe two clips in the phantom, we observed thaton the T1-weighted images, considerably fewerartifacts were present with the titanium clip thanwith the Co-based clip. Also, on the T1-weighted MR image of the rat, only a smallartifact, measuring approximately 7 mm in di-ameter, was detected around the titanium clip(Fig 3B).

Discussion

The new titanium alloy clip was comparedwith a geometrically identical clip made ofPhynox. The reason that the comparison wasmade with this type of clip was that the Phynoxclips and the nearly identical Elgiloy alloy clipstogether account for roughly 75% of all intracra-nial aneurysms clips implanted today in theUnited States.

In manufacturing clips suitable for permanentclosure of intracranial aneurysms, clip design

and choice of material are equally important(5). Suitable alloys must ensure permanent clo-sure, be resistant to corrosion, pose no biolog-ical risk, and be compatible with MR imaging (8,12, 13). MR imaging has established itself asthe most important diagnostic tool for neurosur-gical and neurologic diseases (6, 7, 22). Thedemand for MR-compatible implants has in-creased accordingly.

MR compatibility means that a patient is notat risk as a result of the clip’s shifting or slippingduring MR imaging. It is important to take suchshifting and slippage into account when usingclips made of ferromagnetic alloys, as consid-erable mechanical forces are generated onthese materials (9). In the case of ferromagneticclips, even the proximity of an MR imager, re-gardless of the strength of the magnetic field, isa life-threatening situation for the patient (23).A death has recently been reported during MRimaging of a patient with a ferromagnetic aneu-rysm clip (9).

The physical difference between ferromag-netic and nonferromagnetic materials lies in thedegree of magnetization. In the case of ferro-magnetic materials, there is a sharp rise in mag-netization even when they are exposed to aweak external magnetic field. Magnetization in-creases only slightly when the materials are ex-posed to a more powerful external magneticfield. With nonferromagnetic materials, there isonly a slight increase in magnetization from lowto high magnetic fields. Magnetization of ferro-magnetic materials exposed to an externalmagnetic field of approximately 1.5 T is about1000 times greater than that of nonferromag-netic materials (24).

The degree of magnetism depends primarilyon the composition of the alloy. Some stainlesssteel clips that are being used are ferromagnetic(5, 12). In addition, there is deformation-in-duced magnetism, especially in the insuffi-ciently stable austenites. These materials showno inherent magnetic properties. When de-formed at room temperature, the crystallinestructure of the metal is changed and the ma-terial becomes ferromagnetic. The manufactur-ing processes take advantage of this deforma-tion, for example, to improve the springcharacteristics of the material (5, 14).

A class of stainless steel materials with noferromagnetic characteristics under any cir-cumstances are the stable austenites. This class

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includes, for example, the so-called AISI 316 Lalloy, which is certainly MR compatible.

It must be reemphasized that all materialsbecome magnetized when placed in an externalmagnetic field. The less the magnetization, theweaker the forces exerted on an aneurysm clipduring MR imaging. This magnetization is statedin terms of magnetic susceptibility. Measure-ment of this physical unit has shown that thesusceptibility of the titanium alloy is only onetenth that of the Co-based alloy Phynox. Thus,the forces exerted on the aneurysm clip duringMR imaging are reduced to a fraction of the clipweight. Reduced magnetic susceptibility alsoresults in a reduction of magnetism influencingMR imaging (10, 13, 16).

Two main effects cause artifacts aroundmetal implants. First, a local field inhomogene-ity is produced around the implant in the staticMR field, because of the magnetic susceptibilityof the metal. This local field inhomogeneity in-terferes with the imager gradients and leads toregional distortion of the resonance frequency(13, 26). Second, eddy currents, due to gradi-ent switching, occur in a highly electroconduc-tive material. These eddy currents disturb thelocal magnetic field homogeneity surroundingthe implant, resulting in signal alterations, re-gional hypointensities, increased peripheral sig-nals, and geometric image distortions in theimmediate vicinity of the implant (13, 14, 16)(Figs 1B, 2, and 3B).

The presence of only mild artifacts seenaround the once-used silver clips is due to eddycurrents and not to magnetic susceptibility. Sil-ver, which is highly electroconductive, makesthe generation of eddy currents possible, but ithas a low negative (diamagnetic) magnetic sus-ceptibility, x 5 219.5 3 1026 (25), as com-pared with Phynox AISI 316 L and TiAl6V4.Because eddy currents play a minimal role inthe production of clip-related artifacts, it can beconcluded that magnetic susceptibility (x) ofthe material used and its mass are the mainfactors determining the production of artifacts.

The magnetic characteristics of TiAl6V4 (x 514.6 3 1026 for titanium alloy compared with x5 181 3 1026 for Co-based alloy) make it op-timal for use in aneurysm clips. Titanium alloyhas been shown to be highly biocompatible formore than 20 years, as demonstrated by thelarge number of orthopedic patients with per-manent implants made of this material.

Good mechanical characteristics are impor-

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tant prerequisites for spring aneurysm clips,which is why silver is not currently used. Tita-nium, which is relatively weak, is considered anunfavorable material for springs; but extensivedevelopmental work has resulted in a clip inwhich the closing force is only slightly compro-mised in favor of better magnetic characteris-tics. In most clip models, the titanium alloyTiAl6V4 has the same closing force as the onesmade of the Co-based alloy Phynox.

In MR investigations with a water phantom,we detected a considerable reduction in arti-facts with the titanium clip as compared with theCo-based Phynox clip. The artifacts found withthe titanium clip implanted in the laboratoryanimal, as compared with the phantom mea-surements, can be explained by the bent bladesof the clip, which stuck out of the 3-mm section.Other factors contributing to diminished arti-facts include the use of steeper readout gradi-ents (which depend on the short prescribedecho time), thin sections, and a small field ofview. Steeper readout gradients result in lessspatial frequency spread of the susceptibility-induced resonant frequency distortion (26).However, the chosen section thickness of 3 mmand the fields of view of 12 cm and 16 cm in thein vivo studies were somewhat smaller thanwould be typically applied in two-dimensionalFourier transform (2DFT) brain imaging of hu-mans. The loss of signal due to susceptibilityeffects is less when the size/volume of the vox-els is decreased because of decreased intra-voxel dephasing. Thus, in imaging patients withsuch clips, the size of the artifact for comparablesequences (but with typically larger voxels)would be larger than the one encountered in ouranimal model.

The neuroradiologist should be aware of theMR compatibility of implanted aneurysm clips.The first three generations of Yas"argil clips, la-beled FD, are now thought to be incompatiblewith MR imaging. The a-Phynox type, labeledFE, is a fourth-generation clip and the only onebesides the new titanium type considered to beMR compatible (23). The neuroradiologistshould not rely on verbal assurance from theneurosurgeon that the clip used is MR compat-ible but should require a written confirmation ofthe specific type of Yas"argil clip used in theoperation (9).

The risk of interaction of aneurysm clips withstrong magnetic fields can be reduced by usingthe material TiAl6V4. This alloy has less mag-

netic susceptibility, diminished MR artifacts,and better biocompatibility than the previouslyused material. However, it is still impossible toobtain exact anatomic information about thevessels in the immediate vicinity of a clip bymeans of MR imaging or MR angiography (27).Thus, the challenge remains to find yet moresuitable materials for aneurysm clips that evenbetter fulfil mechanical, biological, and mag-netic requirements.

AcknowledgmentWe thank Rosmarie Frick of the Microsurgical Labora-

tory for her valuable assistance with animal preparation.

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