Liver-MRI With Primovist - Tips and Tricks - Handsout Christian Lienerth

8/20/2019 Liver-MRI With Primovist - Tips and Tricks - Handsout Christian Lienerth

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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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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


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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PharmacokineticECM (Extracellular Conrast Media)

Gadovist® - 1 min vs. 3 min after CM

GV® - 1 min. after CM GV® - 6 min. after CM


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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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]


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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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


Optimized Workflow

Example for a Primovist® Procedure

Pre Contrast Post Contrast


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Workflow

Closer Look to the Details

t1_fl2d_inop_tra_mbh_2


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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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


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

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5

T1w before Contrast Media

Different scans with the same radiological information.

t1_fl2d_inop_tra_mbh_2


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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


MRCP: T2w

Opinion of the Literature ?


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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


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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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 ?


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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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


Injection ProtocolSaline Chaser

The transfer line can hold alone a volume of 7 ml.

Sometimes additional extensions are used.


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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


Individual Timing is

important

different lesions shows

different enhancement

pattern

important information for

tdetection and

characterisation

Dynamic Liver Imaging


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Signal-Variation

Autor: Dr Akihi ro Tanimoto (Diagnostic Radiology, Keio University School of Medicine, Japan

Typical signal-variation of liver lesion with Primovist®


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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Diffusion (DWI)

* 2 Talks ECR 2009, Choi 2009


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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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®


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


TR

MZ


TE

MXY


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Example: T2w - HASTE / SSH / SS-FSE

pre CM ~3 min 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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„Breath hold“ respiratory triggering


Breath hold vs. Respiratory triggering


Increase of image quality with

Gating- or Triggering

breath hold T2w fs gating


Breath hold vs. Respiratory triggering


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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


Respiratory Triggering vs. Motion-Correction


T2w & DWI after Primovist®

Voice of the Literatur?


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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


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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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



3D-Scan

breathhold

time: 1 x bh ca. 20 s

MPR possible

but: limited resolution


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Alternativ #1

2D Scan in „ multi breath hold“ Technique

higher spacial resolution (in-plane) possible


Some General Remarks


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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


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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Oxygen & Breathhold Capacity

Preparation:

offering Oxygen (if possible)

• prolongation of the breath hold capacity


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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Breath hold Position

Exspiration

• heart close to the liver

• sometimes artefacts in the leftliver lobe

Inspiration

• heart more away from the liver

• less artefacts


Breath hold PositionInspiration


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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

Documents

Liver-MRI With Primovist - Tips and Tricks - Handsout Christian Lienerth