F i e l d Strength

Publication for the Philips MRI Community

GRASE Fiber tracking

Center’s business plan highlights 3.0T

quality and applications
Nevada Imaging Centers, Las Vegas emphasizes advanced studies

This article is part of

Field Strength Issue 27
December 2005
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Center’s business plan highlights 3.0T

quality and applications
Nevada Imaging Centers, Las Vegas emphasizes advanced studies

According to William W. Orrison, M.D., Nevada Imaging Centers (NIC, Las Vegas,
Nev., USA), referring physicians and patients alike prefer and seek out the high
quality healthcare providers in any given market.This belief drove Dr. Orrison’s
strategy for NIC’s Spring Valley clinic, which acquired a Philips 3.0T (Intera)
system in 2004. Instead of using the 3.0T system’s power to boost throughput,
Spring Valley harnesses the 3.0T to create superb images and conduct advanced
studies.Today, Spring Valley is an economically viable clinic performing the most
sophisticated studies available, such as diffusion tensor imaging (DTI), MR
William W. Orrison, M.D. spectroscopy (MRS) and BOLD fMRI. It has seen significant gains, especially, in
spinal cord and brain multiple sclerosis imaging.

Whether performed at a 0.2T or 3.0T field
"Three years ago I believed strength, U.S. health insurance companies
3.0T was ready for reimburse MR scans at the same level.
outpatient operation and Accordingly, many clinics improve their
I wanted to prove that."
cost-benefit ratio by acquiring a relatively
cheaper low field system and scanning as
many patients as possible. Some might
regard Nevada Imaging Centers’ (NIC)
strategy to purchase a more costly 3.0T
system as economically counterintuitive.
NIC radiologist, Dr. William Orrison,
however, had a vision for the 3.0T: calculate
a reasonable patients-per-day goal and then
maximize the 3.0T system’s advanced
imaging capabilities to attract patients and
referring physicians.
“Three years ago I believed 3.0T was ready
for outpatient operation and I wanted to
prove that,” Dr. Orrison says. “Secondly, I
thought 3.0T would raise the overall quality
of healthcare and attract both patients and
referring physicians.”
service and support. It became operational
in May 2004 at NIC’s new Spring Valley
clinic.
NIC’s 1.5T Philips system has provided
100% uptime, Dr. Orrison notes. “Plus,
Philips service has been phenomenal. The
third reason for selecting Philips is that we
have an extremely supportive Philips
representative.”
While Dr. Orrison believed in the
technological excellence of Philips MR
systems, keeping a 3.0T system up and
running was the most critical issue. NIC
calculated a pro forma that dictated a
break-even mark of 20 patients per day.
Today, the system exceeds that goal by five
patients, reducing NIC’s initial seven-year
projected return-on-investment to four
years.
Focus on advanced applications

Net Forum
w w w. p h i l i p s . c o m / n e t f o r u m
Visit the MRI NetForum Community
to view or download NIC's 3.0T
ExamCards.
Photo of Dr. Orrison by MichaelG.org
Dr. Orrison’s 3.0T conviction was reinforced
after seeing 3.0T images at Philips’ RSNA
exhibit in 2003 and test-running 3.0T
techniques at Philips’ Cleveland facility.
After evaluating several vendors’ products,
NIC radiologists chose the Philips 3.0T
system based on Philips’ excellent uptime,
Spring Valley specializes in a wide range
of neuro MRI cases, and adding the 3.0T
system – to NIC’s complement of 0.3T,
0.7T, 1.0T and 1.5T scanners (five total) –
has opened the door to additional
sophisticated studies, which demand high
SNR for higher resolution and/or thin slice
imaging.

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FLAIR GRASE
9-year-old male with post-inflammatory encephalomalacia. The axial FLAIR sequence demonstrates bilateral parietal
encephalomalacia with decreased signal intensity (arrow). Diffusion tensor imaging (32 directions) with fiber tracking
demonstrates marked loss of superior cortical spinal tract fibers in the region of encephalomalacia identified in the FLAIR image.
The images were acquired using the SENSE Head coil.
The most significant difference between
Spring Valley and NIC’s four other imaging
centers is a marked increase in the diagnosis
of spinal cord multiple sclerosis. “We make
that diagnosis daily now,” he says. “Working
at 1.5T, I might have made it monthly,
possibly weekly at most.”
Similarly, brain MS studies are considerably
more sensitive at 3.0T, greatly increasing
clinicians’ diagnostic confidence. “I find
brain MS lesions that I would have difficulty
finding or not finding at all at 1.5T, due to
noise, artifacts or insufficient resolution,”
Dr. Orrison says. “The Philips 3.0T system
has reduced lesion subtlety, improving
visualization and enabling us to confidently
call abnormal lesions.”
Clinicians have been noting that 3.0T helps
better to detect MS lesions than 1.5T, Dr.
Orrison observes.1 Spring Valley achieves its
MS imaging results using conventional T1-
and T2-weighted sequences, FLAIR, DTI
(white matter) fiber tracking, MR
spectroscopy and SENSE and now
preferentially conducts MS studies on the
3.0T system.
“SENSE buys us time”
Spring Valley uses SENSE factor 1.6
(i.e. exactly 1.6 times faster scan time than
without SENSE) on MS exams and nearly
all other studies to afford increases in matrix
or number of signal averages, while avoiding
raising scan time.
Issue 27 - December 2005
Page 15
Fiber tracking
“We could run this system like a fast 1.5T
scanner as some centers do, but instead we
use it specifically to make more difficult
diagnoses,” Dr. Orrison notes. “A significant
percentage of patients we see here have failed
a diagnosis elsewhere, so we use the scanner "For patients that failed a
at its maximum capability rather than diagnosis elsewhere, we use
maximum throughput. We concentrate on the scanner at its maximum
high quality and accept that it will take capability rather than
longer. SENSE allows us to keep a higher
maximum throughput."
matrix and more signal averages, so we can
acquire a higher quality scan in the same or
less time. SENSE buys us time.”
MR spectroscopy helps to evaluate
MS lesions
Spring Valley is exploiting the advantage that
higher field strength brings to MR
spectroscopy for evaluating the levels of n-
acetyl aspartate (NAA), choline and creatine
in MS lesions. Differences in metabolic levels
are seen between active and inactive MS
plaques and between MS lesions and tumors.
Jon Gibson, MR Technologist Nevada Imaging Centers, Sping Valley clinic
Field Strength 15
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T2 weighted STIR T2 weighted

33-year-old female with multiple sclerosis. The sagittal T2-weighted image demonstrates focal abnormal signal intensity within
the cervical spinal cord (arrow). The sagittal STIR sequence demonstrates two focal areas of abnormal increased signal intensity
within the cervical spinal cord (arrows). The axial T2-weighted image demonstrates a focal area of abnormal signal intensity
centrally within the spinal cord (arrow). The images were acquired using the SENSE NeuroVascular coil.

FLAIR T2 weighted “In an active lesion, NAA is usually more

normal, choline is elevated and creatine is
decreased. In addition, you may see also see
elevated lactate and lipids,” he says. “Inactive
MS plaques normally have an elevated
myoinosotol level and the choline, creatine
and NAA are typically more normal.”

“Depressed NAA levels are usually associated

with neoplasms,” he adds. “If the NAA is
normal, we’re reasonably confident it’s not a
tumor.”
GRASE fMRI
“MR spectroscopy represents a technique we
don’t perform at 1.5T for the simple reason
that we have 3.0T,” he continues. “Three
Tesla gives us tremendously better spectro-
scopic data across the board and takes
significantly less time.”

DTI fiber tracking’s many applications

MS cases have benefited from Spring Valley’s
use of DTI fiber tracking, as have other
indications involving white matter,
including dementia, head trauma, stroke
The axial FLAIR image demonstrates focal encephalomalacia in the right frontal cortex
secondary to prior head trauma. The coronal T2-weighted image demonstrates right and pre-surgical brain tumor evaluation.
inferior frontal and left superior frontal “coupe-contrecoup” injury from head trauma. At press time, Spring Valley had performed
The axial T2-weighted GRASE sequence demonstrates right frontal encephalomalacia DTI scans for a total of 165 patients,
secondary to head trauma. fMRI demonstrates significantly decreased cortical activity currently conducting 5 to 10 cases weekly.
on the right following motor activation task. The images were acquired using the
SENSE Head coil.
In MS cases, DTI is used to depict
pathology and the three-dimensional
nature of white matter fiber tracts. “Clearly,
a major goal is to diagnose MS earlier to
facilitate earlier treatment,” he says. “It may

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GRASE
22-year-old male with left visual field defect and left optic nerve glioma. The coronal T2-
weighted GRASE demonstrates focal abnormal signal intensity within the left posterior
prechiasmic optic nerve. The coronal post-contrast T1 SE demonstrates peripheral
contrast enhancement in the focal left prechiasmic optic nerve mass. The images were
acquired using the SENSE Head coil.
also afford a better way to track a patient’s
response to therapy.”
In head trauma cases, DTI can help doctors
determine disruption of white matter fiber
tracts, such as that wich might occur in a
rear-end automobile collision, in which an
occupant in the lead vehicle may have
suffered a shearing injury of the fiber tracts.
DTI also helps Spring Valley radiologists
evaluate different types of dementia, based
on fiber tract loss. Different dementias
impact different brain regions; Alzheimer’s
disease affects parietal and temporal brain
areas, while the frontal and temporal lobes
are primarily impacted in frontotemporal
dementia. “We have been correlating
marked decreases in fiber tracts in areas of
the brain affected by a particular type of
dementia,” Dr. Orrison says.
Stroke can disrupt white matter fiber tracts,
so Spring Valley employs DTI to isolate
affected tracts. While both 1.5T and 3.0T
platforms are comparable in general stroke
MRI, Dr. Orrison says, the 3.0T system
excels in defining brain stem strokes and
small strokes.
Philips 3.0T impresses referring
physicians
“A referring neurologist who attended the
American Academy of Neurology meeting
told me he didn’t see anything there that
Issue 27 - December 2005
Page 17
Post-contrast
"It’s important to know that
world-class imaging is
available in Las Vegas."
was as up-to-date or impressive as the work “It may take these sites a long time to
we’re doing,” Dr. Orrison relates. “A local accumulate a healthier, more routine patient
neurosurgeon also said it’s important for group for a study. Our patients are relatively
people to know that world-class imaging is healthy patients who can participate easily in
available in Las Vegas.” studies, allowing us to get clinical trials done
faster.”
More neurosurgeons are referring to Spring
Valley, he adds, based on the facility’s MR Spring Valley’s first large patient study will
spectroscopy, DTI, CSF flow and BOLD ultimately recruit 50 to 100 patients with
fMRI. Spring Valley performs two to three multiple sclerosis to evaluate certain imaging
BOLD fMRI cases per week, including aspects of DTI. “We hope to share the
research on normal patients and also results with other 3.0T users as quickly as
patients suffering from stroke, hearing or possible,” he says.
vision loss and head trauma. BOLD fMRI
also is employed in studies of language
dominance and for surgical planning of
tumor resections.
Independent imagers contribute to
3.0T clinical knowledge
While Spring Valley has demonstrated
the feasibility of operating a 3.0T system
in the outpatient environment, bringing
high quality, advanced imaging to the
community is only half of the story.
Increasingly, centers like Spring Valley are
conducting 3.0T clinical trials that will
inform 3.0T diagnostic knowledge and
shape utilization.
Reference:
“We don’t necessarily scan more patients,
just more of a given type of patient. While 1. Bachmann, R, Reilmann, R, Kraemer, S, et. al.
Multiple Sclerosis: Comparative MR-Imaging at
tertiary centers don’t get high volumes of
1.5 and 3.0 Tesla.
routine cases, we may get thousands of those Scientific Papers (RSNA): Dec. 5, 2003.
in a few months,” Dr. Orrison explains.
Field Strength 17