The Technology of MRI - The Next 10 Years?: Hounsfield Review Series

The British Journal of Radiology, 81 (2008), 601617
HOUNSFIELD REVIEW SERIES
The technology of MRI the next 10 years?

A M BLAMIRE,
PhD
Newcastle Magnetic Resonance Centre, Campus for Aging and Vitality, Newcastle University, Newcastle upon Tyne NE4 6BE, UK
ABSTRACT. MRI is the most flexible of our diagnostic imaging modalities, possessing the ability to characterize a wide range of parameters in the living subject and provide exquisite spatial resolution. Here we first review the rise of MRI to its current clinical state-of-the-art status and then consider the future directions for this technique. The long-term impact on clinical practice of recent innovations in MRI scanner hardware and sequence design are also considered. Key changes in clinical practice that we predict for the coming 10 years include: a widespread shift to higher field imaging (3T); further improvements in MRI coil technology, including further increases in the number of channels; the introduction of ultra-short echo-time imaging; the introduction of combined modality methods (e.g. positron emission tomography (PET)-MRI and single photon emission CT (SPECT)-MRI); and significant advances in molecular MRI agents. Even after 30 years of continuing developments in human MRI, the coming decade will provide further major advances in diagnostic MRI.
Received 29 October 2007 Revised 10 January 2008 Accepted 27 February 2008 DOI: 10.1259/bjr/96872829
2008 The British Institute of Radiology
MRI is without doubt the most versatile of all medical diagnostic technologies. MRI emerged in the 1970s from the laboratories of physical scientists where the basic phenomenon of nuclear magnetic resonance (NMR) was being investigated, and has rapidly expanded to permeate most areas of clinical science and research. In this review, we consider how the technology and its applications have developed, and try to foresee how current developments will impact on clinical diagnosis over the next 10 years.
The genesis of a new technique from research tool to clinical investigation

To consider how MRI will evolve in the future requires us to briefly consider the nature of MRI measurement. The versatility of MRI revolves around its ability to link many forms of clinically relevant processes to the image contrast. The intrinsic contrast of the MR image is produced by differences in proton density (PD) and MR relaxation times (T1 and T2). However, by selection of appropriate magnetization preparation schemes, signal intensity can be modulated by other important processes such as flow effects (e.g. bulk flow for angiography [6] or microflow for tissue perfusion [7]), Brownian water motion (e.g. diffusion imaging to assess tissue microstructure) [8], and tissue oxygenation (for functional information) [9, 10]. Furthermore, the local chemical environment of the nucleus of interest modulates the MR frequency (the chemical shift), allowing the identification of molecular groups using MR spectroscopy (MRS) and thus providing metabolic measurements [11]. No other imaging modality can rival this flexibility. For all of these MR measurements, the required scanning hardware remains essentially constant, with selection of the contrast type determined by the specific pulse sequence alone. Therefore, while the increasing complexity of modern commercial scanners limits hardware development to the preserve of system manufacturers and a few dedicated research groups, the exploration and development of sequences with new contrast types or data acquisition techniques remain accessible to many physics and engineering research groups. Thus, the place to look for the clinical methods of the future is within current cutting-edge research. Historically, the transition from research investigation to clinical tool has taken many years. From the
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A historical overview
In 1974, the famous publication of the first in vitro images using NMR began the race to develop a system capable of imaging a living human [1, 2]. This race passed significant milestones in 1976 when Mansfield and Maudsley published the first in vivo cross-sectional image (finger; [3]), followed by publication of images of the thorax by Damadian et al [4] in 1977. A shift in image quality occurred in 1980 when the spin-warp (or Fourier) imaging technique was published by Edelstein et al [5], which is at the heart of most modern clinical imaging routines. The first commercial systems became available in 1983. Since then, an estimated 20 000 MRI systems have been installed worldwide and the market for systems continues to expand. The pace of development and some of the significant milestones for each decade are highlighted in Table 1.
Address correspondence to: A M Blamire, Newcastle Magnetic Resonance Centre, Campus for Aging and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK. E-mail: a.m.blamire@newcastle.ac.uk
The British Journal of Radiology, August 2008
A M Blamire Table 1. Major developments in MRI

Decade Development Year Impact
19701980
Demonstration of imaging by nuclear mag- 1973 netic resonance Slice selection 1974 Cryogenic magnets 1977 Spin-warp imaging 1980
Lauterbur Mansfield Improved homogeneity, stability Increased static field strength Improved image quality Abandonment of line-scan and back-projection methods (FONAR) FDA approved (1984) Optimized image uniformity Improved stability and SNR Faster imaging Improved image quality Improved clinical contrast Faster exam times, dynamic studies (cardiac)
19801990
First commercial MRI available Birdcage coils Introduction of clinical cryogenic magnets Shielded gradient designs Gadolinium contrast agents Turbo sequences FLASH TSE Phased array coils and multiple receivers Parallel imaging Actively shielded magnets Clinical 3T systems become available Commercial 7T magnets and above
1980 1985 1985 1986 1988 1985 1986 1990 1999 1999 2000 2002
19902000
Extended FOV imaging for spine Paved the way for parallel imaging Enhanced sensitivity and speed Improved siting
FLASH, fast low angle shot; TSE, turbo spin-echo; FOV, field of view; FDA, Food and Drug Association.
first description of a new method, the stability of the measurement in normal subjects must be demonstrated, followed by proof of clinical utility in small selected patient cohorts. The results of these trials must be accepted and requested by the radiological community before being incorporated into a clinical diagnostic platform. A prime illustration of this process is the development of diffusion-weighted imaging (DWI). The first description of the potential of DWI to detect acute ischaemia was reported in small animal models of acute stroke in 1990 [12, 13]. The method was transferred to a stable human application over the next 5 years [1418] before clinical products emerged in 1996 (e.g. [19]). Today, diffusion imaging sequences are key components of the neurological examination protocol. In considering how MRI will develop over the next 10 years, we have reviewed the recent research literature [2022] to examine those areas that appear to offer a practical benefit to the clinical community were they to be developed fully. Although it is unlikely that most of these developments will become globally useful across all branches of MRI, many will find use in specialist diagnostic and treatment centres. We divide our discussion into four sections: (i) MR hardware advances; (ii) new imaging methods and inherent contrast mechanisms; (iii) image analysis and interpretation; and (iv) the development of contrast-enhancing media.
system, and the digital electronics. We consider the future advances for each.
Magnet systems field strength considerations

Following the initial introduction of a range of lowfield scanners in the early 1980s, clinical MRI systems were introduced in 1985 using cryogenically cooled 1.5T magnets. These scanners determined the benchmark for subsequent magnet developments and have dominated the clinical use of MRI to the current day. In conventional MRI, the static magnetic field strength determines the polarization of the magnetization, which in turn directly determines the achievable signal-to-noise ratio (SNR) of the image (i.e. image quality). In 1993, research sites began to move to 3T systems to investigate the feasibility of higher field applications. This was followed in 1998 by the introduction of the first clinical 3T product. The doubling of static field strength yields a theoretical doubling of SNR that can be traded for speed, image resolution or a combination of the two. Recently, commercial ultra-high-field human MRI machines (4 9.4T) have been installed at a number of research sites, and an illustration of neuroimaging datasets from systems operating at 7.0T and 9.4T are shown in Figure 1. Higher field strength provides higher resolution images with new image contrast. Given the increased SNR that can be achieved, a shift to higher static field strength systems might be anticipated. However, the optimal field strength for clinical investigation is a complex mixture of health economics surrounding the cost of the system (high field strength is more expensive), patient throughput and magnet siting issues. The expected doubling of SNR when working at 3T compared with 1.5T has largely been
The future
Hardware advances MR physics and engineering development
The MRI system consists of four essential components: the magnet, the gradient system, the radiofrequency (RF)
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Hounsfield Review Series: MRI the next 10 years? Figure 1. Examples of neuroimaging datasets acquired in control subjects at ultra-high field strengths. (a) Image acquired using a 9.4T experimental MR system (fast low angle shot (FLASH) sequence, repetition time (TR)5150 ms, echo time (TE)55 ms, matrix 5126400, 0.5 mm60.5 mm62 mm, flip angle55 , number of excitations54, no intensity correction). The scan also employed B1 shimming techniques (see text for further details). (Data courtesy of Lance DelaBarre and Tommy Vaughan Center for Magnetic Resonance Research, University of Minnesota.) (b) Image acquired using a 7.0T experimental MR system (magnetization prepared rapid gradient echo (MPRAGE) sequence, 0.5 mm isotropic resolution, imaging acceleration (SENSE) factor 2, 11 min acquisition time for the whole head). (Data courtesy of Peter Morris, University of Nottingham.) (c,d) Images acquired using a standard clinical 3.0T product for comparison of image quality and resolution. Data were acquired using an 8-channel radiofrequency head coil using a turbo spin-echo (TSE) sequence with TR53000 ms and TE518 ms with 0.560.5 mm in-plane resolution and a 3.0 mm slice. Although total scan times, sequences and durations for each image are not identical, these images illustrate the potential of high field strength MRI neuroimaging. It should be noted that the very high field strength systems have not been developed to the point of being a clinical product. Very high spatial resolution and increasing contrast around small vessels and within the white matter are evident in these datasets. Nonuniform spatial intensity variation remains an issue to be improved. Although the use of such high field strength systems will not become routine in clinical practice, the technology developed to address the new challenges at such field strengths will impact on the design of lower field strength systems.
demonstrated to be achievable across all body areas [23 28], including brain, heart, liver and musculoskeletal imaging, thus paving the way for a shift to 3T for clinical work. Current clinical 3T products have been designed to fit within the physical constraints of 1.5T platforms through the development of compact magnets with small fringe fields. Although this does address the siting of 3T systems within existing radiology departments, the main field homogeneity (ppm) of 3T magnets is typically lower than in equivalent 1.5T systems, which presents challenges for
some clinical applications. While superb resolution can be achieved at high field strength in the brain (Figure 1), other regions of the body such as heart and abdomen represent a greater challenge [2933]. In particular, fat suppression and sequences that achieve contrast based on steady-state behaviour of the magnetization and rely on relatively uniform precessional frequency (e.g. fast imaging with steady-state precession (FISP, TrueFISP, etc.) used extensively in cardiac imaging at 1.5T) do not routinely perform well at higher field strengths [30]. New approaches to optimize magnetic field homogeneity are
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required to regain routine performance at 3T; such developments are currently under way. Further changes to MR sequence design are also required to cope with differences in relaxation (T1 and T2) at higher field strengths in order to deliver the same tissue contrast expected from a 1.5T system [34, 35] and to limit RF power deposition in the patient (specific absorption rate (SAR)) [36]. Such technological challenges will always be overcome if there is a justifiable clinical (and commercial) need.
Pre-polarized MRI While clinical scanners continue to move upwards in terms of field strength in order to increase the SNR, the impact of metallic implants on image quality becomes more severe. For specific applications such as imaging around implanted joint prostheses, alternative approaches to improve image quality have been suggested and
preliminary data presented. One such method is the use of pre-polarized MRI (PMRI). In this technique, the main magnetic field is generated using a resistive electromagnet to produce a relatively large spin polarization, which is then ramped to zero allowing the magnetization measurement to be performed at a much lower readout field (typically 0.05T, again produced by a resistive magnet that is coaxial with and contains the higher strength polarizing magnet, as illustrated in Figure 2c). The SNR is determined entirely by the temporary polarizing field, whereas image artefacts from off-resonance effects scale with the readout field. Susceptibility-related distortion of the main magnetic field by metallic implants, which cause image distortion and large signal voids at typical clinical strengths (1.0T and above), is almost negligible at the readout field strengths used in PMRI [3739]. PMRI systems are considerably cheaper (by a factor of ,10) than superconducting systems, but currently can achieve images to rival a conventional 0.5T system. Illustrative
Figure 2. Example image of the

human hand/wrist collected using an experimental pre-polarizing MRI (PMRI) scanner. (a) Comparison between conventional MRI and PMRI of the wrist. The conventional image (left-hand side) was acquired at 1.5T using a standard wrist protocol (slice-interleaved spin-echo), whereas the PMRI scan (right-hand side) was acquired using a prepolarizing field strength of 500 mT and a readout of the magnetization field of 130 mT with a three-dimensional rapid acquisition with relaxation enhancement (RARE) sequence. Both scans used the same resolution and field of view (FOV586866 cm3; matrix51926192620). The MRI scan time was 4 min and the PMRI time was 6 min. (b) Axial spin-echo images of a volunteer wrist with metal plate and screws. The four screws are distinct in the PMRI image (arrows, right image) with only minor distortion. Surrounding anatomy, including the distal radialulnar joint and the extensor and flexor tendons, are clearly visible under PMRI, but are obscured in the conventional 1.5T image (left-hand image). This comparison shows how PMRI enables assessment of the joint immediately adjacent to metallic implants. (c) Schematic diagram of a PMRI scanner. Two co-axial resistive magnets are used. A strong polarizing magnet is housed within a larger and weaker readout magnet. Conventional radiofrequency and gradient coils are required to excite and localize the MRI signal. Adapted from data in [38]. (Data courtesy of Steve Conolly, University of California at Berkeley.) Copyright 2006; reprinted with permission of WileyLiss, Inc., a subsidiary of John Wiley & Sons, Inc.
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data demonstrating the quality of PMRI images of the wrist compared with clinical field strength are shown in Figure 2. Although PMRI will not find a place in wholebody or neurological applications, the small scale of the required hardware, the high image quality and the low cost potentially make this a method of choice for routine joint imaging in a small clinic environment.
RF coils Major developments in RF coil technology over the past 10 years have already made a significant impact on scanner design and clinical practice. Here, we discuss the potential for further developments. Phased array coils were first described in 1990 [40] and clinical suppliers soon introduced multiple receiver channel systems to take advantage of the improved sensitivity and extended field of view that come from multiple receiver coil design. The extension of MRI sequences to utilize these multiple coils for spatial encoding soon followed (e.g. Sensitivity Encoding (SENSE), [41], Simultaneous Acquisition At Spatial Harmonies (SMASH) [42, 43]). Extensive work has since shown that major improvements in the SNR are available from multi-channel head coils (an improvement in SNR of two- to three-fold is routinely achieved using 8-channel devices compared with a circularly polarized birdcage design [44]), such that all modern systems use at least 8channel devices and are often equipped with the capability for at least 16 channels. Studies to determine the optimal number of channels is ongoing [45], with research systems commonly using 32 channels [4649] and, in some cases, approaching 100 channels, particularly for brain imaging investigations where the small field of view (and hence low depth penetration) of the individual coil elements is acceptable [50]. Figure 3a,b shows an experimental 32-channel RF coil configuration for neuroimaging. Scanner design has already followed this trend by introducing modular and extendable numbers of receiver channels. As larger numbers of increasingly small receiver coils are incorporated into array structures, the uniformity of the received signal profile is gradually eroded. Although specific neurological applications such as functional MRI undoubtedly benefit from the higher SNR over the cortex produced by these coils, the reduced sensitivity deep within the brain is not desirable for clinical investigation where uniform sensitivity is required. Over the next 10 years, further developments in coil technology are inevitable and the range of coil options for specific clinical investigations will increase accordingly.
Figure 3. Illustrative data from a high-channel experimental

head coil. (a) Photograph of an experimental 32-channel radiofrequency (RF) coil designed for neuroimaging applications. (b) Sensitivity maps showing the signal-to-noise ratio improvement by using a high number of RF coils (left panel, 32-coil array) vs a commercial 12-channel array coil (middle panel). Transverse volume magnetization prepared rapid gradient echo acquisition using the depicted coil at 3T (right panel). Image resolution is 0.460.461.5 mm, four times greater than typical parameters used with commercial lowchannel devices. (Data courtesy of Graham Wiggins and Lawrence Wald, Athinoula A Martinos Center for Biomedical Imaging, Charlestown, MA.)
Parallel transmit technology In the previous section, we discussed the use of multichannel (parallel) receiver coil systems. The impact of multi-coil systems (with low numbers of channels, e.g. 8 or 16) is already clear in clinical use. These multi-channel receiver coils are used in conjunction with a large wholebody RF transmit coil to provide a uniform excitation pulse across the imaging field of view. Performance of the body coil is therefore also a characteristic to be considered. Inhomogeneity in the body transmit coil
profile can lead to a variation in sensitivity and in image contrast when sequences rely on differential saturation to provide T1 weighting. Even with an ideal, perfectly uniform RF coil, the conducting nature of the human body leads to inhomogeneous RF excitation owing to the presence of dielectric effects within the tissue. At higher field strengths, the wavelength of the RF wave within the tissue begins to become comparable with the size of the body itself, leading to standing wave patterns (dielectric resonances) within the tissue [51]. Such resonances have only a small effect at 1.5T but become increasingly important at 3T and above. Techniques to alleviate this effect have been proposed, including careful RF coil design and the use of parallel transmitter coil systems [5255]. Parallel transmission is achieved using similar coil array systems to multi-channel receivers, but uses these coils to both excite and receive the imaging signal. Using a process termed RF or B1 shimming (B1 denoting the magnitude of the RF excitation field) [52], the signal from separate parts of the object can be independently excited in a tailored fashion such that variations in RF field penetration can be overcome, leading to a more uniform image, as illustrated in Figure 4. Interestingly, these techniques have arisen from the need to improve image quality at ultra-high field strengths, but have found to be of potential benefit at 3T [56, 57].
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A M Blamire Figure 4. Illustration of the use of

B1 shimming of a multichannel transmit/receiver coil to improve image homogeneity. (a) Low-resolution fast low angle shot (FLASH) image acquired to qualitatively evaluate the radiofrequency excitation homogeneity using an 8-element transverse electromagnetic transmit/receiver coil. Severe signal dropout (destructive interference) is seen in the right hemisphere (arrow). (b) During the process of B1 shimming, the phase of the signals driving each element of the coil was modified by the operator, entered into the driving system (phase and gain controller) and a new image acquired, showing much improved uniformity. (c) Using this B1 shim setting, high-resolution FLASH images were acquired (repetition time/echo time5150/7 ms, 512 6 400 acquisition matrix size, ,5 excitation, 0.5 mm60.5 mm62.0 mm resolution, two averages). The acquisition time was 2 min. All data were acquired on an experimental 9.4T scanner. (Data courtesy of Lance DelaBarre and Tommy Vaughan, Center for Magnetic Resonance Research, University of Minnesota.)
Combined modality scanners (MRI, PET, SPECT and linear accelerators) Positron emission tomography (PET) enables molecular imaging at a level of sensitivity that is far beyond that achievable by MRI. This is particularly important in oncology where an increased metabolic rate of glucose consumption is a hallmark of active tumour and can be readily measured using 18F-deoxyglucose (FDG). The high sensitivity of molecular PET probes is, however, not matched by the achievable imaging resolution, and PET does not provide any information on regional tissue anatomy. For this reason, current PET systems are integrated with X-ray CT devices to provide simultaneous anatomical details. Combining PET with MRI may further enhance the application of clinical PET by providing a much wider range of possible image types with good soft-tissue contrast [58]. There is current commercial interest in producing such devices, although at present none is available as a clinical product. Conventional PET technology using photo-multiplier tubes to detect c-wave radiation from positron annihilation exhibits a strong loss of gain when placed in even a small magnetic field. Combined PET/MRI systems therefore require a different approach for the main detector system [59]. Such new detectors have now been demonstrated, particularly using long fibre-optic systems to separate the photomultiplier system from the scintillation crystals and eliminate interaction with the MRI magnetic field [60]. A significant amount of research and development has been carried out towards combining small animal MRI and PET. Of key importance is the validation of image quality acquired by one modality in
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the presence of the other, i.e. verification that PET quality is not impaired by placing the detector system into the magnetic field, and that MRI quality is not degraded by the presence of the PET detectors. Results in this area are extremely encouraging, with illustrative data showing minimal interactions at MRI field strengths of 3T and above [61, 62]. An illustration of a small-scale MRIcompatible PET insert and accompanying in vivo simultaneous MRI-PET data acquired using a 7T animal system are shown in Figure 5. In working towards combined clinical instruments, PET images of test objects have been collected within a clinical 3T scanner [63], and human data have been reported during 2007 [61] with significant commercial interest. The ability to simultaneously collect high-quality anatomical MRI together with associated metabolic information using PET in a single examination produces shorter patient scanning times and improves data registration, which may play a role in radiotherapy planning. The technology required for combined PET/MRI is therefore primarily available today and will continue to develop to affect clinical practice within the next decade, with the largest impact being in specialist oncology centres. Similar approaches are being followed to integrate MRI with single photon emission CT (SPECT) in order to take advantage of the ability to monitor multiple tracers via their differing energy spectra. The feasibility of placing the SPECT detector array within the MRI scanner has been proven at clinical field strengths, thus paving the way for future developments [64]. The concept of merged scanning and treatment technology is also being investigated for radiotherapy. Raaijmakers et al [65] have
Hounsfield Review Series: MRI the next 10 years? Figure 5. Combined technology for
simultaneous MRIPET. (a) Photograph of MRI-compatible positron emission tomography (PET) scanner utilizing magnetic field-insensitive avalanche photodiode scintillation detectors. (b) Photograph of a PET insert inside a 7T animal MRI system. (c) Simultaneously acquired in vivo MRI (greyscale) and PET (colourscale) images (showing several different coronal sections) of a mouse. The PET radiotracer is 18F-fluoride (administered dose of 200 mCi) a bone-seeking agent which highlights the skull and other bony structures of the head. MRI was acquired using a rapid acquisition with relaxation enhancement (RARE) sequence with a field of view of 464 cm and a matrix size of 2566256. (Data courtesy of Simon Cherry and Ciprian Catana (University of California, Davis).)
proposed combining a linear accelerator within the MRI scanner to potentially improve dose delivery, although this is only at the theoretical level at present.
Hardware advances summary In summary, over the next 10 years, we anticipate that there will be a widespread move to 3T instruments as existing 1.5T systems are replaced at the end of their useful lifecycle. This is particularly likely at sites where the major workload is routine neurological investigation. Increasingly higher numbers of RF channels (.16) will become standard, again with particular impact in neurological work. Commercial products for simultaneous acquisitions, such as PET/MRI, are already in the pipeline and will become commonplace in specialist centres where dedicated equipment offering tailored capabilities can be justified by improved throughput, patient compliance and improved diagnostic accuracy.
Methods and contrast

In predicting which new scanning methods will have clinical impact and be adopted into widespread use over the coming decade, it is necessary to consider the criteria that such a technique must meet. A method must be: (i) robust for general application; (ii) relatively rapid to acquire; (iii) clinically relevant and interpretable; and, most importantly, (iv) able to provide new or improved information (e.g. faster speed, higher contrast, etc) that is not available using existing techniques. Candidate techniques that we consider might make such a transition from research to clinical practice are discussed below.
New contrast (ultra-short echo time) The transverse relaxation time of water (T2) partly defines image contrast across all sequences owing to differential decay of transverse magnetization according
to local spinspin interactions. Echo times (TEs) of less than 10 ms are often referred to in clinical use as providing PD contrast. However, quantitation of the total amount of water visible at such TEs suggests that, within the brain, approximately 10% of the water within the tissue is unaccounted for in the MR measurement [66]. In other tissues, such as tendon, the visibility of the entire structure can be essentially zero. The missing signal component in each case is caused by almost complete decay of the signal before data acquisition begins owing to a very short T2. Investigation of these short T2 signals has suggested that there are components in tissue with T2 values ranging from 1520 ms to several milliseconds [67 69]. In current clinical neuroimaging practice, the compartment with the shortest components, believed to be associated with myelin, is probed indirectly using magnetization transfer ratio (MTR) imaging [70, 71]. Research studies in multiple sclerosis have shown that subtle changes in the MTR can be detected, particularly when analysed using histogram approaches [72]. Imaging contrast seen using the MTR technique is, however, related to a complex mix of many parameters, including compartment size, relaxation times (T1 and T2 in both long and short T2 compartments) and the exchange rate of water between the pools. Given the potential to detect early changes in brain myelin concentration, methods for direct imaging of very short T2 species may play a significant clinical role in the future. Techniques to shorten the effective TE of the MR sequence were proposed as far back as 1989 [73], but have not been developed extensively until more recently [7476]. By revisiting radial sampling schemes (as used in CT and some of the earliest MR developments), which sample the K-space origin (which in turn determines the image weighting) with the shortest possible delay time, has led to a new class of ultra-short echo time (UTE) sequences with effective TEs of 50100 ms (i.e. 40 times shorter than conventional Fourier sequences). The potential of UTE imaging in clinical practice is in its infancy, but images of tendon (Figure 6 [77, 78]), cortical
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MRE measurement offers high-resolution three-dimensional capability, which should provide improved sensitivity and specificity over ultrasound methods.
Figure 6. Ultra-short echo time (UTE) imaging data showing

the posterior cruciate ligament. Oblique coronal fat saturated UTE scan (repetition time5500 ms, echo time512 ms) acquired using a radial projection imaging technique. The posterior cruciate ligament is indicated by the arrow. (Data courtesy of Graeme Bydder, University of California, San Diego.)
bone [77, 79] and dentine [76] have been produced, as well as intriguing images of altered brain contrast in disease [74]. Alternative approaches to achieving very short TEs using radically new MRI sequences with low gradient power and which are inherently quiet have also been demonstrated [80]. UTE sequences are already being investigated in clinical research machines and are likely to arrive in clinical use in the coming few years.
Elastography Changes in tissue elasticity often correlate with its pathological state, making measures of elastic properties of clinical interest in the diagnosis of various conditions. MR elastography (MRE) [81] provides a method to mimic palpation of a tissue or organ and quantitatively determine the elastic properties of the tissue. This method uses propagating low-frequency shear waves (produced either acoustically or by mechanical vibration) combined with phase-contrast MRI to measure the motion of the tissue, from which shear modulus and shear viscosity can be modelled and determined. Interest in this approach comes from the potential to detect small lesions or abnormalities within the tissue, not via their direct effect on tissue relaxation but by their effect on the propagation of the shear wave through the tissue. Early detection of conditions such as breast tumours [8284] or the degree of liver fibrosis [8587] is a particular goal for the application of this technique. Although elastography imaging is also possible using ultrasound devices, the
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Functional MRI clinical uses Functional MRI (fMRI) using the blood oxygenationdependent (BOLD) contrast mechanism was first described over 15 years ago [8892] and was heralded as a potentially important technique for clinical use, particularly in pre-surgical planning in oncology and epilepsy [93, 94]. To date, relatively few true clinical studies have been published using fMRI, compared with the large number of neuropsychological-based studies investigating normal brain function. In the past decade, major improvements in scanner hardware (e.g. general availability of high-quality echo planar imaging sequences), computer processing speed and standardization of processing techniques [95, 96] have allowed routine, on-line and real-time analysis of fMRI data on clinical instruments, setting the scene for routine clinical use. To apply fMRI in pre-surgical planning, the data must be quantifiable, easily interpretable and robust. Early work, however, suggested that localization of regional brain activity via BOLD did not precisely superimpose on activity measured either by electroencephalography [97] or directly using depth or cortical surface electrodes [98, 99]. Such findings have been repeated [100], with suggestions that the precise nature of the task (e.g. vocalized speech vs silent speech) may affect visualization of the truly activated brain region [101]. The BOLD signal combines contributions from cerebral blood flow, cerebral blood volume, oxygen extraction and local metabolic rate, and so is only related indirectly to local brain activity. At the current time, the fundamental coupling mechanisms that modulate the BOLD response remain undetermined, hampering the interpretation of changes in the BOLD response in disease. There is also evidence that the presence of some types of tumour may have a direct effect on the BOLD response within adjacent non-cancerous tissue [102, 103]. Such observations cast doubt on the localization of activity determined in at least some of the patients for whom the technique would be used [104]. Although some researchers have shown a benefit of using fMRI as part of the wider armormentarium for neurosurgical planning [105, 106], improving our understanding of the mechanisms controlling the neurovascular mediation of the BOLD response will allow fMRI to achieve its true potential in a clinical setting. Ongoing research to determine the coupling-specific mechanisms of the BOLD response will change this situation in the coming decade. An alternative technique for localizing and quantifying brain function by MRI is the measurement of cerebral blood flow (CBF) using arterial spin labelling (ASL). CBF is potentially more straightforward to interpret than the complex BOLD response, and ASL studies have been used in a number of investigations into basic brain function [107, 108]. ASL relies upon spin-tagging of inflowing blood by direct preparation (most often inversion) of water magnetization outside the slices of interest, which is delivered by flow processes into the
imaged volume over a period of several seconds. Careful subtraction of paired image data acquired alternately with and without spin-labelling reveals the flow signal, which is typically 12% of the static signal. ASL methodology has been developing over the past 15 years and there is a wide variety of individual methods in use in the research setting (for a recent review, see [109]). However, all are limited in their sensitivity by the inherently small volume of flowing blood within the brain and the T1 relaxation recovery of the spin label. High field strength applications benefit from the inherently greater SNR but also the longer T1 values, both of which are advantageous for the clinical application of ASL. To date, ASL has not been combined with functional testing in patient populations. In the wider area of CBF measurement by MRI, ASL is pitched against the alternative dynamic contrast-enhanced (DCE) techniques [110]. DCE methods are rapid to acquire, provide excellent contrast-to-noise ratio and have been accepted into clinical practice, particularly for stroke diagnosis. Although ASL has the advantage that it remains completely non-invasive, the transition into clinical use requires further work in the coming decade to improve sensitivity and define the optimum clinical protocol.
Magnetic resonance spectroscopy In the past, MRS has shown promise as a clinical tool for evaluating brain injury at the cellular level. In the light of our predicted move towards the routine and widespread use of 3T systems, it is worth considering the impact on sensitivity-limited techniques such as MRS. MRS examines metabolites at millimolar concentrations and therefore has an inherently low SNR, leading to large sampled voxels and long periods of data averaging. Although MRS continues to enjoy popularity for research (in the brain, in particular [11]), it has not broken through into mainstream use at 1.5T. Proton MRS is the most popular technique as it can be performed on an MRI system without the need for additional hardware, and it provides information on tissue damage at the cellular and metabolic level [11]. In a research environment, MRS has demonstrated the potential to detect occult brain injury [111, 112] and monitor therapeutic interventions during clinical trials [113115]. However, at 1.5T, MRS does not fulfil the basic criteria of a routine clinical tool. Spectroscopic imaging acquisitions (MRSI), a class of MRS acquisitions that collect data from multiple regions simultaneously and allow images or maps of metabolite concentrations to be produced, have typically lasted between 15 min and 20 min, achieved low-resolution data over a single thick brain slice and therefore provided limited tissue coverage. Furthermore, interpretation of the spectral peaks is not always straightforward. Methods to increase the speed of MRSI have existed for many years [116, 117] but, at the time of their original description, were not practical for clinical investigation with the available hardware or at low field strength. Technical design of MRS continues to advance and, recently, turbo spectroscopic imaging techniques (TSIs) have been developed [118, 119] that combine high sensitivity, multi-channel receiver coils and parallel data acquisition techniques to increase the sampled field of
view and reduce the MRSI examination time. At 3T, a total TSI acquisition can be currently performed in a minimum time of ,1 min [119], although some data averaging remains desirable to increase sensitivity (as illustrated in Figure 7), leading to more typical acquisition times of 12 min. The major barriers to clinical use have therefore been significantly lowered, and the continuing presence of MRS techniques on the latest clinical products suggests that its future potential is at least envisaged by the major manufacturers. For the clinical application of MRS, the emphasis is placed largely on the signal arising from the proton (1H), as these measurements can be made with conventional MRI hardware. However, MRS is not fundamentally limited in this way, as signals from other biologically relevant nuclei (e.g. 13C, 31P, 23Na and 19F) can be detected with the aid of additional dedicated RF hardware. Signal strength is directly proportional to the number of nuclei within the sampled region and the relative sensitivity of each nucleus (all are lower than the proton). The low concentration of the metabolites of interest forces the examination of larger regions of tissue but, in exchange, these methods provide metabolic data that cannot be acquired in any other way. Altered tissue metabolism is the first indicator of injury or disease, and is likely to be the first indicator of response to therapy. Once again, a shift to higher field strength scanners improves the feasibility of these measurements, and the clinical application of MRS is likely to increase as high field strength systems become increasingly available.
Methods and contrast summary To summarize the role of new sequences and methods over the next 10 years, we suggest that the construct of basic MR examinations in all body areas will expand. The wider application of current methods into other body areas (e.g. the use of diffusion tensor imaging in non-neurological examinations) is inevitable given the existing widespread availability of the techniques. We have highlighted specific research data that show the potential to acquire new and clinically useful information. MRE, UTE imaging and MRS all show potential, whereas fMRI is likely to continue to have only a small impact on clinical practice.
Image analysis and interpretation

In this section, we review potential new approaches for handling and interpreting the large quantities of data that are the hallmark of the modern scanner. Since the introduction of clinical MRI, patient examination time has fluctuated but not declined progressively. Increases in sensitivity and imaging speed have occurred in parallel with the introduction of new methods to provide extended image contrast (e.g. T1 weighted, T2 weighted, dual-echo, fluid-attenuated inversion recover or FLAIR imaging, etc). Routine MRI investigation has, therefore, expanded to fill the available scanning time (determined by patient compliance) and increased the total amount of data collected from the individual patient. Further expansion of the types of data collected is likely to continue in the next decade as clinical examinations begin
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A M Blamire Figure 7. Proton MR spectroscopic image of a normal volunteer collected with a turbo proton echo planar spectroscopic imaging (PEPSI) sequence at 3T using a 32channel receiver coil. Left panel: illustrative spectra extracted from a single pixel region of interest shown on the right-hand N-acetyl-aspartate (NAA) image. The data show the spectra and model fit (solid line) used in the quantitation of the spectrum. Right panel: determining the area under each peak in the spectrum provides information on the concentration of each metabolite. This is displayed here in image format, where peak area is mapped to image intensity. Image data are illustrated for the three main peaks found in the spectrum at chemical shifts of 2.02 ppm (NAA, a metabolite found only within neurons), 3.02 ppm (Cre (total creatine)) and 3.20 ppm (Cho (choline and cholineco ntain ing c ompoun ds)). The sequence used spatial pre-saturation of the outer volume and slice-selective spin-echo with echo time515 ms, repetition time52 s and phase encoding on a 32632 grid to provide nominal voxel sizes of 1.1 cm3. Parallel imaging acceleration factors (Ry) of between 1 and 5 are illustrated, providing total data acquisition times (TAs) of between 64 s and 12 s, respectively. (Unpublished data, courtesy of Ricardo Otazo, Fa-Hsuan Lin and Stefan Posse, University of New Mexico, Albuquerque, NM and MGH-HMS-MIT Martinos Center for Biomedical Imaging, Charlestown, MA.)
to take full advantage of the increased SNR of high field strength scanners and faster image acquisition times using parallel imaging strategies. In a neurological research setting, a single subject examination can now include conventional T1 and T2 weighted imaging, diffusion imaging (providing data on mean water diffusibility and diffusion anisotropy), blood flow imaging, bloodbrain barrier (BBB) integrity (contrast uptake) and metabolic measures through fast spectroscopic imaging. The amount of information that must then be assimilated, analysed and reported is therefore increasing. Importantly, the relationship between these measurements may hold important clinical information on disease processes in tissue, provided that these relationships can be quantified. Such associations become increasingly difficult to determine using visual inspections of scan data alone. Although conventional scans will always be interpreted directly by the radiologist, other automated methods can be used for analysis of the wider multivariate dataset. We predict that improved quantitative and multimodal analysis tools will become integrated into the standard image viewing platforms in order to provide
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enhanced methods to aid in interpretation of the data. Below, we briefly review some of the promising approaches in this field.
Online multivariate analysis to combine highdimensional multi-parametric acquisition Over the past decade, a number of image analysis methods have been applied to analyse multi-parametric datasets including cluster analysis techniques [120123], principal component analysis [124] and statistical techniques known as support vector machines [125127]. Central to each approach is the concept that tissues can be identified and classified based on their similarity or differences across a number of imaging measurements. All pixels within one type of tissue (e.g. white matter) will exhibit essentially the same characteristics across different imaging protocols, whereas pixels within a different type of tissue (e.g. grey matter) or area of abnormality will have different characteristics. (Of course, the diagnosis of abnormality by a human reader is made based on these same characteristics.) By using
co-registered datasets, all areas of the object can be automatically separated into a pre-defined number of tissue types (classes). These classes can then be combined with training datasets that define the limits of normal variation (from independently verified histology) to produce a diagnostic aid. Tumour classification using (primarily) MRS data has shown the most success in this area [125, 127]. Recently, Hofman et al [123] have presented an analysis of atherosclerotic plaque components using five types of MRI data. Automatic classification out-performed human readers in terms of quantitative analysis and reduced bias. Similar protocols have been applied to predict final infarct size in stroke patients based on acute imaging measurements [122]. Although this technology is currently used only in research studies, it may help to identify the best image combinations for detection of disease and, in the future, provide a diagnostic aid.
Quantitative approaches to all modality/contrast types The qualitative nature of image intensity in conventional T1 and T2 weighted imaging does not allow extensive quantitative analysis or even a simple and direct comparison of scans across subjects or imaging sessions. Image intensity weighting can vary with scanner performance, which is partly subject specific (e.g. quality of shim). More recent methods such as diffusion tensor imaging and, to a more limited extent, perfusion mapping using dynamic susceptibility contrast scans [128]) have provided quantitative values that allow the degree of change to be determined. With our suggested shift towards more automated processing or multi-spectral approaches, image acquisition will have to shift further towards quantitative acquisitions. A number of fast mapping techniques to quantify T1 [129, 130], T2 [131] and water content [132] have been described. Some have been applied in clinical research investigations [133] but have yet to find widespread usage because data collection times are generally higher and image resolution often lower than that of conventional qualitative acquisitions. The development of quantitative acquisition strategies and automated analysis approaches go hand in hand, and both are currently topics of active research.
Hyperpolarized MRI Perhaps one of the most exciting developments in the past 10 years of MR research is the introduction of hyperpolarized compounds to overcome the low sensitivity of the nuclear resonance phenomenon. This low sensitivity arises from the small difference in occupation levels of the nuclear spin states, which determines the bulk magnetization at room temperature (e.g. for the proton at 1.5T, the difference in occupation between the two possible spin states is only 1 in 26106 spins). Using pre-polarization techniques, the population difference can be enhanced dynamically via interactions between the nucleus and the electrons, leading to a massive increase in effective nuclear magnetization (up to a factor of 104) [134]. The potential of these techniques has been most widely developed for clinical applications using imaging of gaseous 3He to detect lung structure and function [135137] and, to a lesser extent, gaseous 129Xe [138, 139]. However, the largest impact of this technology in the future is likely to arise from the dynamic nuclear polarization (DNP) or parahydrogen-induced hyperpolarization (e.g. PASADENA) experiments on 13C. In these experiments, polarization enhancement by factors of 10 000 has been reported and, in animal models, angiographic images of the pig heart have been obtained using 13C urea as a contrast agent [140, 141]. The true
Development of contrast-enhancing media

For many years, clinical MRI practice has benefited from the additional specificity for certain disease processes that is afforded using injectable contrast media. These contrast agents highlight areas of abnormality via passive accumulation of agent within the tissue; for example, a normal brain with an intact BBB excludes contrast from the parenchyma, but damaged tissue allows passive diffusion of contrast agent through the compromised BBB, leading to T1 enhancement. The future is likely to see a new generation of high sensitivity agents that either are targeted to specific disease processes or provide specific information on regional metabolism. We discuss here several of the most important methods.
13 C spectra and spectroscopic images acquired at 9.4T from a mouse bearing an EL-4 tumour. (a) Time series of spectra acquired every 2 s for 2 min starting from 12 s after the intravenous injection of 0.2 ml of 75 mM hyperpolarized [113C]-pyruvate. The resonance at 171 ppm is from [113C]-pyruvate, and the resonance at 183 ppm is from [113C]-lactate produced from metabolism of the injected substrate. (b) Metabolic maps showing the lactate/pyruvate ratio in an untreated tumour (left image) and following treatment with the chemotherapeutic drug etoposide (right image). Etoposide induces apoptosis causing loss of the coenzyme nicotinamide adenine dinucleotide (NAD(H)), which is required in the lactate dehydrogenase-catalysed flux between lactate and pyruvate. Adapted from data in [156]. Data courtesy of Kevin Brindle, Cancer Research UK, Cambridge Research Institute and Department of Biochemistry, University of Cambridge, UK. Reprinted with permission from Macmillan Publishers Ltd [156].
Figure 8. Hyperpolarized
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potential, however, is to measure metabolic reactions in living patients and to monitor the effects of therapy through their earliest impact on metabolism, e.g. in tumour treatment using targeted agents. Recent data have begun to demonstrate this potential in animal models, where metabolism of injected alanine has yielded maps of lactate and alanine production [142], as illustrated in Figure 8. These tracers are 13C enriched and hyperpolarized to produce large signals, but otherwise these compounds can be naturally occurring metabolites and therefore have limited, if any, side effects. As patient treatment becomes increasingly tailored and individualized, tools that can monitor direct drug interactions will play an increasingly important role. Over the next 5 years, the wider investigation of the application of hyperpolarized compounds to study metabolism will undoubtedly show clinical utility in specialist areas, such as oncology. Specialist centres are then likely to invest in DNP technology and the multifrequency (multi-nuclear) imaging equipment that is required to work with the 13C nucleus (see MRS above). Both the equipment required for hyperpolarization of 13C and the multi-nuclear MR hardware are already commercially available for experimental purposes. The production of clinical quality hyperpolarized compounds is a vital step for the future clinical application of this technology.
Targeted contrast media Molecular imaging by MRI is a growing field at the present time [143, 144]; the goal is to allow highresolution, non-invasive mapping at the cellular or molecular level. Nuclear medicine techniques such as
PET and SPECT already offer sensitive methods to map molecular pathways, receptor density, etc., via appropriate radioligands but cannot provide the level of spatial resolution offered by MRI; they also have limited availability. Alternatively, MRI clearly offers excellent resolution but is inherently insensitive to anything other than the properties of tissue water. However, in animal systems, the future potential of molecular and cellular imaging by MRI is being demonstrated. Using existing clinical iron oxide-based contrast media (ultra-small particles of iron oxide (USPIOs) or superparamagnetic particles of iron oxide), cultured cells have been labelled, thus making them visible on MRI via susceptibility-based distortion of the magnetic field within the tissue [145, 146]. Such labelled cells can now be routinely tracked following injection into tissue, and have clear potential for tracing injected stem cells [147]. Detection of single labelled cells has been demonstrated both in uniform test objects [148] and in vivo in animal models [149151]. The largest factor in achieving this level of sensitivity seems to lie in acquiring data at a very high image resolution (better than 0.1 mm isotropic pixels) and, although such experiments have been performed at 1.5T [151], higher field strengths will always provide an advantage. This level of sensitivity is unlikely to be achievable in a routine clinical environment, but the development of new, smaller and more potent contrast particles is proceeding and may eventually lead to clinical utility. An associated approach follows an even closer parallel to PET methodology, where contrast agents have been designed with affinity for a specific receptor or cell surface marker. These agents have used either gadolinium complexes or UPSIO particles to provide image
Figure 9. Example of targeted contrast media data in a mouse model of acute brain inflammation. Mice were injected with the pro-inflammatory cytokine interleukin-1b stereotaxically into the brain to induce an acute inflammatory response that leads to rapid upregulation of endothelial vascular cell adhesion molecule-1 (VCAM-1). A novel contrast agent targeted to VCAM-1 was subsequently injected via the tail vein to highlight areas of VCAM-1 expression. (a) Gradient echo images showing widespread binding (low signal) of the agent throughout the left hemisphere. (b) Similar images acquired from an animal into which an antibody to VCAM-1 was injected prior to the contrast agent, thus blocking binding of the agent and demonstrating its targeting specificity. (c,d). Threedimensional representations of the binding pattern for the two animals illustrated in (a) and (b). Adapted from data in [155]. Data courtesy of Nicola Sibson and Robin Choudhury, University of Oxford. Reprinted by permission from Macmillan Publishers Ltd [155].
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contrast. Images of the one of the earliest phases of the neuroinflammatory process have been demonstrated using a gadolinium agent targeted to E-selectin in an animal model, demonstrating that MRI does show sufficient sensitivity [152]. Similarly, agents that bind to fibrin have been developed and tested in vivo [153], which may eventually lead to specific agents to detect fibrous areas of intravascular plaque. The existing USPIO agents (which label macrophages via phagocytosis) have been shown in humans to demonstrate sites of active inflammation in carotid plaques [154], and the combination of these approaches will lead to improved characterization and eventual treatment of the atherosclerotic plaque. A recent and startling dataset is illustrated in Figure 9; it shows binding of an USPIO agent targeted to vascular cellular adhesion molecule-1, which is upregulated during the earliest phases of the inflammatory response in the mouse brain [155]. Although the transfer of such technology into useful clinical compounds requires further development and product licensing, these data show clear potential for this technique.
Research, University of Minnesota); Peter Morris (University of Nottingham); Steve Conolly (University of California at Berkeley); Graham Wiggins and Lawrence Wald (Athinoula A Martinos Center for Biomedical Imaging, Charlestown, MA); Simon Cherry and Ciprian Catana (University of California at Davis); Graeme Bydder, (University of California at San Diego); Ricardo Otazo, Fa-Hsuan Lin and Stefan Posse (University of New Mexico, Albuquerque, NM, and MGH-HMS-MIT Martinos Center for Biomedical Imaging, Charlestown, MA); Kevin Brindle (University of Cambridge); and Nicola Sibson and Robin Choudhury (University of Oxford).
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Contrast media summary Development of targeted media is a rapidly expanding area in MR research at the current time, and is already yielding exciting results in animal systems. The eventual application of these new technologies is not solely within the domain of the radiologist. Clinically relevant targets must be identified; appropriate agents need to be developed and approved for clinical use; and, in the case of cell-tracking techniques, the application of stem cell technologies must also become a routine clinical tool. With the pace of current developments in all of these fields, it is very likely that some forms of these methods will find clinical utility within the next 10 years.
Conslusions
To summarize this view of the next 10 years in MRI, the move towards a large installed base of 3T scanners is the most predictable development, particularly for neurological imaging. The use of 3T body imaging will also increase but is likely to be more limited owing to continuing issues of image quality and power deposition (SAR). Further advances in MRI hardware in the form of improved coils, with increased sensitivity, will accompany the shift to 3T. Sensitivity-limited sequences such as MRS will see a resurgence in use based on all of the above mentioned developments that increase the SNR at 3T. In the longer term, the development of technologies such as targeted contrast agents and hyperpolarized compounds will take many years to perfect, license and enter clinical usage, but all offer huge potential for personalized investigation by MRI.
Acknowledgments
The author would like to acknowledge the following people for allowing use of their research data and contributing figures for this review: Lance DelaBarre and Tommy Vaughan (Center for Magnetic Resonance
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The Technology of MRI - The Next 10 Years?: Hounsfield Review Series

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The British Journal of Radiology, 81 (2008), 601617

HOUNSFIELD REVIEW SERIES

The technology of MRI the next 10 years?

The genesis of a new technique from research tool to clinical investigation

The British Journal of Radiology, August 2008

A M Blamire Table 1. Major developments in MRI

Magnet systems field strength considerations

Figure 2. Example image of the

The British Journal of Radiology, August 2008

Hounsfield Review Series: MRI the next 10 years?

Figure 3. Illustrative data from a high-channel experimental

A M Blamire Figure 4. Illustration of the use of

Methods and contrast

Figure 6. Ultra-short echo time (UTE) imaging data showing

Hounsfield Review Series: MRI the next 10 years?

Image analysis and interpretation

Hounsfield Review Series: MRI the next 10 years?

Development of contrast-enhancing media

The British Journal of Radiology, August 2008

Hounsfield Review Series: MRI the next 10 years?

The British Journal of Radiology, August 2008

Hounsfield Review Series: MRI the next 10 years?

The British Journal of Radiology, August 2008

The British Journal of Radiology, August 2008

Hounsfield Review Series: MRI the next 10 years?

The British Journal of Radiology, August 2008

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