MRI OF THE

HOSSAM MOUSSA SAKR

❑ Indications.
❑ Contra indications.
❑ Equipment.
❑ Patient preparation
❑ Protocol (sequences , planes, …)
❑ Pain.
❑ Swelling.
❑ Limitation of function:
▪ Limited movement.
▪ Instability
❑ Cardiac pacemaker
❑ Artificial cardiac valves.
❑ Cerebral artery coils & clips.
❑ Cochlear implant.
❑ Insulin pump.
❑ Metallic FB in the eye
❑ Machine:
▪ Closed
▪ Open
❑ Coil:
▪ Surface coil
Closed MRI
Open MRI
 Closed MRI Open MRI

• Higher resolution • Suitable for claustrophobics

• Shorter acquisition time • Suitable for muscular patients

• Smaller pore • Lower resolution

• Not suitable for claustrophobics • Longer acquisition time
Surface coil
 Imaging planes

Coronal Sagittal
Axial
oblique oblique
 Protocol

T2WI, PD FS WI & T1WI

T2WI

PDWI
 Post IV contrast

axial, sagittal oblique & coronal oblique

MR arthrogram

axial, sagittal oblique, coronal oblique &

ABER position
 Abduction and external rotation
(ABER) position

❑ Coronal localized them images taken along the long axis

of the humerus.
 Indications for IV contrast

❑ Inflammatory conditions: synovitis.

❑ Neoplastic conditions.
 Contra indications for IV contrast

❑ Avoid gadolinium-containing contrast agents in patients

whose GFR is <30 mL/min/1.73 m²
❑ ​Cautionary use of gadolinium-containing contrast
agents in patients whose GFR is <60 mL/min/1.73 m²
 Contra indications for IV contrast

❑ There are no proven risks to pregnant women or

fetus from MRI exams.
❑ Gadolinium contrast should be used in a pregnant
woman only if it significantly improves diagnostic
performance and is expected to improve fetal or
maternal outcome.
 Contra indications for IV contrast

❑ Breast feeding should not be interrupted after

gadolinium administration
 Indications for Shoulder MR
arthrogram

❑ Shoulder joint instability for labral & capsular

pathology
❑ Rotator cuff injuries.
❑ Chondral lesions
 Contraindications
❑ Active joint infection
❑ Cellulitis
❑ Reflex sympathetic dystrophy
❑ History of contrast allergy:
▪ follow standard prophylaxis protocols
▪ Consider using normal saline for shoulder distension for MR
Arthrography
❑ Anticoagulation
▪ Perform Arthrography when INR<1.5-2.0
▪ Risk-benefit of withholding or reverting anticoagulation
▪ Smaller gauge needle
 Technique of Shoulder MR
arthrogram
Before procedure:
❑ Review indication and previous exams and procedures
❑ Assess possible contraindications
❑ Conduct brief clinical history (bleeding risk,
medication, allergy)
❑ Ensure patient's consent and understanding of the
procedure and possible complications, and patient's
consent
 Technique of Shoulder MR
arthrogram

❑ Inject 12 cc of a solution of 5 cc normal saline, 5 cc

Omnipaque 300, 10 cc 1% lidocaine, and 0.1 cc
gadolinium.
X ray or CT guided
 The rotator interval (anterior)
approach
❑ Supine position, with the arm in external rotation (palm
facing upwards)
❑ Anesthetize the skin and subcutaneous tissue
(perpendicular to tabletop)
❑ Insert needle (vertical) until contact with bone.
❑ Contrast flow should be without resistance
❑ CT or US guidance allow confirmation of intra-articular
position before test injection is performed
 The posterior approach

❑ Prone position, with the arm in external rotation (palm

facing downwards)
❑ Fluoroscopy tube perpendicular to the glenohumeral
joint
❑ Skin marked just lateral to the medial articular cortex of
the humerus
 Signs of intraarticular position
❑ "Bony touch" from needle tip
❑ Resistance "give" after passage of capsule
❑ Image evidence of intraarticular positioning
❑ Low resistance when small amount of fluid injected
(beware: low resistance is also felt if needle tip is in
periarticular bursa or tendon sheath). Contrast should
flow away, not pool around the needle tip.
❑ Joint fluid returns spontaneously or with aspiration
(aspirate effusion before injecting contrast)
US guided
 Posterior approach

❑ The patient was seated on a chair, upright with the back to the
radiologist and the ipsilateral hand positioned on the patient’s
contralateral shoulder
❑ The transducer was positioned over the long axis of the
myotendinous junction of the infraspinatus muscle and angled to
show the contours of the posterior glenoid rim, posterior glenoid
labrum and posteromedial portion of the humeral head.
❑ The needle was introduced from a lateral to a medial direction
parallel to the long axis of the transducer
 Rotator interval approach

❑ The patient in a supine position on the examination table with the

shoulder in external rotation
❑ The coracoid process and the adjacent superomedial subchondral
aspect of the humeral head are identified
❑ The needle entry was made just superior to the subscapularis
tendon and lateral to the coracoid process. The needle was
advanced freehand, from medial to lateral, until the tip reached the
cartilage of the humeral head. The needle was then positioned into
the glenohumeral joint capsule at the margin of the humeral head
 Complications
❑ Post injection pain is common, possibly related to
synovitis may affect up to 66% of patients several hours
after the procedure and resolves within days.
❑ Bleeding.
❑ Infection
❑ Allergic reaction.
❑ There are currently no known reports of nephrogenic
systemic fibrosis related to arthrography