h4ngnetic Resonance Imaging, Vol. 9, pp. ISI-154, 1991 0730-725X/91 $3.00 + .

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Printed in the USA. All rights reserved. Copyright 0 1991 Pergamon Press plc

0 Original Contribution

MR IMAGING OF EXCESSIVELY OBESE PATIENTS:

THE USE OF AN OPEN PERMANENT MAGNET

PETER A. ROTHSCHILD,* JAMES M. DOMESEK,~ MARK E. EASTHAM,~ AND LEON KAUFMAN*

*Department of Radiology, University of California at San Francisco, Radiologic Imaging Laboratory,
South San Francisco, California 94080, tpennsauken MRI Center, Pennsauken, New Jersey 08109,
SDepartment of Neurosurgery,‘San Jose Medical Center, San Jose, California 95112, USA

Excessive obesity can pose a limitation to both clinical and radiographic evaluation. Although CT and MR have
revolutionized head and body imaging, patients with weights above 300 lb present a restriction of these imaging
modalities. Magnetic resonance imaging (MRI) is well suited for imaging excessively obese patients, because the
RF used does not have difficulty in penetrating large amounts of adipose tissue as ionizing radiation or sound
waves does. The limitations of conventional MR imaging in these obese patients are the gantry size and the ta-
ble weight limit. The recent development of a new low field MR imager with a larger gantry size and greater weight
capacity, has the potential for imaging obese patients that cannot be evaluated by standard CT or MR. In this
paper, we report our experience in imaging nine excessively obese patients with weights between 350 and 490 lb
using a permanent magnet operating at 0.064 T.

Keywords: Obesity; Magnet resonance imaging (MRI); Low field.

INTRODUCTION MRI lacks “ionizing radiation” in image formation,

The evaluation of morbidly obese patient is a difficult
problem for clinicians and specialists. Massive obesity
makes a complete physical exam nearly impossible.
The referring clinician must rely to a greater extent on
the use of imaging procedures. Ultrasound and plain
films have major limitations with large patients be-
cause of difficulty in penetrating through massive
amounts of adipose tissue. CT has proven helpful, but
the table weight limits of approximately 300 pounds
(lb) (137 kg) present a major limitation. Furthermore,
the increased scattered radiation and beam hardening
secondary to the massive amounts of fat, will often
degrade the CT scan so as to limit the diagnostic in-
formation.’ Another disadvantage of CT in obese pa-
tients is that the radiation doses are much greater than
for the average patient.
Magnetic resonance imaging (MRI) has great po-
tential for evaluating excessively overweight patients.
Any RF penetration problems are negligible at mid or
low field and easily compensated at high field.2 Also,
but conventional MR has two major limitations.
These are the gantry size and the table weight limit.
The recent introduction of a vertical low field MR
with a table weight limit of over 400 lb (182 kg), a 42-
cm gap from the table to the magnet, and open from
side to side, holds promise for imaging excessively
overweight patients. We describe our experience with
this permanent magnet MR system in nine obese pa-
tients that could not be imaged with conventional
MRI or CT scanning.
MATERIALS AND METHOD
Nine patients with weights over 350 lb (159 kg)
were evaluated with a 0.064 T MR system from 4/89
to 10/89. The patients’ ages ranged from 16 to 62 yr.
There were 3 females and 6 males. Their weights
ranged from 350 to 490 lb (159 to 223 kg) with a av-
erage weight of 400 lb (182 kg). All MRIs were per-
formed on a 0.064 T (Toshiba America MRI, Inc.,

RECEIVED 9/7/90; ACCEPTED 10/15/90. Address correspondence to Peter Rothschild, UCSF-RIL,

Acknowledgment-These investigations are supported in 400 Grandview Dr., S. San Francisco, CA 94080.
part by Toshiba America MRI Inc., South San Francisco,
CA 94080, USA.
151
152 Magnetic Resonance Imaging 0 Volume 9, Number 2, 1991

Case 1
A 420-lb male was in a motor vehicle accident and
presented with paralysis of his lower extremities and
dysesthesia from the nipples down. A cervical thoracic
spinal cord injury was suspected. Conventional X rays
were attempted but a lateral view of the cervical-tho-
racic junction was impossible because of the patient
size. A myelogram was performed but no contrast
could be visualized in the cervico-thoracic junction.
Because of the patient’s massive obesity neither a CT
or standard MRI could be performed. An MRI study
was obtained with the patient in an MRI compatible
cervical halo using a belt type coil. The study showed
a herniated disk at C7-Tl level with cord impingement
(Fig. 2). With the aid of the MRI, the exact level of
abnormality was identified and the patient underwent

Fig. 1. 0.064 T low field MRI system (Toshiba America

MRI, Inc., South San Francisco, CA). This vertical field
MRI with a table weight limit of over 400 lb, a large 42-cm
gap from the table to the magnet, and open design is capable
of imaging excessively overweight patients. Furthermore, the
open design of this magnet has excellent patient acceptance
and facilitates patient monitoring during the examination.

South San Francisco, CA) permanent magnet MR im-

ager. This MR system uses a vertical field permanent
magnet supported by four posts (Fig. 1) and has a 42-
cm gap between the table and the magnet. A solenoi-
da1 head coil with a 24-cm aperture was used in the
knees and most heads. For larger heads and all cervi-
cal spines a small (3 1-cm aperture) or a large solenoi-
da1 belt-type coil (37-cm aperture) was used. The
inferior cervical and upper thoracic spine were imaged
using the fringe field of these belt coils, since the chest
size exceeded the diameter of the coil. No scan was
longer than 20 min. The current recommendation on
table weight limit is about 400 lb. In one emergency
case a 490 lb (223 kg) patient was imaged without
problems. No special modifications were made to the
low field MR imager or the patient table for this
Fig. 2. Sagittal 3DFT (TR 65 msec; TE 24 msec; 45degree
study. flip angle) of a 420-pound male that was in a motor vehicle
accident and presented with paralysis of his lower extremi-
RESULTS ties and dysesthesias from the nipples down. A herniated
disk at C7-Tl (arrow) with impingement on the spinal cord
All nine patients had diagnostic magnetic resonance is identified. The low signal to noise is from having to use
the peripheral field of the lumbar solenoidal belt coil to ob-
scans. Four illustrative cases are presented to describe tain signal from the cervical-thoracic area. (Notice the mas-
how MRI was helpful in the evaluation of these exces- sive amount of adipose tissue posterior to the thoracic
sively obese patients. spine.)
 MR imaging of excessively obese patients l P.A. ROTHSCHILDET AL. 153

an anterior cervical discectomy at C7-Tl with an iliac

bone graft. A large disk fragment was removed from
the C7-Tl level and the hole in the posterior longitu-
dinal ligament was identified. The patient’s symptoms
improved after surgery.

Case 2
A 490-lb 16-year-old retarded boy presented with a
new onset of gait disturbance. Neurological testing
was severely hampered by the patient’s excessive size
and inability to cooperate. CT and conventional MR
could not be performed due to the patient’s size. The
clinical suspicion was a brain tumor or a demyelinat-
ing process. The low field MR examination was per-
formed without problems and was normal. No further
testing was deemed necessary and the gait disturbance
was attributed to the patient’s massive obesity.

Case 3
A 410-lb 40-year-old female presented with severe
headaches and paresthesia of the lower extremities.
Extensive neurological evaluation raised the suspicion
of a posterior fossa tumor. The patient was too large
for an arteriogram, CT or conventional MR. The
0.064 T MRI study demonstrated a type one Chiari
malformation (Fig. 3) which was felt to be the cause
of the patient’s symptoms. No tumor or demyelinat-
ing process was identified. Incidental note was made
of an empty sella.
Case 4
A 390-lb 61-year-old male who presented with se-
vere paresthesia of the upper extremities and numb-
ness in both hands. The patient’s massive obesity
precluded a cervical myelogram, CT or conventional
MR. The 0.064 T MRI showed disc herniations at C2-
3, C3-4, C4-5 (Fig. 4) with spinal stenosis. The multi-
ple levels of disc herniation and severe cord narrowing
were not well appreciated on neurological evaluation.
Fig. 3. Sagittal 3DFT (TR 65 msec; TE 24 msec; 45-degree
flip angle) of a 410 lb female with severe headaches and
paresthesia of the lower extremities. The MRI study demon-
strates a type one Chiari malformation which was felt to be
the cause of the patient’s symptoms. Incidental note is made
of an empty sella.
The ages, weights, coils used, pre- and post-MRI
diagnosis of all nine cases are summarized in Table 1.
DISCUSSION
Modalities such as CT and MR have greatly en-
hanced imaging of the head and body. While relatively
few patients weigh over 350 lb (159 kg), they have in
the past often been denied these advanced imaging
procedures. This is predominantly because of the ta-
ble weight limit of these imaging devices. A further

Table 1. Summary for the nine excessively overweight patients

Patient no. Weight/Age Coil used Pre MRI Dx MRI findings

420 lb/62 y Small belt MVA R/O cord lesion HNP C7-Tl
490 lb/16 y Head R/O intracranial lesion Normal
420 lb/45 y Head R/O posterior fossa tumor Chiari type 1
390 lb/61 y Small belt Cervical disc disease vs. mets HNP C2-3, C4-5, C5-6, No mets
380 lb/39 y Large body R/O mets Fracture TlO, No mets
350 lb/27 y Small belt R/O C spine lesion Syrinx
380 lb/16 y Head R/O pituitary tumor Pituitary macroadenoma
350 lb/30 y Large belt R/O lumbar disc disease No HNP
420 lb/25 y Head R/O internal derangement of the knee Tear posterior horn medial meniscus

MVA = motor vehicular accident; HNP = herniated nucleus palposis.

154 Magnetic Resonance Imaging 0 Volume 9, Number 2, 1991

(4 @I
Fig. 4. (A) Sagittal and (B) axial 3DFT (TR 65 msec; TE 24 msec; 45-degree flip angle) 4.5mm slice, MR images in a 390-
lb male that presented with paresthesia of the upper extremities with numbness in both hands. Disc herniations are identified
at C2-3, C3-4, C4-5. An axial scan (B) at the C2-3 level shows severe cord compression that was not well appreciated on neu-
rological evaluation. The poor signal-to-noise ratio in the interior cervical spine is because the belt coil could not be placed
over the area of interest due to the patient’s large size. This study was performed with the belt coil placed in the region of
the posterior fossa; therefore, only the fringe field was used to collect signal from the lower cervical spine.

limitation of MRI and CT is the gantry size which can
even limit access to patients under 300 lb (136 kg) with
large shoulders. Few articles have been written on im-
aging obese patients and, to our knowledge, there has
not been a patient over 350 lb reported in the English
language literature imaged with CT or MRI.
Finch was the first investigator to address the prob-
lem of imaging excessively overweight patients.3 He
modified a CT table to be used with two hoyer lifts.
These lifts would help support patients, whose weight
was too great to be sustained by the table alone. The
hoyer lift system could only be used for head CT work
and the maximum weight described was 350 lb (159
kg). Radionuclide imaging has been performed in
morbidly obese patients, especially gastrointestinal
tract studies.4 A major disadvantage of nuclear med-
icine scanning is its limitation in evaluating the brain,
spinal cord, most internal organs, and the knee when
compared with CT and MRI.
The permanent magnet MR system used, with its
higher table weight limit and wide gap for patient en-
try, avoids many of conventional MRI’s limitations in
imaging obese patients. The major limitation of the
open MR is that the signal to noise ratio obtained
from patients above 350 lb is low when compared to
normal size patients. This is because often a larger re-
ceiver coil is used than would normally be needed for
the same body area, and occasionally the fringe fields
of these coils are used, because the coil cannot be po-
sitioned over the anatomy of interest. Nevertheless, all
nine excessively obese patients reported here had diag-
nostic low field MRI procedures.
In conclusion, there is a small but significant seg-
ment of the population that, because of their size,
cannot undergo diagnostic imaging procedures which
may be life saving. MRI units with an open design
have great potential for the evaluation of these exces-
sively obese patients.
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1. Baer, J.W. Radiology of obesity surgery. Gastoenterol.
Clin. North Am. 16:349-375; 1987.
2. Glover, G.H.; Hayes, C.E.; Edelstein, W.A.; et al. Com-
parison of linear and circular polarization for magnetic
resonance imaging. J. Magn. Reson. 64:255-270; 1985.
3. Finch, I.J.; Sun, Y.; Shatsky, S.A. Technique for cranial
CT scanning of excessively obese patients. AJNR 10:434;
1989.
4. DeRogatis, A.J. Radionuclide imaging in morbid obesity.
Gastroenterol. Clin. North Am. 16:377-382; 1987.