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vi Contents
9 Spine 138
Cervical spine 141
Thoracic spine 151
Lumbar spine 157
Whole spine imaging 167
10 Chest 172
Lungs and mediastinum 175
Heart and great vessels 184
Thymus198
Breast201
Axilla212
Brachial plexus 215
11 Abdomen 220
Liver and biliary system 223
Kidneys and adrenal glands 231
Pancreas239
Vascular imaging 246
12 Pelvis 250
Male pelvis 253
Female pelvis 261
Obstetrics266
x
Preface xi
Catherine Westbrook
Acknowledgements
CW
Contributors
vii
viii Contributors
www.wiley.com/go/westbrook/mritechnique
xii
1 How to use this book
1
Introduction
This book has been written with the intention of providing a step-by-step
explanation of the most common examinations currently carried out
using magnetic resonance imaging (MRI). It is divided into two parts.
Part 1 contains reviews or summaries of those theoretical and practical
concepts that are frequently discussed in Part 2. These are:
1
2 Handbook of MRI Technique
imaging the brain, temporal lobes, pituitary fossa, etc. Under each exami-
1 nation, the following categories are described:
•• basic anatomy
•• common indications
•• equipment
•• patient positioning
•• suggested protocol
•• image optimization
•• patient considerations
•• contrast usage.
Basic anatomy
Common indications
These are the most usual reasons for scanning each area, although occa-
sionally some rarer indications are included.
Equipment
This contains a list of the equipment required for each examination and
includes coil type, gating leads, bellows and immobilization devices. The
correct use of gating and RC is discussed in Part 1 (see Gating and
respiratory compensation techniques). The coil types described are the
most common currently available. These are as follows.
•• Volume phased array (parallel imaging) uses the data from multiple
coils or channels arranged around the area under examination to 1
either decrease scan time or increase resolution. Additional
software and hardware are required. The hardware includes several
coils perpendicular to each other or one coil with several channels.
The number of coils/channels varies but commonly ranges from
2 to 32. During acquisition, each coil fills its own lines of k-space
(e.g. if two coils are used together, one coil fills the even lines of
k-space and the other the odd lines. k-space is therefore filled either
twice as quickly or with twice the phase resolution in the same
scan time). The number of coils/channels used is called the r eduction
factor and is similar in principle to the turbo factor/echo training
length (ETL) in fast spin echo (FSE) (see section on Pulse sequences
in Part 1). Every coil produces a separate image that often displays
aliasing artefact (see section on Artefacts in Part 1). Software
removes aliasing and combines the images from each coil to
produce a single image. Most manufacturers offer this technology,
which can be used in any examination area and with any sequence.
•• Surface/local coils are traditionally used to improve the SNR when
imaging structures near to the skin surface. They are often specially
designed to fit a certain area and, in general, they only receive
signal. RF is usually transmitted by the body coil when using this
type of coil. Surface coils increase SNR compared with volume
coils. This is because they are placed close to the region under
examination, thereby increasing the signal amplitude generated in
the coil, and noise is only received in the vicinity of the coil.
However, surface coils only receive signal up to the edges of the
coil and to a depth equal to the radius of the coil. To visualize
structures deep within the patient, either a volume, linear or volume
phased array coil or a local coil inserted into an orifice must be
utilized (e.g. a rectal coil).
The choice of coil for any examination is one of the most important
factors that determine the resultant SNR of the image. When using any
type of coil remember to:
A small foam pad or tissue paper placed between the skin surface
1 and the coil is usually sufficient insulation.
•• Ensure that the coil does not move when placed on the patient. A
moving coil during acquisition means a moving image!
•• Always ensure that the receiving surface of the coil is parallel to the
Z (long) axis of the magnet. This guarantees that the transverse
component of magnetization is perpendicular to the coil and that
maximum signal is induced. Placing the coil at an angle to this axis,
or parallel to the X or Y axis, results in a loss of signal (Figure 1.1).
Patient positioning
It is assumed in Part 2 that the following areas are examined with the
patient placed head first in the magnet:
•• pelvis
•• hips
•• lower limbs.
Suggested protocol
High SNR
(b)
High SNR
(c)
Lower SNR
(d)
neither the radiologist nor the practitioner knows how to proceed. The
protocols given are mainly limited to scan plane, weighting, suggested
pulse sequence choices and slice positioning.
It must be stressed that all the protocols listed are only a reflection
of the authors’ practice and research, and are in no way to be considered
the law!
If all your established protocols are satisfactory, this section is included
for interest only. If, however, you are unfamiliar with a certain examina-
tion, the suggested protocol should be useful.
Occasionally in this section coordinates for slice prescription are given
in bold type in millimetres (mm) where explicit prescription can be uti-
lized (mainly for localizers). Graphic prescription coordinates cannot be
given as they depend on the exact position of the patient within the mag-
net and the region of interest (ROI). The explicit coordinates are always
given as follows:
•• Left to Right L to R
•• Inferior to Superior I to S
•• Posterior to Anterior P to A.
As for axial PD/T2, except prescribe slices from the cerebellum to the
frontal lobe.
How to use this book 7
This indicates that the pulse sequence, timing parameters, slice thickness
and matrix are the same as the axial except the slices are prescribed 1
through a different area. This format is intended to avoid repetition. In
most examinations, there is a section reserved for additional sequences.
These are extra sequences that we do not regard as routine but may be
included in the examination. Of course, some practitioners may regard
what we call ‘additional’ as ‘routine’, and vice versa.
Image optimization
•• Technical issues
•• Artefact problems
Patient considerations
Contrast usage
The reasons for administering contrast in each particular area are discussed.
Again, contrast usage varies widely according to radiological preferences.
This section is a guideline only (see also Contrast agents in Part 1).
Follow this 10-point plan for good radiographic practice:
Conclusion
•• Find the anatomical region required and then locate the specific
examination.
•• Study the categories under each section. It is possible that all the
categories are relevant if the examination is being performed for
the first time. However, there may be occasions when only one item
is appropriate. For example, there could be a specific artefact that
is regularly observed in chest examinations, or image quality is not
up to standard on lumbar spines. Under these circumstances, read
the subsection entitled Image optimization.
•• If the terms used, or concepts discussed, in Part 2 are unfamiliar,
then turn to Part 1 and read the summaries described there.
How to use this book 9
Abbreviations
1
A summary of common abbreviations used in the field of MRI and
throughout this book is given below.
A Anterior
AC Number of acquisitions
ADC Apparent diffusion coefficient
ADEM Acute disseminating encephalomyelitis
ASIS Anterior superior iliac spine
AVM Arteriovenous malformation
AVN Avascular necrosis
BFFE Balanced fast field echo
BGRE Balanced gradient echo
BOLD Blood oxygenation level dependent
CE-MRA Contrast-enhanced MRA
CNR Contrast to noise ratio
CNS Central nervous system
CSE Conventional spin echo
CSF Cerebrospinal fluid
CT Computer tomography
CVA Cerebral vascular accident
DE prep Driven equilibrium magnetization preparation
DTI Diffusion tensor imaging
DWI Diffusion weighted imaging
ECG Echocardiogram
EPI Echo planar imaging
ETL Echo train length
FA Fractional anisotropy
FAT SAT Fat saturation
FC Flow compensation
FDA Food and Drugs Administration
FFE Fast field echo
FID Free induction decay signal
FIESTA Free induction echo stimulated acquisition
FISP Fast imaging with steady precession
FLAIR Fluid-attenuated inversion recovery
FLASH Fast low angled shot
fMRI Functional MRI
FOV Field of view
FSE Fast spin echo
GFE Gradient field echo
GMN Gradient moment nulling
GMR Gradient moment rephasing
GRASS Gradient recalled acquisition in the steady state
GRE Gradient echo
GRE-EPI Gradient echo EPI
HASTE Half acquisition single-shot turbo spin echo
10 Handbook of MRI Technique
I Inferior
1 IAM Internal auditory meatus
IM Intramuscular
IR Inversion recovery
IR-FSE Inversion recovery FSE
IR prep Inversion recovery magnetization preparation
IV Intravenous
IVC Inferior vena cava
L Left
MP RAGE Magnetization prepared rapid gradient echo
MR Magnetic resonance
MRA Magnetic resonance angiography
MRCP Magnetic resonance cholangiopancreatography
MRI Magnetic resonance imaging
MS Multiple sclerosis
MT Magnetization transfer
NEX Number of excitations
NSA Number of signal averages
P Posterior
PC Phase contrast
PC-MRA Phase contrast MRA
PD Proton density
Pe Peripheral
PEAR Phase encoding artefact reduction
PSIF Reverse FISP
R Right
RC Respiratory compensation
REST Regional saturation technique
RF Radio frequency
ROI Region of interest
RR R to R interval
S Superior
SAR Specific absorption rate
SAT Saturation
SE Spin echo
SE-EPI Spin echo EPI
SNR Signal to noise ratio
SPAMM Spatial modulation of magnetization
SPGR Spoiled GRASS
SPIR Spectrally selective inversion recovery
SS Single shot
SS-EPI Single-shot EPI
SSFP Steady-state free precession
SS-FSE Single-shot FSE
STIR Short TAU inversion recovery
SW Susceptibility weighted
TE Echo time
TFE Turbo field echo
How to use this book 11
TI Inversion time
TIA Transient ischaemic attack 1
TLE Temporal lobe epilepsy
TMJ Temporomandibular joint
TOF Time of flight
TOF-MRA Time of flight MRA
TR Repetition time
True FISP Siemens version of BGE
TSE Turbo spin echo
VENC Velocity encoding
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In Louisiana, Mississippi and Tennessee; and there we find an
increase of nearly 85 per cent, or an addition to the Negro population
of something like 88,000.
These facts, therefore, disclose the weakness of the Southern
argument that the diffusion of slaves would not have resulted in any
extension of slavery. Theoretically it was a sound argument, that the
slaves being spread over the face of the country, they and their
masters would be brought more and more under the influences
which would work against slavery and for emancipation. But if illicit
importation from abroad was proceeding to any great extent, the
premise upon which the argument was based gave way, and this is
what must have been the case, as has been shown.
This is also where the argument of Prof. Ulrich Bonnell Phillips
fails to convince, when he expresses the opinion, that “the
importance of the repeal, in 1818, of the law which had prohibited
the importation of slaves from other States into South Carolina has
been exaggerated.” He bases his reason for this view upon the claim
that “the Federal Censuses show that the average rate of increase of
the Negro population in South Carolina between 1810 and 1860,
was substantially smaller than that of the Negroes in the United
States at large, “which” he thinks, “indicates that South Carolina was
in that half century more of a slave exporting than a slave importing
State; and that a prohibition of slave imports would have had no
appreciable influence upon the ratio of increase of her Negro
population.”[45]
Unless it can be shown, however, that there were no accessions to
the Negro population of the United States from without, between the
periods selected by Prof. Phillips, the mere fact that the rate of
increase of the Negro population of South Carolina was substantially
smaller than that of the United States at large does not establish that
South Carolina was more of a slave exporting than importing State
for that period; for the greater increase without could well be due to
importation in great volume elsewhere, and that there was such was
asserted by many, notably by Henry Middleton, in Congress, the very
year of Hayne’s speech in the South Carolina Legislature against
importations from other States.[46] But apart from this, before this,
South Carolina had become the State with the largest Negro
population to its white population of all the States of the Union and
that, the rate of increase of her Negro population from this date, or
even a decade earlier, to 1860, “was substantially smaller than that
of the Negroes in the United States at large” was simply due to the
tremendous accessions of the Negro population of the four new
cotton States: Georgia, Alabama, Mississippi, and Louisiana,
superimposed upon a Negro population originally much smaller than
that of South Carolina. The Negro population of those four States did
in that period increase 1,384,555; but in the same time their white
population increased 1,438,607; while in the same period the white
and Negro population of South Carolina increased respectively
53,860 and 147,028. And so difficult was it to overcome this
tremendous start attained by South Carolina in these early fatal
years, that in 1860 the excess of South Carolina’s colored population
over her white population was 121,029, as compared with an excess
of only 83,505 for Mississippi, the next greatest. Undoubtedly in the
period selected by Prof. Phillips many Negro slaves passed out of
South Carolina; but many whites did also; for “from 1820 to 1860,
South Carolina was a beehive from which swarms were continually
going forth to populate the newer growing cotton States of the
Southwest,” and “in 1860 there were then living in other States
193,389 white persons born in South Carolina.”[47] In the half century
the average rate of increase of South Carolina whites was between 7
and 8 per cent, colored 21. In Virginia and Maryland in 1810 the
Negro population amounted to 668,515. It increased by 1860 by an
addition of 151,523. In South Carolina in 1810 the Negro population
amounted to 200,919, by 1860 it had received an addition of
212,401, of which 64,382 had arrived in the decade of the repeal of
the law prohibiting importation from other States, and 58,021 in the
following decade. It is true that in the following decade from 1830 to
1840, the increase of the Negro population of South Carolina was
comparatively slight, being only 11,992, but it was followed in the
next decade by again an increase of 58,630, while the white
increase in the same two decades was respectively 2,221 and
15,479.
But there was another way of measuring the importance of the
repeal. Necessarily with the inflowing tide came some such as
Denmark Vesey and Gullah Jack, slaves and free Negroes whose
past was not known, and according to the report of the
Massachusetts legislative committee in 1821, dealing with only 6,740
free persons of color in the State, among other “evils,” from such,
appeared, inter alia:
2. Collecting in the large towns an indolent and disorderly and
corrupt population.
3. Substituting themselves in many labors and occupations which
in the end it would be more advantageous to have performed by the
white and native population of the State.[48]
It is apparent then, from this, as well as from the arguments of Mr.
Sergeant, that the real situation of the representatives of the two
sections, in the great Missouri debate, has never been put with
absolute accuracy. It was an assertion upon the part of the
Southerners of their right to carry their property with them wherever
they went in the Union, and upon the part of the Northerners a denial
of this right. It precipitated an argument whether extension and
diffusion of slavery meant the same thing, many Southern men, of
eminence, contended that by the process of diffusion there would be
apt to be the beginning of the end of slavery, and if there had been
no illicit importation of slaves possible, there would have been great
merit in this suggestion. But beyond all these arguments on the part
of the Northerners, the Missouri Question indicated opposition to the
mere presence of the Negro, bond or free, in the Northwest. He was
an undesirable resident.
Up to this time, in the main, the attitude of the Southern statesmen
had been free from sectionalism. On the other hand, New England
had exhibited sectionalism, and it was New England’s deputies in the
Constitutional Convention, who joining with those of Maryland, North
Carolina, South Carolina and Georgia, had “formed a bargain,”
abrogating the slave trade in such a way as practically to recognize
slavery as a property interest secured by the Constitution. The time
allowed the slave trade had been long enough, as Madison had said
it would be. As great as had been the rate of increase of the white
population, it had been exceeded by that of the colored in the
proportions of 90 to 95 per cent. What Col. Mason had prophesied
had also come to pass. He had declared in 1787: “The Western
people are already calling out for slaves for their new lands and will
fill that country with slaves, if they can be got through South Carolina
and Georgia.”
They had been got no doubt in large numbers through South
Carolina and Georgia; but also, in all probabilities, through
Louisiana, and if not through, to some extent from, Maryland and
Virginia. The Negro population had in the West, in three decades
sprung up from 16,322 to 385,825; while the seven States, Virginia,
North Carolina, South Carolina, Georgia, Alabama, Mississippi and
Louisiana, held some 1,193,732 head of this species of property,
representing an investment of something like $477,492,800,
stamped as property by having been made dutiable under Federal
law up to 1808. Such a property interest was almost certain to
produce a sectional policy for its protection, and in the assertion of
such a policy, South Carolina having the largest stake and the most
forceful representatives, would naturally take the lead.
The consequences were that the broad national policy of
Lowndes, from this date gradually succumbed to the influences
which forced Calhoun away from it, despite his efforts to mould into
one form a national and sectional policy, based upon the declared
recognition of slavery, in place of, or in addition to, the implied
recognition furnished by the Constitutional compromise or “bargain”
over the sanction of the slave trade up to 1808. As the South drew
together in support of slavery, the overshadowing dimensions of its
greatest exponent cast into oblivion Barnwell, Hamilton and Alston,
who had so clearly perceived the dangers from its increase, and
even reduced the proportions of men as preëminently great as
Lowndes and his successor, Robert Y. Hayne.
As long as the tariff held the center of the stage, the change was
not so clearly apparent; but with the settling down, after the
explosion of sentiment which nullification occasioned, the division
between the sections was unmistakable. From that period the Lower
South presented an unbroken front in defence of slavery, under the
leadership of South Carolina.
From 1800 the South had, to a great extent, directed the policies
of the Republic, and, in the persons of Lowndes, Cheves and
Calhoun, South Carolina had from 1813 to 1820 been a potent
influence therein; but the Missouri Compromise and Taylor’s election
over Lowndes in 1820, for the Speakership, marked the beginning of
the change. No man saw it more clearly than the great man whom
Taylor defeated. His views on the condition of affairs at this time is
thus expressed by a contemporary: “The Northern people had
outstripped the Southern and desired to see the offices of the
Government in Northern hands. This inevitable result Mr. Lowndes
saw clearly forty years ago, and thought it wise for the South to yield
the hold she had so long possessed on political power, when she
was no longer able to retain it.”[49] The clear judgment of Lowndes
had revealed to him what the fatal brilliancy of Calhoun’s intellect
prevented him from perceiving, viz.: that there could not be
fashioned for the needs of imperfect humanity a perfectly
symmetrical policy. Lowndes had brought Webster and Clay together
and pushed through the tariff bill of 1816.[50]
Of that bill in reply to the fierce criticism that it was the worst thing
done since universal suffrage, he simply said, “neither was
altogether good, but the best possible for the time.” “He thought
some protection due to infant industries and that the question was,
what measure of protection do they require?” He held; “We are
obliged to leave some questions to posterity. We do our best with
those that come to us and future generations must bear their share
of the trouble.”[51] Accordingly, when the Baldwin bill of 1820 was
brought forward, “he opposed it on the ground that the increased
duties were not necessary.”[52] Before the tariff bill of 1824 could be
presented, he had passed away; but in his place, to share with
Webster, the honors of the splendid fight against it, South Carolina
had sent up to Congress Robert Y. Hayne, by Benton extolled as: “Of
all the young generation of statesmen coming on I consider him the
safest, the most like William Lowndes, and best entitled to future
eminent lead.”[53]
How well Hayne lived up to this a study of his achievements
exhibits. But while so good a judge as the late Edward M. Shepard,
in his Life of Van Buren, ranks Hayne’s effort in the Senate, against
the tariff of 1824, as fully up to, if not beyond, that of Webster in the
House, scarcely any attention is paid to it by those historians who
extoll the speech of Webster.
Again, while almost every history deals at length with the
Senatorial debates, and elaborates Hayne’s speech on the Panama
Mission in 1825, absolutely no mention appears concerning the far
more important utterance with regard to the Colonization Society in
1827. Yet Hayne’s speech, in his debate with Chambers over the
Colonization Society, is one of the most important utterances ever
made by a Southern Statesman. It indicates what was the prevailing
view with regard to the Negro Question, before the unfortunate
episode of nullification, by which Calhoun fastened upon the South
the belief that slavery as it existed in the Southern States, was a
good. In the speech in 1827, Hayne first showed the absurdity of the
scheme of transporting the blacks to Africa in such a number as to
affect the situation. That the presence of Negroes in the country was
an evil, he did not attempt to deny, but declared, “The progress of
time and events is providing a remedy for the evil.” He showed by
statistics that the relative increase of free white population was
rising, while that of the colored, whether bond or free, was
diminishing, and that “while this process is going on the colored
classes are gradually diffusing themselves throughout the country,
and are making steady advances in intelligence and refinement, and
if half the zeal were displayed in bettering their condition that is
wasted in the vain and fruitless effort of sending them abroad, their
intellectual and moral improvement would be steady and rapid.”[54]
Why is it that this utterance of the leader of his party in the Senate is
never alluded to by historians? Is it because it invites investigation as
to the condition of the blacks in the Northern and Western States at
this period and for the twenty years which followed? It is difficult to
tell. But from this time the question took a change. Subordinating to it
the tariff and the interest in railroad development, with the conditions
created by nullification by 1833, the State of South Carolina, and, by
1839, the South, was committed to the view of Calhoun: “Our fate as
a people is bound up in the question. If we yield, we will be
extirpated; but if we successfully resist, we will be the greatest and
most flourishing people of modern time. It is the best substratum of
population in the world, and one on which great and flourishing
Commonwealths may be most easily and safely reared.”[55] And to
this “Negro substratum population” policy both the tariff and the
railroad development of the South were accordingly subordinated
until Calhoun’s death, when Georgia, as a result of having
outstripped South Carolina in both men and material, stepped into
the place of leadership South Carolina could no longer fill, and with
the ambitious scheme of forcing slavery to the Pacific, in ten years,
produced the War Between the States.
FOOTNOTES:
[41] Jervey, Robert Y. Hayne & His Times, p. 67.
[42] Statutes of S. C. Vol. 7, p. 451.
[43] Charleston Courier, Dec. 22, 1818. Jervey, Hayne, p. 80.
[44] Niles’ Register, Vol. 18, p. 383.
[45] American Hist. Review, Vol. 15, No. 3, p. 630.
[46] Suppression of Slave Trade, DuBois, p. 124.
[47] McCrady, S. C. Under Proprietary Govt. p. 1.
[48] Studies American Race Problem, Stone, p. 57. Robert Y.
Hayne & His Times, Jervey, p. 114.
[49] Grayson, Memoir of James L. Petigru, p. 116.
[50] City Gazette, Sept. 16, 1820.
[51] Ravenel, Life & Times of William Lowndes, p. 154-5.
[52] Jervey, Robert Y. Hayne & His Times, p. 112.
[53] Benton, Thirty Years View, Vol. 2, p. 188.
[54] Jervey, Robert Y. Hayne & His Times, pp. 205-209.
Abridgment of Debates of Congress, Vol. 9, p. 303, et seq.
[55] Calhoun’s Correspondence, p. 368.
CHAPTER IV