Liver MRI Teaching Case

Submitted by G. Jerry Trotti, MD Body Imager and Imaging Directed Interventionalist Riverside Radiological Associates

Clinical History
Obese female found to have an abnormal appearance of the liver on an outside abdominal CT and ultrasound with elevated liver function test.

Outside Ultrasound

Middle hepatic vein Left hepatic vein

Right hepatic vein

Hypoechogenic area

Outside Ultrasound

MRI of the Liver: T1 Flash in Phase

T1 Flash out of Phase

T1 Flash in Phase

T1 Flash out of Phase

T1 Flash in Phase

T1 Flash out of Phase

Liver high in signal

Liver drops in signal

T1 Flash in Phase

T1 Flash with Fat saturation

T1 Flash out of Phase

Next Slide for Diagnosis

Diagnosis

Multifocal Fatty Infiltration of the Liver

Discussion
Hypoechogenic area on outside ultrasound
Fatty elements are hyperechoic (bright) on ultrasound. Therefore the entire fatty infiltrated liver was brighter then normal and the normal fatty spared liver appeared hypoechoic (dark). Given that most neoplastic tumors of the liver are hypoechoic by ultrasound there was concern. Although this diagnosis can sometimes be made with ultrasound it is sometimes difficult especially if the patient is obese. Both CT and MRI can be used to make the Diagnosis. Given that the outside inconclusive CT was not available an MRI was preformed.

Middle hepatic vein Left hepatic vein

Right hepatic vein

Normal Fatty spared Liver

Outside Ultrasound

Discussion
MRI is a great modality to diagnose a fatty liver. Two types of sequences work best:
T1 FLASH with and without fat saturation pulse or T1 FLASH in and out of phase Fat has a high signal on T1 and you are looking for a signal drop (dark area) on the fat saturation or out of phase sequence.

T1 Flash in Phase

T1 Flash out of Phase

Fatty Liver high in signal

Fatty Liver drops in signal

Discussion
Fatty liver represents an excess of triglycerides within hepatocytes due to a nonspecific response to certain metabolic insults. Some of the more common Insults: Alcohol Abuse Obesity Hyperalimentation DM Hepatitis Steroids / Cushings syndrome Chemotherapy

Discussion Continued
3 Common Hepatic Patterns: Diffuse
The entire liver involved. Most common and easiest to recognize.

Focal
Fan shaped or geographic (non-spherical) portions of the liver. Typically extends to the liver capsule, without bulging the contour. Usually at the medial segment, near falciform lig and fissure for lig teres

Discussion Continued
Multifocal
Multiple Patchy (geographic) areas of fatty infiltration through the liver. Focal areas of fatty sparring my simulate a tumor as demonstrated on outside ultrasound. The hypoechogenic area was normal liver. Common focal sparring
periphery of the liver Abutting porta hepatis and gallbladder fossa

Discussion Continued
Differentiating focal fatty liver from malignancy
Angulated geometric margins Interdigitating margins with fingers of normal tissue Absence of mass effect or vessel displacement Rapid change over time. Fatty infiltration can be seen within 3 wks following an insult and can resolve 6 days after removing an insult.