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Liver-Imaging
Demand
Liver-Imaging
Demand
Desirable: 4 criterions
strong T1w
high spacial resolution
fast scanning (< 20s)
whole coverage of the liver
further wishes:
good fat-saturation
3D-scan for MPR / MIP
Pharmacokinetic
ECM (Extracellular Contrast Media)
1. Alpha Phase = vascular Phase, t1/2 = 2 - 3 min.
2. Beta Phase
Pharmacokinetic
ECM (Extracellular Conrast Media)
Gadovist - 1 min vs. 3 min after CM
GV - 1 min. after CM
GV - 6 min. after CM
Workflow Recommendations
Sequences and Waiting Period
1.
2.
3.
4.
Localizer
T1w_tra_(T)SE_nativ
T2w_sag_FLAIR
___ CM-Injection ___
5.
T2w_tra_(T)SE
6.
7.
8.
T1w_tra_(T)SE_CM_1
T1w_cor_(T)SE_CM_2
..
Tip:
~ 2 min.
1.
2.
3.
Localizer
T1w_tra_(T)SE_nativ
___ CM-Injection ___
4.
5.
6.
T2w_sag_FLAIR
T2w_tra_(T)SE
DWI
7.
8.
T1w_tra_(T)SE_CM_1
T1w_cor_(T)SE_CM_2
~ 5 min.
Pharmacokinetic
of Primovist - Liver Specific
Modified Gd-Complex
lipophilic side-chain
(Ethoxyb enzylgruppe)
intravenous BolusInjection
Dosage: 0.025 mmol/kg
0,1ml/kg BW
Protein-Binding: ~ 10 %
Relaxivity 6,9 l/mmol/ s
(in Blood-Plasma, bei 37C, und 1,5T) *
T1w Images
[* Rohrer et al., Investigative Radiology 2005, 40 (11): 715-724]
Pharmacokinetic
of Primovist - Liver Specific
excretion via Gallbladder: ~ 50%
complete elimination: 24 h
[Hamm et al., Radiology 1995, 195:785-792]
Primovist
Product Information
Stand 07/2010
Optimized Workflow
Example for a Primovist Procedure
Pre Contrast
Post Contrast
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Workflow
Closer Look to the Details
t1_fl2d_inop_tra_mbh_2
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Localizer
Expansion of the Liver
fast coronal scout, to estimate the size of the liver
(HASTE / SSH / SS-FSE or TruFisp / b-FFE / FIESTA)
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In-Out-Phase
Scan before Contrast Media
T1w-Sequence
different precession frequencies of H in the CHx in the H2O molecule
(3,5 ppm shifted, @ 1,5 T 217 Hz)
possibility of fat-quantification
Primovist will influence the T1-relaxation time,
In-Opp-Seq must be run before CM
all other sequences could be run after CM
BHC Radiology Dr. Christian Lienerth Bangkok October 2012
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Workflow
T1w before Contrast Media
Different scans with the same radiological information.
3
4
5
Tip:
t1_fl2d_inop_tra_mbh_2
14
MRCP: T2w
MRCP is an alternative to ERCP (Endoscopic retrograde cholangiopancreatography)
Primovist will be excreted via the biliray system
the beginning of Primovist excretion will be accelerate the T2* dephasing
TE (ms)
T2*-dephasing
15
MRCP: T2w
Opinion of the Literature ?
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Primovist Injection
T1w-dynamic with fat-saturation (3D: VIBE / THRIVE / LAVA)
Dosage:
0,1ml / kg BW 1 ml / 10 kg KG
Injection:
Flow rate: ~ 1 2 ml/s
followed by 30 40 ml NaCl
Tip:
Injection of Primovist
slow flow rate of 1 ml/s
inject sufficient NaCl
be aware of dead volume in the transfer-line
17
Tip:
18
MIP
Tip:
19
Injection Strategies
Small Volume
0,1 ml/kg BW
0,2 ml/kg BW
0,1 ml/kg BW
Gd-EOB-DTPA
(Primovist )
Gd-DTPA (Magnevist)
Gadobutrol
(Gadovist 1.0)
Gd-BOPTA (MultiHance)
Gadodiamide (Omniscan)
Gadoteridol (ProHance)
Gadoterate meglumine (Dotarem)
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better
Tip:
better
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Injection Protocol
Saline Chaser
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Signal-Variation
Typical signal-variation of liver lesion with Primovist
Autor: Dr Akihiro Tanimoto (Diagnostic Radiology, Keio University School of Medicine, Japan)
25
Signal-Variation
Typical signal-variation of liver lesion with Primovist
Autor: Dr Akihiro Tanimoto (Diagnostic Radiology, Keio University School of Medicine, Japan)
26
Diffusion (DWI)
27
28
Reasonable Worklist
uptake of Primovist in the hepatocytes needs 10 20 minutes
to avoid, that the patient has to be a second time on the table, T2w
and possible DWI scans should be performed after the
administration of Primovist
29
MXY
MZ
TR
TE
30
pre CM
BHC Radiology Dr. Christian Lienerth Bangkok October 2012
31
T2w-Single-Shot
HASTE / SSH / SS-FSE
T2w-motion correction
BLADE / ROPELLER / MultiVANE
BHC Radiology Dr. Christian Lienerth Bangkok October 2012
32
Breath hold
respiratory triggering
33
breath hold
BHC Radiology Dr. Christian Lienerth Bangkok October 2012
T2w fs gating
34
Tip:
35
36
Late Images
Hepatobiliary Phase
FNH
37
Hepatobiliary Phase
10 min. vs 20 min.
Uptake in the hepatocytes reaches a plateau after
20 min. which holds about 120 min.
At the time of approval: late phases after 20 min.
was investigated and approved
Tip:
38
Hepatobiliary Phase
10 min. vs 20 min.
Hyperintense HCCs
Tip:
39
Late Images
Hepatobiliary Phase
3D-Scan
breathhold
time: 1 x bh ca. 20 s
MPR possible
but: limited resolution
BHC Radiology Dr. Christian Lienerth Bangkok October 2012
40
Late Images
Hepatobiliary Phase
Alternativ #1
2D Scan in multi breath hold Technique
higher spacial resolution (in-plane) possible
41
42
General Remarks
Patient Prepatarion
good instruction about the procedure
comfortable position
train the breathhold commands
Breathhold Capacity
determine the time interval of breath hold capacity
before start the examination
adapt the scan duration to this capacity
Control
respiratory belt for visual control of the movement
43
Breathhold Capaity
Avoid Movement-Artifacts
Adapt the scan duration to the breath hold capacity of the patient
too long, movement artefacts
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45
Inspiration
perception is more convenient
position sometimes deep, sometimes not
so deep
compressed liver
less slices, shorter scan
46
Inspiration
heart more away from the liver
less artefacts
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48
Artefacts
Tip:
Avoid Artefacts
be sure that the coils are well positioned on the patient
explain and train the breath hold commands before the procedure
determine the individual breath hold capacity before start
adapt the scan duration to the patient
dont hurry, give breath hold command in a calm manner
respiratory belt for visual control
better and reproducible results in expiration
short delay between breath hold command and start of the sequence
patient must really finished the breathing
if necessary, give antispasmodic drugs (Buscopan, Glukagon)
to calm down the bowel activity
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