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Christian Lienerth, Ph.D.

Bayer Vital GmbH / Germany


Head of CT-/MR-Application Service
Business Unit Radiology & Interventional

Liver-Imaging
Demand

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Pharmacokinetic
ECM (Extracellular Contrast Media)
1. Alpha Phase = vascular Phase, t1/2 = 2 - 3 min.
2. Beta Phase

= vaskular and interstitial distribution: t1/2 ~ 60 - 90 min.

For good tumor enhancement you have to scan in the -Phase.


Waiting period of 2-3 min. after CM-injection are recommended.
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Pharmacokinetic
ECM (Extracellular Conrast Media)
Gadovist - 1 min vs. 3 min after CM

GV - 1 min. after CM

GV - 6 min. after CM

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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.

Arrange your sequences in a clever order


Its a pharmacokinetic property.
For excellent enhancement in -phase you have to wait !

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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) *

Uptake into Hepatocytes

T1w Images
[* Rohrer et al., Investigative Radiology 2005, 40 (11): 715-724]

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Pharmacokinetic
of Primovist - Liver Specific
excretion via Gallbladder: ~ 50%

excretion via kidney: ~ 50%

excretion via kidney or biliary


could be supplemented in both ways

plasma t1/2: ~ 60 min.

complete elimination: 24 h
[Hamm et al., Radiology 1995, 195:785-792]

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Primovist
Product Information

Stand 07/2010

intelligent MR sequencen ordering


Tip:

For a time optimized workflow it is important, that Primovist


will be given very early in the liver examination procedure.

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Optimized Workflow
Example for a Primovist Procedure
Pre Contrast

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Post Contrast

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Workflow
Closer Look to the Details

t1_fl2d_inop_tra_mbh_2

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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)

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

A separated pre T1w sequence (3) could be skipped, as


the In-Out Phase (4) contains the pre T1w information and
the dynamic series (5,6,7,8) includes a pre T1w scan as well

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

Echo Amplitude (SI)

T2w-MRCP must be run before Primovist,


to avoid signal dropout in the biliary system

TE (ms)

T2w-MRCP before Primovist

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

T2*-dephasing
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MRCP: T2w
Opinion of the Literature ?

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Injection and Scan-Delay


Test-Bolus oder Fluroscopic Method

Tip:

Each patient has different circulation time


individual timing is necessary
goal: arterial phase of the liver lesion

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Injection and Scan-Delay


Arterial or Venous Phase ?

MIP with wrong liver-timing

MIP

Tip:

Each patient has a different circulation time


individual timing is necessary
goal: arterial phase of the liver-lesion

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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)

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Injection of Small Volume

better
Tip:

better

Be aware of anatomy and physiology


the small amount of CM should be transferred to the heart,
by an appropriate amount of saline-chaser (NaCl)

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Injection Protocol
Saline Chaser

The transfer line can hold alone a volume of 7 ml.


Sometimes additional extensions are used.
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Dynamic Liver Imaging


Dynamic Phases
the arterial Phase should be measured
with fluroscopic control
the portal-venous Phase should be measured 15-20 sec.
after the end of the arterial phase
the dynamic late Phase should be measured 2-3 min.
after the injection of Primovist
[Ringe, et al. AJR 195:13-28 (2010)]
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Dynamic Liver Imaging


Individual Timing is
important

different lesions shows


different enhancement
pattern
important information for
tdetection and
characterisation
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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)

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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)

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Diffusion (DWI)

* 2 Talks ECR 2009, Choi 2009


BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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DWI: ADC and Primovist


Comparison of ADC-Werte
BEFORE and AFTER Primovist

Choei e.a.: Diffusion-weighted MR imaging of liver on 3.0-Tesla system:


effect of intravenous administration of gadoxetic acid disodium, Eur Radiol 2009
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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T2w after Primovist


in general: Gadolinium will influence T1- as well T2-time

Echo Amplitude (SI)

MXY

Echo Amplitude (SI)

MZ

TR

TE

higher concentration of CM will be more seen on the images


the influence of PV onto T2w is not disturbing,
it will sometimes increase the tissue-lesion contrast
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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T2w after Primovist


Example: T2w - HASTE / SSH / SS-FSE

~3 min after Primovist

pre CM
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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T2w after Primovist


Basically you have different sequences for T2w

T2w-Single-Shot
HASTE / SSH / SS-FSE

T2w- triggered TSE


free breathing/ navigator / respiratory triggered

T2w-motion correction
BLADE / ROPELLER / MultiVANE
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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T2w after Primovist


Breath hold vs. Respiratory triggering

Breath hold

respiratory triggering

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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T2w after Primovist


Breath hold vs. Respiratory triggering
Increase of image quality with
Gating- or Triggering

breath hold
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

T2w fs gating
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T2w after Primovist


Respiratory Triggering vs. Motion-Correction

Improvement of liver vessels and reduction of pulsation artifacts

Tip:

use the waiting period in an reasonable manner


run T2w respiratory triggered scans or motion corrected scans
after Primovist this is convenient for the patient

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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T2w & DWI after Primovist


Voice of the Literatur?

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Late Images
Hepatobiliary Phase
FNH

Tipp: In the late phase it should be


no or less CM visual in the vessels
the hepatobiliary excretion should be visible
BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

Hepatobilire Phase 10 min p.i.

Recent studies has shown that:


After 10-15 min. no significant less lesions are
visible and the signal enhancement will not change
Hepatobiliary Phase 20 min p.i.

Tip:

the late phase could be started after 10 15 min.


exception: Liver Cirrhosis here wait 20 min.

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Hepatobiliary Phase
10 min. vs 20 min.

Hyperintense HCCs

[Suh Y, et al. AJR 2011;197:W44-W52]

Tip:

the late phase could be started 10 15 min.


exception: Liver Cirrhosis here wait 20 min.

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

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Late Images
Hepatobiliary Phase
Alternativ #1
2D Scan in multi breath hold Technique
higher spacial resolution (in-plane) possible

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Some General Remarks

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Breathhold Capaity
Avoid Movement-Artifacts
Adapt the scan duration to the breath hold capacity of the patient
too long, movement artefacts

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

adopted scan duration

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Oxygen & Breathhold Capacity


Preparation:
offering Oxygen (if possible)

prolongation of the breath hold capacity

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Breath hold Position


Exspiration
position is more defined and robust
liver is more stretched
maybe more slices, scan longer

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Inspiration
perception is more convenient
position sometimes deep, sometimes not
so deep
compressed liver
less slices, shorter scan

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Breath hold Position


Exspiration
heart close to the liver
sometimes artefacts in the left
liver lobe

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

Inspiration
heart more away from the liver
less artefacts

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Breath hold Position


Inspiration

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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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

BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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Science For A Better Life


BHC Radiology Dr. Christian Lienerth Bangkok October 2012

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