magnetic resonance imaging of the fetus · low-intensity fetal lungs on mri may suggest the...
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Magnetic Resonance Imaging of the fetus
John A. Cassese M.D. Assistant Professor
Departments of Diagnostic Imaging and Pediatrics
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MR as an Imaging Tool
Nuclear Magnetic Resonance Spectroscopy
– Known for a long time in the chemistry lab
•Idea of Medical Imaging arose in 1980’s
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Basic Principals of MRI
How does Magnetic Resonance Imaging work?
– Certain nuclei act like tiny magnets
1H imaging
– By using a large external magnetic field and radio waves -manipulate magnetic properties to determine relative concentration and position of 1H within tissue
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Basic Principals of MRI
Strong magnetic field
– 0.3 -> 3 Tesla
1 Tesla = 10,000 Gauss
Earth’s magnetic field 0.3 - 0.7 Gauss
Refrigerator magnet 100 Gauss
– Aligns protons with field creating strong vector
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Basic Principals of MRI
Superimposed a variable magnetic field (gradient)
Introduce energy (radio waves)
– Frequency just below FM radio
Some protons absorb energy
Turn off radio waves and listen for return frequency as proton release energy (relaxation time)
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Basic Principals of MRI
Two separate characteristics of protons that are recorded (T1 and T2)
Numerous applications (sequences) to enhance and display differences in these characteristics
First clinical applications 1980
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Magnetic Resonance Fetal Imaging
Then- first described in 1983
– Conventional spin echo technique
– Required maternal and/or fetal sedation
Now- advances in hardware/software allow an image to be obtained in milliseconds
– Effectively freezing fetal motion
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MR Fetal Imaging- T2 Sequences
– Single shot fast spin echo (SSFSE)
– HASTE half-Fourier single-shot turbo spin echo
– Imaging blurring
– High RF deposition- heating
– Low SNR
Workhorse
– anatomy
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MR Fetal Imaging- T1 Sequences
– FLASH fast low angle shot Relatively slow (20 sec) without high
performance gradients
Hemorrhage
Calcification
Lipomas
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MR Fetal Imaging- Diffusion Weighted Imaging Sequences
– Distinction between water moving freely or in a restricted way
Hypoxic-ischemic injury
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MR Fetal Imaging- Timing of exam
Late 2nd trimester onward
Avoid first trimester- effects not studied
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MR Fetal Imaging- Adjunct to US
Ultrasound remains the primary screening modality
– But may be limited by
Reverberation artifact
Poor penetration through the ossified skull
Oligohydramnios
Fetal position- particularly in late pregnancy
Nonspecific appearance of certain abnormalities
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MR Fetal Imaging- Advantages
Superior contrast resolution
Better visualization of CNS structures
Large field of view
True multiplanar imaging
Non-ionizing radiation
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MR Fetal Imaging- Adjunct to US
Confirm diagnosis/offer alternative diagnosis
Identify additional abnormalities
Patient counseling/pregnancy management
Problem solver
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MR Fetal Imaging- Indications
CNS abnormality
Neck/Chest/Abdominal Mass
Lung hypoplasia
Renal/GU abnormality
Spine/Sacrococcygeal teratoma
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MR Fetal Imaging- CNS
Fetal MRI of the CNS is particularly helpful
– Etiology of ventriculomegly
– Evaluation of posterior fossa collections
– Evaluation of mylination/migration abnormalities
– Documentation/extent of hemorrhage or ischemia
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MR Fetal Imaging- CNS
Levine D, et al. obstet gynecol 1999; 28:169-74
– MRI lead to a change in diagnosis 26/44 (40%)
Twickler D, et al. Am J Obstet Gynecol 2003; 188:492-6
– Additional information 64%
– Change in diagnosis 28%
– Alter timing/mode of delivery 11%
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17 wk 23 wk
33 wk term
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Aquaductal Stenosis
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Hydranencephaly
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Dandy Walker Malformation
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Arachnoid Cyst
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MR Fetal Imaging- Non CNS
Airway/ thoracic abnormalities
– Obstructing neck mass
– Lung Hypoplasia
– CDH: document position of the fetal liver
Liver “up” vs. “down”; mortality 57% vs. 7%
– Chest masses
CCAM
Sequestration
Bronchogenic cyst
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MR Fetal Imaging- Non CNS
Fetal lung hypoplasia
– Lung volume
Vs. Gestational age
Vs. Fetal size
Vs. predicted volume
– Signal intensity
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Low-intensity fetal lungs on MRI may suggest the diagnosis of
pulmonary hypoplasia
Shigeko Kuwashima, et al. (Pediatr Radiol. 2001;31:669-672.)
MR Fetal Imaging- Lung Hypoplasia
•Concept of lung-to-liver intensity ratio
•Value <2 suggests hypoplasia in fetuses after 26 weeks
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Lung= 90
Liver=91
Ratio=0.99
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Achondroplasia
coronal chest anterior to posterior
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coronal chest anterior to posterior cont.
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axial chest with grossly normal signal intensity within the
lungs
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Congenital Diaphragmatic Hernia
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MR Fetal Imaging- Non CNS
Airway/ thoracic abnormalities
– Obstructing neck mass
– Lung Hypoplasia
CDH: document position of the fetal liver
– Liver “up” vs. “down”; mortality 57% vs. 7%
Chest masses
– CCAM
– Sequestration
– Bronchogenic cyst
– Chest Wall
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MR Fetal Imaging- Non CNS
Abdominal masses
GI/GU anomalies
Sacrococcygeal teratoma
TTTS
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Renal dysgenesis oligohydramniosis
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Twin-To-Twin Transfusion Syndrome
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MR fetal Imaging- Cutting Edge
Evaluation of the placenta
Ungated fetal cardiac cine –Echoplanar imaging
Assessment of nutritional status by evaluation of adipose tissue
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MR fetal Imaging- Cutting Edge
Functional MR
– 33+ weeks
– Brain oxygenation
MR spectroscopy
– Lactate in Brain
– Myelin in Brain
– Lecithin in amniotic fluid and/or lung parencyma lung maturity
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MR Fetal Imaging- Conclusions
Useful Adjunct to ultrasound
– Any CNS anomaly
– Any chest mass
Problem solver
– Abdominal/pelvic lesions
Surgical planning
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