MRI MSK Protocol

7/13/2019 MRI MSK Protocol

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Protokol MRI Muskuloskeletal

Dr. Paulus Rahardjo

@2014


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SHOULDER


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ANATOMY


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Shoulder MR Routine Protocol

Coronal obliqueFS PD FSE (tendinosis)

T2 FSE (cuff tear)

Axial

T2* (theta > TE) intrasubstance signal &

subscapularis tendon

FS PD FSE (paralabral cyst & articular cartilage)

Sagittal obliqueT2 FSE (cuff tear)

FS PD FSE (tendinosis)

P i P i


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Patient Preparation

Have the patient to go to the toilet

Explain the procedure to the patient

Offer the patient ear protectors or ear plugs

Ask the patient to undress except forunderwear

Ask the patient to remove anything

containing metal (hearing aids, hair-

pins, body jewelry, necklace, etc.)

P i i i


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Positioning

Supine

Shoulder coil (oval surface coil, flexible coil)

Arm in neutral rotation or supination

Cushion the legs


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Ti & T i k


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Tips & Tricks

Positioning: Secure coil at the side with sandbags

Place sandbags or a strap across the lower arm in

supination (if this should prove difficult it is easier

to have the lower arm in neutral rotation)

Get the shoulder to be imaged as far into the

isocenter of the magnet as possible

It may be necessary to position the patient in themagnet at an oblique angle of 45 (place cushions

at the shoulder, buttocks, and knees)

Sh ld i l


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Shoulder, axial


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Sagittal oblique(orthogonal to sequence 2

or parallel to the glenoid cavity)


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C l Obli ( ll l t th


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Coronal Oblique (parallel to the

supraspinatus muscle on the axial)

slice) Sequence 2


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ELBOW

Positioning


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Positioning

Prone: arms straight above the head, palms

against the table, secureOr supine: arms straight alongside the body

Or slight lateral decubitus: arm immobilized bythe body

Surface or wraparound coil

Tips & Tricks

If necessary, immobilize the forearm with a

sandbagTry to position the elbow to be imaged in the

isocenter of the magnet

Elbow Protocol


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Elbow Protocol

Coronal T1/PD FSE (sclerosis, tendinosis) Coronal FS PD FSE (ligament and tendon tear)

Axial T1/PD FSE

Axial FS PD FSE (biceps, ulnar nerve, collateral lig. and

tendons) Sagittal T1/PD FSE (triceps, olecranon bursa)

Sagittal FS PD FSE (triceps, capitellar chondral surface)

Hints

TR = 3000 msec and FS PD FSE - TE 40-50 msec

10 cm FOV

Axial plane extend to radial tuberosity

T2* GRE used if poor fat suppression


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Coronal


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Axial


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Sagittal


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WRIST

Positioning


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Positioning

Prone: arm extended above the head, palm

flat on the table, secure,

surface coil

Or supine: arm extended alongside the body

Tips & Tricks

If necessary immobilize forearm with sandbag

Wrist MR Routine Protocol


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Wrist - MR Routine Protocol

CoronalT1 or PD FSE

FS PD FSE

AxialT1 or PD FSE

FS PD FSE

STIR or T2* for heterogenoufat suppresion

SagittalFS PD FSE


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Coronal


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Axial


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Sagittal


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HIP

Hip Protocol


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Hip Protocol

Coronal T1/PD FSE (acetabular sclerosis)

Coronal FS PD FSE (subchondral edema, labral tears and cysts)

Coronal FS PD FSE with cardiac coil (femoroacetabularimpingement)

Axial FS PD FSE (labrum, iliopsoas bursa, muscle)

Sagittal FS PD FSE (anterior labral tears and femoral head

morphology) HintsHints


Coronal use cardiac coil with FOV = 16 cm

IV vs. intraarticular contrast for femoroacetabular impingement -

optional Radial imaging for labrumoptional

Use anterior-most coronal images to diagnose acetabular dysplasia

Positioning


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PositioningSupine

Body array coil (body coil, wraparound coil)

Cushion the legs with a small roll under the knees (do notelevate the

thighs too much)

Have the patient cross the arms over the upper abdomen

Tips & Tricks

Positioning aid:

Center on anterior inferior iliac spine

If the coronal images show vascular artifacts due to the iliacvessels, switching the phase encoding gradient to HF mayhelp (with oversampling in order to avoid foldover)

Coronal across the femoral heads


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(allow for an oblique presentation of

the pelvis)

Axial across the femoral heads and


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Axial across the femoral heads and

acetabula (caudad to the lower aspect of

the greater trochanter)

Sagittal across both femoral heads


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Sagittal across both femoral heads


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KNEE


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Knee Protocol Axial T1/PD FSE (sclerosis)

Axial FS PD FSE (patellofemoral cartilage)

Sagittal FS PD FSE (meniscal morph., cruciates, articular cartilage)

Sagittal T2* GRE (meniscal deg., patellar tendon,chondrocalcinosis)

Coronal T1/PD FSE (sclerosis, condylar erosions)

Coronal FS PD FSE (collateral ligaments, meniscal root (g

attachments)

Hints


FOV 12-14 cm Do not externally rotate knee

Use sagittal plane to diagnose trochlear groove lesions

Evaluate meniscal root attachments on posterior-most coronalslices

Positioning


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Positioning

Supine, feet first

Knee coil (wrap around)Place knee into the coil (check that it really is

the one due for investigation)

1015 external rotation gives better imagingof the anterior cruciate ligament

Center the joint in the coil and secure the

knee in the coilCushion other leg


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Patellar

cartilage


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Patellar

cartilage


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Trochlear

cartilage

Patellar

cartilage


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S i l d A i l Sli


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Sagittal and Axial Slices


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LAT

Meniscus


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LAT

Meniscus


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LAT

Meniscus


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LAT

Meniscus


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ACL PCL


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ACL PCL


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ACL PCL


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PCL


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MED

Meniscus


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MED

Meniscus


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MED

Meniscus


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MED

Meniscus


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CORONAL SLICES


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(parallel to the condyles)


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MED

Meniscus


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MED

Meniscus


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ACL PCL


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MCL

PCL


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MCL

PCL


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LCL

PCL


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PCL


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Coronal (parallel to the condyles)


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Coronal (parallel to the condyles)

Sagittal


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Sagittal

Axial


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Axial

Tips & Tricks


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Cushion the knee well (sandbags, wedges)

To avoid repeatedly having to set up two scout sequences (in the off-

center position), have a right and left sagittal scout set up for the knee

in the standard scout program; one scout always displays the joint

while the other does not

In children, comparative images of the two knees may be performed

with the knees in the head coil. Secure the knees with cushions, and

for the sequences either adjust TR according to the number of slices orrun the sequences separately for each side

The anterior cruciate ligament is delineated best at 1520 of external

rotation, the posterior cruciate ligament at 0 or 5 internal rotation


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ANKLE


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ANATOMY


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N *


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N *


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N *


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N *


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N *


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N *


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N *


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N *


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N *


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N *


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N *


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*N


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N *


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N *


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N *


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N *


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PERONEAL


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BREVIS

LONGUS


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MRI Normal tibiofibular ligaments


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g

MRI Normal tibiofibular ligaments


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Axial T1-weighted MRimage obtained at the

joint level

demonstrates the

anterior (straight

arrows) and posterior

(curved arrow)

tibiofibular ligaments.

Normal talofibular ligaments.


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Normal talofibular ligaments.


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Axial T1-weighted MRimage depicts the

anterior talofibular

ligament (arrow).

The posterior

talofibular ligament

normally

demonstrates a

striated pattern due to

interspersed fat (*).

NORMAL ATFL (arrow) and NON-VISUALIZED ATFL/ TEAR


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Calcaneofibular


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Normal calcaneofibular

ligament.


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g

Axial T1-weighted MRimage shows the

calcaneofibular

ligament (straight

arrows) immediatelyadjacent to the

peroneal tendons

(curved arrow).

Chronic tear of the calcaneofibular ligament. Axial T2-weighted

MR image demonstrates marked thickening and waviness of the

calcaneofibular ligament (arrows).


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g ( )

Calcaneofibular


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Sequential coronal T1-weighted

Injury of the calcaneofibular

ligament.


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g

Sequential coronalT1-weighted MR

images

demonstrate

increased signal

intensity and

thickening of the

calcaneofibular

ligament (*)

Achilles tendinosis


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Acute Achillesperitendinosis.

Sagittal T2-weightedMR image shows a

reticular pattern ofincreased signalintensity in the preAchilles tendon fat (*),

a finding that indicatesthe presence ofedema.


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Chronic tendinosis ofthe Achilles tendon.

Sagittal T1-weighted

MR image shows

fusiform thickening of

the Achilles tendon

without evidence of

Increased

intrasubstance signal

intensity (arrows).

Partial and Total tear


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Ankle Protocol


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Sagittal T1/PD FSE (sclerosis)

Sagittal FS PD FSE (soft tissue, subchondral edema, cartilage) Coronal T1/PD FSE (sclerosis)

Coronal FS PD FSE (tibiotalar chondral surf., osteochondral

lesions)

Axial T1/PD (sensitivity for tendinopathy and ligament sprains)

Axial FS PD FSE (sens. for tenosynovitis and ligament

disruption)

Hints

TR = 3000 msec

FS PD FSE - TE 40-50 msec

Include Achilles tendon and plantar fascia in sagittal plane

Image in neutral ankle position, plantar flexion foreshortens ATFL Tibialis anterior requires axial or coronal oblique

Lisfranc ligament evaluation requires axial parallel to tarsometatarsal

Positioning

Supine


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p

Knee coil (head coil or wraparound coil forboth ankles)

Secure ankle in coil

Cushion the other leg well

Sagittal


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Coronal


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Axial


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Tips & Tricks

Optimized imaging of the


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p g g

Calcaneonavicular and deltoid ligaments(tibiocalcanean and talotibial part): coronal slicein maximum dorsiflexion (1020)

Anterior and posterior talofibular ligaments: axial

slice in maximum dorsiflexion (1020)Calcaneofibular ligament: axial slice in maximum

plantar flexion (4050)

Deltoid ligament (tibionavicular and anteriortalotibial part): coronal slice in maximum plantarflexion (4050)

MRI of the Achilles Tendon


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Sagittal

Coronal & Axial


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CERVICAL SPINE

Positioning


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Supine on cervical spine coilCushion the legs

Arms straight alongside the body (cushion

them, if needed)

Sagittal


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Axial


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Cervical spine,

axial, parallel to

the relevant

end plates

Coronal


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Tips & TricksIn patients with increased kyphosis cushion the pelvis; in patients with

cervical spine problems it may be advisable to elevate the head somewhat


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and cushion it

Cushion the neckIf needed, have the patient put on a neck brace (under the coil, secures

the neck and ensures stability)

Before running sequence 1, have the patient swallow and clear his/her

throat

In patients with severe scoliosis ensure that enough slices capture thelateral aspects

In patients with a short neck the upper part of the cervical spine coil

may not fit: either use phased-array coil or acquire the images without

the upper strap (image quality will be poorer); for phased-array coil

select cervical and thoracic

Positioning aids:

Cervical spine: center on the middle of the throat (lower in patients

with a short neckalmost all the way to the jugular fossa)


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THORACIC SPINE

Positioning

Supine


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Cushion the legs and secure them ifnecessary

The arms should be alongside the bodyexcept in obese patients, where they should

be raised above the head

Positioning aid:

Center on a spot about 23 inches (58 cm)

below the jugular fossa(or on the center of the sternum)

Sagittal


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Axial


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Coronal


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Tips & Tricks


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In patients with increased kyphosis cushionthe back; in those with additional neck

complaints it may be advisable to elevate and

cushion the head

In patients with severe scoliosis, ensure that

in the sagittal images enough slices capture

the lateral aspects


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LUMBAR SPINE

Positioning


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SupineSpine coil

Cushion the legs and secure them if needed

Arms alongside the body (over the head forobese patients)

Sagittal


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Axial


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Tips & Tricks

In patients with increased kyphosis; cushion the back;in those with


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in those with

additional neck complaints it may be advisable toelevate and cushion the head

If the patient is in pain, secure cushions to the outsideof the knees with straps (this relaxes the back muscles)

In patients with severe scoliosis, ensure that enoughslices will capture the lateral aspects

Positioning aid:

Center on a spot about 23 inches (58 cm) above thesuperior anterior iliac spine or iliac crest (in a tallpatient)


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SACROILIAC JOINTS

Sagittal


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Axial oblique


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Coronal Oblique


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Documents

MRI MSK Protocol