BODY APPLICATIONS OF MRI 15

Chapter Two

Tom Schrack, BS, ARMRIT

Fairfax Radiological Consultants
Fairfax, VA
CHAPTER TWO

Body MRA Imaging:

Bolus Detection Techniques
After completing this chapter, the reader will be able to:
I Explain the fundamentals of different bolus detection techniques

I Identify the advantages and disadvantages of different bolus timing methods

I Describe the two types of stepping tables

Gadolinium contrast bolus timing in MR body applications is critical to the success of the exam.
As we will show later, dynamic-contrast imaging of the liver is essential for proper diagnosis as the
series requires precise contrast bolus timing. Likewise, MR angiography comprises a large compo-
nent of body applications. Body MRA applications include ascending, thoracic, and abdominal
aorta; renal arteries; superior mesenteric artery; and MRA “runoffs” (abdominal, iliac, femoral,
popliteal, lower leg, and feet arteries). Bolus timing for these areas, as with dynamic liver imaging,
must be precise. A discussion about differing bolus detection and timing techniques follows.

OVERVIEW BOLUS DETECTION TECHNIQUES

WITH TIME-OF-FLIGHT IMAGING
Because of ongoing advances in technology,
MRA continues to be one of the fastest- The use of a gadolinium-based contrast
growing applications in MR imaging in general agent (GBCA) for imaging the vascular system
and in body applications in particular. As changed the way MRA examinations were
recently as the mid-2000s, advanced MRA performed. Until the mid 1990s, the vast
was far from customary. Outside of routine
intercranial MRA imaging, more advanced
MRA imaging, such as contrast-injected
POINTS FOR PRACTICE
carotids and MR peripheral runoffs, were
fraught with pitfalls, including difficult set-up 1. Why is the use of a gadolinium-based
and variable results. contrast agent especially beneficial for
imaging of the vascular system?
More powerful gradients, more sophisticated
software, specialized coils, and faster recon- 2. List the primary methods for predicting and
truction processors have all made MRA fast detecting the arrival of the bolus of contrast.
and easy to prescribe by the technologist, Which is the most effective, and why?
resulting in more consistent, highly diagnostic 3. What are the benefits of ultrafast scanning?
images.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
16

majority of MRA scanning was done using ITOF can overestimate the degree of
non-contrast-enhanced 2D or 3D time-of-flight stenosis.
(TOF) imaging. With these techniques, the I Flow that is not perpendicular to the

scanning sequence uses a gradient-echo series imaging plane can become saturated with
in the plane most perpendicular to the flow RF energy, appearing dark and falsely
direction of interest. For example, if the carotid resembling a stenotic vessel.
arteries are the vessels of interest, the scan I Flow that is slow also may become

plane is typically in the axial direction, which is saturated with RF and appear dark.
perpendicular to the flow (carotid arteries run I Long scan times (four to six minutes for a

inferior to superior). In this example, imaging 2D TOF and six to nine minutes for a 3D
would create contrast in the image based on TOF) increase the risk of patient motion
the flow-related enhancement of flowing blood and consequently blur the images.
into an axial slice plane, where magnetization I Specific to body applications, images of

of the blood is at its greatest. The resultant the lower extremities are often badly
images show darker (non-flowing) stationary smeared due to naturally occurring
tissues against very bright flowing blood. tri-phasic flow velocities, where arterial
Images are then postprocessed into maximum flow moves in three distinct phases: fast
intensity pixel (MIP) projections in a 3D forward, short reverse, then fast forward.
display. While 2D and 3D TOF imaging is See Figures 11 and 12 for examples of flow-
robust, it is not without its disadvantages: related enhancement and 3D TOF.

Figure 11. Axial view of 4 images acquired Figure 12. Collapsed MIP projection of the
perpendicular to the carotid and vertebral intercranial arteries. This time-of-flight
arteries. A short TR and a high flip angle image takes advantage of the flow-related
ensure heavy saturation of stationary tis- enhancement of the fast-flowing blood.
sues while providing maximum flow-related The individual source images are displayed
enhancement of the carotid and vertebral as a singular MIP projection to visualize the
arteries. These “source” images are then entire vasculature.
post-processed into a 3D MIP projection.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BODY MRA IMAGING: BOLUS DETECTION TECHNIQUES 17
Chapter Two

Role of Gadolinium Contrast multiphase series is performed while a small

in Vascular Imaging amount of contrast (2–3 mL) is injected over
two to three seconds. After the series is
The introduction of gadolinum contrast
complete (typically ~1 minute), the technolo-
enhancement in vascular imaging dramatically
gist reviews the images to determine which
altered the methods used to perform most
image has the greatest degree of contrast in
MRA examinations. Because gadolinum is
the vessel of interest by using a region-of-
paramagnetic, it does not rely on flow-related
interest (ROI) tool that displays the actual
enhancement to provide strong (bright) signal,
pixel values of the contrast entering the vessel.
and the scan plane orientation is no longer
Once a specific image is identified, the tech-
required to be perpendicular to the flow.
nologist calculates the time it took for the
The use of ultrafast 3D gradient-echo
bolus to arrive by looking at the time stamp
sequences significantly reduces scan times
on the image (provided on all MR systems).
while increasing resolution. Finally, the occur-
The challenges of manual timing for the tech-
rence of tri-phasic flow is no longer a factor
nologist are correctly calculating timing, as
because the gadolinum does not saturate with
well as determining if a small amount of
RF energy such that it does not emit the
contrast used in the test bolus lingered in the
absorbed RF energy (saturated tissues, like
venous system and obscured some arterial
stationary soft tissue in a TOF sequence, emit
vessels. But, to be sure, a well-timed, manually
little signal and appear dark on the image).
calculated bolus series is indistinguishable from
The technical challenge of using contrast was
the more automated methods discussed next.
delivering the bolus of contrast at the exact
time of imaging, timing the acquisition to
obtain images of the vessels of interest
precisely upon contrast arrival.

SPECIFIC BOLUS DETECTION

TECHNIQUES
Methods for predicting or detecting the
arrival of a bolus of contrast into the vessel
of interest typically fall into one of three
categories:
I Manual Timing
I Computer-aided Detection
I Visual Detection

Figure 13. Axial image showing abdominal

Manual Timing
aorta with a graphically prescribed 3D
Manual timing is very effective in determining “tracker” pulse cube. The area inside the
bolus arrival. It allows facilities without dedi- cube is monitored in real time for rapid
increases in pixel signal intensity resulting
cated bolus detection software to acquire a from gadolinium in-flow. When a set
high-quality MRA. The technologist sets up threshold of signal increase is reached, data
a scanning series so that a single slice is acquisition of the 3D MRA begins.
prescribed to be imaged multiple times. This

©2009, International Center for Postgraduate Medical Education. All rights reserved.
18

System senses 3 standard

deviation increase in signal
in the tracker

Signal Data
intensity acquisition
of the automatically starts
tracker
volume

System messages 3D MRA scanning

to start injection sequence
Baseline signal
intensity established

Tracker volume TIME

scanning begins

Figure 14. Time course of events in an automated bolus detection technique.

Computer-aided Detection monitor the tracker volume. When the bolus

arrives in the area of interest, the pixel values
MRI is a versatile imaging modality, capable of
from the tracker quickly increase in dramatic
analyzing signal data from the patient in near-
fashion, signaling the MR system that the bolus
real time. The ability to perform real-time data
has arrived. The system then launches the
processing is extremely useful in the MRA
ultrafast gradient-echo sequence for the
application for determining when a contrast
contrast MRA series (Figure 14).
bolus arrives at the area of interest.
Automated computer-aided bolus detection
The automated bolus detection method
methods are highly effective, producing excel-
requires the technologist to prescribe a small
lent contrast MRA studies. The technique is
volume area of interest (10 mm x 10 mm x
automated, with little outside intervention and
15 mm) on a scout image – such as the
no manual calculations required. There is no
abdominal aorta for renal MRA – and the fully
contamination of the images from small
prescribed area to be scanned when the
amounts of test bolusing in the venous system.
contrast is delivered. The scanner begins the
imaging sequence and analyzes the pixel inten- The challenge of the automated computer-
sity from the small volume, often called the aided bolus detection method is that it
“tracker” (Figure 13). Once the system deter- requires precise placement of the tracker
mines the average pixel value of the volume volume. If the tracker is misplaced or the
(the baseline of pixel values), the technologist patient moves between the time of placement
injects the contrast. The system continues to and the time the actual scan begins, the bolus

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BODY MRA IMAGING: BOLUS DETECTION TECHNIQUES 19
Chapter Two

may not be detected or may be detected the term “fluoro” as in real-time x-ray
too late, yielding non-diagnostic images. Also, imaging. The injection is made during the
the central k-space line of the MRA sequence display of the images in real time, and the
must be filled first to meet the arrival of the technologist can often watch the patient’s
contrast bolus. breathing during an abdominal MRA. The
technologist visually inspects the images to
note the arrival of the contrast bolus. Once
Visual Detection
the bolus is seen, the technologist switches
Visual detection methods combine the best the imaging parameters in real time to a
of manual timing and computer-aided tech- higher resolution scan, which produces excel-
niques. Visual detection integrates the lent contrast MRA results.
real-time display of image data from the
The advantage of the visual method is that
automated computer-aided bolus detection
the technologist is in control of the start of the
with the visual cues of the manual timing
scan, eliminating the need for a test bolus, and
method. Visual detection is often referred to
breathing commands can be tailored to indi-
as “fluoro-triggered MRA.” The area of
vidual needs. The only potential drawback is
interest is scanned at first with a very low-
that the technologist must be vigilant in
resolution technique so that the images are
watching the images in order to track the
displayed in near-real time—thus, the use of
arrival of the bolus. Again, as mentioned

Contrast Injection
The contrast used in MRI is media containers for FDA • Dizziness
safe in almost all cases, but recommendations. • Vomiting
some people do experience Courtesy of Stephen Dashnaw, • Vasovagal reaction. A vaso-
side effects. Every technologist ARMRIT, Columbia University vagal reaction is not due to
should read and familiarize contrast media. It is not
The following is not a com-
themselves with the Prescrib- fully understood by the
plete list of possible contrast
ing Information that medical community, but
reactions, but contains the
is enclosed with the contrast every technologist should
most common side effects.
media used at their facility. recognize the symptoms:
Care must also be taken to • A slight to severe burning
cold sweats, increased pulse
know the serum creatinine pain at the sight of the
rate, decreased blood pres-
levels of all patients with injection, dependent upon
sure, and fainting. Elevate
kidney disorders in order to the amount of contrast
the patient’s legs and pro-
evaluate the risk of nephro- material infiltrated between
vide a cool, wet cloth until
genic systemic fibrosis (NSF). the skin and vessel
the symptoms pass.
See Prescribing Information • Headache
form enclosed in all contrast • Metallic taste

For in-depth discussion of the different types of contrast media, their uses, and potential side effects, please refer to
MRI for Technologists, Module 2, Chapter Five.

Table 1. Contrast Injection

©2009, International Center for Postgraduate Medical Education. All rights reserved.
20

above, the central k-space lines need to be mines the number of times the volume will be
sampled first in order to meet the arrival of scanned. Each of these scans is referred to as a
the contrast bolus. “phase.” The technologist must then balance
the spatial resolution with the necessary
See Table 1 for a list of possible side effects
temporal resolution, that is, how fast each 3D
of gadolinium-based contrast and a warning
volume must be acquired. (As spatial resolu-
about the rare but potential development of
tion increases, temporal resolution decreases.)
nephrogenic systemic fibrosis.
Once set, the technologist simply injects and
starts the scan at the same time as the injec-
tion. As each 3D volume is acquired, usually
ULTRAFAST SCANNING CAN ELIMINATE
in a matter of seconds, it is quickly recon-
BOLUS TIMING
structed and processed into a MIP that is then
Imagine scanning so fast that: displayed on the screen while the subsequent
3D volume is acquired. Each 3D MIP displays
I entire 3D volumes are acquired as fast
an increasing, then decreasing amount of
as a single slice.
contrast in the vasculature (Figure 15).
I one simply prescribes the required 3D
volume of interest and then tells the
system how many times to scan this
STEPPING TABLES
volume.
I the course of a bolus of contrast is Mobile MR tables, also called “stepping
captured as it progresses through the tables,” are now widely available on all new
vasculature of interest. MR systems and are usually standard equip-
I it does not matter when the bolus arrives ment on high-field magnets. The primary
because the scanner is already acquiring application of a stepping table is to provide an
the data before, during, and after peak automated method for doing the MR periph-
enhancement. eral runoff exam. In this application, a bolus
I this technique takes no longer than the of contrast is injected and then, through
typical 3D time-of-flight sequence. careful timing, the patient is imaged in stations
to essentially chase the bolus from the mid-
This technique is now used on many high-end abdominal aorta to the feet. Most MR systems
MR scanners. Referred to by various manufac- can be retrofitted with a stepping table if not
turer names (GE – TRICKS; Siemens – TWIST, originally equipped with one.
TREAT; Philips – 4D-TRAK), this rapid tech-
The automated stepping table is motorized
nique is finding its way into the mainstream.
and controlled remotely from the MR console
It requires very fast and high performance
without need for intervention in the scan
gradients (to acquire the data quickly) and
room. Most high-field systems are equipped
very fast array processor reconstruction
with an automated stepping table designed
engines. In less than five minutes, 1,000 or
and installed into the MR hardware system.
more individual images can be acquired,
The scan operator can reposition the table and
making ultrafast reconstruction processors an
perform multiple scans directly from the scan
absolute requirement.
console without entering the scan room or
In essence, the technologist prescribes the repositioning the table or the patient, which
3D volume of interest of, for example, the increases patient safety and comfort.
patient’s lower legs. The technologist deter-

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BODY MRA IMAGING: BOLUS DETECTION TECHNIQUES 21
Chapter Two

a b c

d e f

Figure 15. Selected MIP phases of a multi-phase multi-3D pelvic MRA/MRV of a 35-year-old
female with pelvic pain. (a) Early arterial phase. (c) Peak arterial phase. (d) Early venous phase.
(f) Late venous phase. Note the extensive and prominent pelvic veins consistent with venous
pelvic congestion.

Application to Peripheral Runoff MRA be completed in as little as 15 minutes of

imaging time and cover 75–150 cm of
A complete peripheral MRA runoff can be
anatomy (Figure 16).
acquired with a single bolus of IV contrast.
The patient initially is positioned at the first Acquisition of such a large field-of-view
anatomic station. Contrast is injected and the without repositioning the patient is most effi-
first set of images acquired. Next, the table is ciently performed using an appropriate set of
moved a specific distance (typically 30–45 cm) coils. Dedicated peripheral vascular coils are
to center the patient towards the lower available from a variety of vendors.
extremities, and the acquisition is repeated. Alternatively, multiple coils covering the
The process continues until a complete anatomy of interest can be applied simultane-
angiographic set is acquired within the single ously by manually switching the coil used at
contrast bolus. The entire process can often each station. Some MR systems are capable of

©2009, International Center for Postgraduate Medical Education. All rights reserved.
22

automatically switching to the coil set covering

the current anatomic station.
Other examinations that take advantage of a
stepping table for an extended field-of-view
include abdominal and pelvic vascular imaging
and whole body imaging for metastatic
surveys (Figure 17).

Figure 16. An Continuous Table Movement

example of a MR
Recent advances in technology have made it
peripheral runoff
exam. Note the possible to allow the table to continuously
coverage of the advance during the image acquisition. The
exam from superior advantage of a continually moving table is
to the renal arteries that the data acquisition is continuous through
to the level of the the entire runoff exam. In addition, the speed
feet. Also note the
of the automatic table advance can be
boundaries between
“stations” indicating adjusted to track the movement of the
the three levels of contrast bolus, ensuring that the timing of
scanning from the the images at each location is correct so that
abdomen (upper the arterial phase is seen throughout and
station), lower pelvis preventing venous contamination.
and femoral areas
(middle station), and
the lower legs (lower
station). Courtesy of SUMMARY
F. Scott Pereles, MD,
Northwestern
MR angiography remains a very useful
Memorial Hospital. application. A typical MRI facility routinely
performs MRA examinations every day for
many different body areas. The use of contrast
enhancement is preferred when imaging areas
other than the intercranial vessels. Various
methods are employed to time the imaging
sequence to coincide with the arrival of a
bolus of contrast in the area of interest.
Understanding the capabilities and limitations
of the particular MRI system is essential for
perfecting the techniques for this important
examination.

Figure 17. Example of placement of a

run-off coil used for imaging blood vessels
of the legs. Courtesy of Siemens.

©2009, International Center for Postgraduate Medical Education. All rights reserved.
 BODY MRA IMAGING: BOLUS DETECTION TECHNIQUES 23
Chapter Two

POINTS FOR PRACTICE

1. Why is the use of a gadolinium-based contrast agent especially beneficial for imaging of
the vascular system?
Because gadolinum is paramagnetic, it does not rely on flow-related enhancement to provide
strong (bright) signal, and the scan plane orientation is no longer required to be perpendicular to
the flow. The use of ultrafast 3D gradient-echo sequences significantly reduces scan times while
increasing resolution. Finally, the occurrence of tri-phasic flow is no longer a factor because the
gadolinum does not saturate with RF energy such that it does not emit the absorbed RF.

2. List the primary methods for predicting and detecting the arrival of the bolus of contrast.
Which is the most effective, and why?
Manual timing, computer-aided detection, and visual detection are the three primary methods.
Visual detection combines the best of manual timing and computer-aided detection by inte-
grating the real-time display of the image data with the visual cues of manual timing.

3. What are the benefits of ultrafast scanning?

Ultrafast scanning can eliminate the need for bolus timing. 3D volumes can be acquired in a
single slice, and the course of a bolus of contrast is captured as it progresses through the
vasculature of interest. The operator prescribes the 3D volume of interest, then tells the system
how many times to scan that volume.

All images, tables, and protocols courtesy of Fairfax Radiological Consultants, Fairfax, VA, unless otherwise noted.

Notes

©2009, International Center for Postgraduate Medical Education. All rights reserved.
24

Notes

©2009, International Center for Postgraduate Medical Education. All rights reserved.