MRI Future updates. Clinical Applications. What s near future? Clinical applications that advance MRI. Clinical applications that advance MR

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MRI Future updates Clinical Applications Roy Peter MRI Applications

Clinical applications that advance MRI Ready Brain 3D ASL PROPELLER 3.

Enabled Therapies Clinical applications that advance MR Ready Brain

Midsagittal Localizers plane acquired detected Scan planes computed

Post-processing completed per protocol Raw data to PACS & selected

scan, reformatting, postprocessing and data management Automatic

Extreme (>45 deg) rotation correction Fully automated exam for

1 MRI Future updates Clinical Applications Roy Peter MRI Applications Specialist, GE Healthcare near future? Clinical applications that advance MRI Ready Brain 3D ASL PROPELLER 3.0 Enhanced DWI MR Touch Inhance Delta Flow Advanced Cardiac MRI MR Enabled Therapies Clinical applications that advance MR Ready Brain Ready Brain & Express Exams Ready Brain or No user interaction needed Midsagittal Localizers plane acquired detected Scan planes computed Scan all series Scan all series per protocol per protocol Post-processing completed per protocol Raw data to PACS & selected series to AW per protocol PAC S Reading room Automatic localizer, Rx, scan, reformatting, postprocessing and data management Automatic midsagittal plane calculation for 2D3D Rx and ACPC determination Extreme (>45 deg) rotation correction Fully automated exam for improved productivity Accurate planes and reproducible intra- and inter-patient slice positions Prescription made simple for non-expert users GE

Clinical applications that advance MRI STROKE T2, DWI & Dynamic EPI T2 3D Arterial Spin Labeling (3D ASL) (reveals

information about Tissue already Dead Perfusion Provides information about tissue at Risk Diffusion = dead

(MTE) Blood Fow Shows tissue at risk Perfusion Weighted Imaging (PWI) -Perfusion MRI provides a relative

contrast -Dynamic injection Power injector, or quick hand injection -Acquire the first pass image with a fast EPI

signal drop during the first pass of contrast.

2 Clinical applications that advance MRI STROKE T2, DWI & Dynamic EPI T2 3D Arterial Spin Labeling (3D ASL) (reveals same information) DWI Dynamic EPI reveals tissue at risk blood volume (NEI) transit time (MTE) Diffusion Provides information about Tissue already Dead Perfusion Provides information about tissue at Risk Diffusion = dead Perfusion = dying Diffusion Shows infarct blood volume (NEI) Blood volume Shows infarct Dynamic EPI Blood Flow (MTE) Blood Fow Shows tissue at risk Perfusion Weighted Imaging (PWI) -Perfusion MRI provides a relative measurement of the parameters of cerebral micro vascularisation -We have to use a tracer or exogenous gadolinium contrast -Dynamic injection Power injector, or quick hand injection -Acquire the first pass image with a fast EPI GE or EPI SE sequence -Due to the magnetic susceptibility (T2*) effect of paramagnetic gadolinium there will be signal drop during the first pass of contrast. Perfusion Graph Brain Perfusion Haemodynamic maps rcbv rcbf Perfusion abnormality in the left brain hemisphere (MCA territory). Reduced Blood Volume and Blood Flow (rcbv, rcbf) (red arrow) TTP delay MTT increase TTP MTT GE

3DASL -In ASL the tracer is the arterial blood itself (or we call it as endogenous contrast) -Magnetically labeled or saturated blood acts as the contrast -Acquire two sets of data, one saturated

5T 3x3x4 mm 5:21 min Full brain coverage Note strong signal in the retina (arrow) High SNR Robust with susceptibility & motion Free of geometrical distortion (typical for EPI) Courtesy of Dr.

3 3DASL -In ASL the tracer is the arterial blood itself (or we call it as endogenous contrast) -Magnetically labeled or saturated blood acts as the contrast -Acquire two sets of data, one saturated blood and other without saturated blood 3D Arterial Spin Labeling (3D ASL) 3D ASL at 1.5T 3x3x4 mm 5:21 min Full brain coverage Note strong signal in the retina (arrow) High SNR Robust with susceptibility & motion Free of geometrical distortion (typical for EPI) Courtesy of Dr. Zaharchuk, Stanford Radiology 3D FSE acquisition with spiral readout Pulsed continuous labeling close to the imaged slab Background suppression for motion insensitivity Currently perform ASL on all patients with suspected or known cerebrovascular disease. The 3D FSE readout permitted the visualization of small structures. Robust, SNR-rich ASL in 3D Clinical applications that advance MR PROPELLER 3.0 Periodically Rotated Overlapping ParallEL Lines with Enhanced Recontruction Combat Patient motion Motion during the encoding process corrupts MR images through both displacement-related blurring and motion-related phase artifacts. -Patient instruction -Restrain -Fast scan -Repeat scan -Sedation Propeller Reduction of in-plane motion and rotation, Phase changes due to motion, and Through-plane motion Propeller Technology How does it work? Conventional FSE Propeller Technology How does it work? Each TR, one fast spin echo train collects all phase-encoded lines for a shot Shots are repeated, until k-space fills Only ONE shot crosses the center of k-space Each TR, one fast spin echo train collects all phase-encoded lines for a blade The blades are successively rotated in k-space by an incremental angle, Radial k-space filling Center of k-space over sampled signal-rich FSE GE

4 PROPELLER PROPELLER 3.0 Infant and pediatric Applications Usual scan PROPELLER scan Significantly reduced motion and flow effects Enhanced tissue contrast Reduced susceptibility artifacts in DWI Contrasts T1 FLAIR, T2, T2 FLAIR, DWI Combat patient motion, flow and susceptibility artifacts Propeller DWI Dental Work Susceptibility Artifact Propeller DWI Interface Susceptibility Artifact Conventional DWI PROPELLER DWI Conventional DWI PROPELLER DWI PROPELLER 3.0 FSE FS PROPELLER 3.0 More Contrasts, All Planes, Everywhere PROPELLER T1 FLAIR 3.0 provides virtually artifactfree images with fine anatomical detail and superb tissue contrast Physiologic motion pushed to background Effort free consistency Reliable fine detail delineation Small FOV imaging No phase wrap Over sample K-space center - high SNR FSE PROPELLER Significantly reduced motion effects such as peristalsis and flow Excellent tissue contrast Same scan time Free breathing acquisition with respiratory gating For everyday usage helping to leave rescans behind 2 Compared to conventional techniques Combat patient motion, flow and susceptibility artifacts GE

Clinical applications that advance MRI Enhanced Diffusion Weighted Imaging - edwi edwi: the Next Level in Diffusion Imaging 1 Pseudo-3D DWI at (vs.

8 BW=125 khz TI 150 NEX 4 4:49 min Adjustable multiple B values Tetrahedral encoding provides more SNR STIR for robust fat suppression (1.

b values IR-prep for fat suppression Respiratory triggered- Free breathing acquisition Clinical applications that advance MRI Liver mets 3 in 1 option, B500, 4 NEX (vs.

Pancreas tumor B800, 4 NEX Respiratory Trigger More SNR, less scan time, more accurate ADC MR Touch- Elastography MR Elastography - A unique and non-invasive method for evaluating

5 Clinical applications that advance MRI Enhanced Diffusion Weighted Imaging - edwi edwi: the Next Level in Diffusion Imaging 1 Pseudo-3D DWI at (vs. conventional DWI) Accurate, reproducible ADC maps Improved SNR and contrast Reduced scan time 1.5T FOV 22*24 Matrix 128x128 Slice 2 mm TR=8500 TE=87.8 BW=125 khz TI 150 NEX 4 4:49 min Adjustable multiple B values Tetrahedral encoding provides more SNR STIR for robust fat suppression (1.5T only) edwi with coronal reformat, ADC and eadc maps More SNR, less scan time, more accurate ADC edwi: Enhanced Diffusion Imaging 1 EPI single shot sequence with adjustable multiple b values IR-prep for fat suppression Respiratory triggered- Free breathing acquisition Clinical applications that advance MRI Liver mets 3 in 1 option, B500, 4 NEX (vs. conventional DWI) Improved quantification Improved SNR and contrast Reduced scan time smart averaging Improved spatial resolution IR-prep DWI oncology staging and treatment monitoring Pancreas tumor B800, 4 NEX Respiratory Trigger More SNR, less scan time, more accurate ADC MR Touch- Elastography MR Elastography - A unique and non-invasive method for evaluating tissue stiffness MR Elastography - Concept Drop a pebble in a pool of water Drop a pebble in a pool of gel Non-invasive staging Early detection Reduce biopsy Patient biopsy refusal Normal Fibrosis Cirhosis Short Wave Length Lon g Tissue Stiffness Soft Stiffness Hard New Touch in MR Imaging extension of diagnosing by Touch GE

6 Blood Pool Myocardium 20 9 Minutes TI (ms) Blood Pool Myocardium TI (ms) 9 Minutes MR Elastography - Technology MR-Touch MR Elastography Active driver Vibration Passive driver Acquisition Reconstruction MRI Image MR Elastogram Patient with healthy liver Sound Waves Shear waves generated by external acoustic driver External acoustic driver triggered by PSD. Shear waves Shear waves transmitted to tissue by passive driver. Motion Synthesis MRE Scan MEG gradient synchronized with external acoustic vibrations Wave Image Shear waves captured using phase contrast gradients GRE with modified cyclic motion-encoding gradients Soft Hard Elastogram Inversion algorithm used to convert wave images into stiffness map 61 year old female with elevated serum liver tests and nonalcoholic fatty liver disease. 72 year old male with cryptogenic cirrhosis In these cases of advanced liver fibrosis, The elastograms show that the liver is much stiffer than subcutaneous tissues and the overall stiffness of the liver. The heterogeneity of the stiffness of the liver is also increased (compared with the normal volunteers shown in top row) New Touch in MR Imaging extension of diagnosing by Touch Clinical applications that advance MRI - Vascular Imaging Inhance 3D DeltaFlow NCE Peripheral MRA Excellent contrast and surrounding tissue subtraction 3D FSE acquisition with cardiac gating Subtracts systolic from diastolic phase to help eliminate venous and background signal Deploys interleaved acquisition with k-space optimization and ASSET Inhance Delta Flow 2D TOF 3DTOF 2D PC 3DPC 3D Inhance Inflow IR TD1 Systolic acquisition Fast arterial flow Faster flow TD2 Diastolic acquisition Slow arterial flow Excellent arterial flow visualization with high contrast and robust venous and tissue subtraction Reduced misregistration due to motion Better visualization of slow flow arteries compared to current runoff techniques Short scan time (< 5 min for 40 cm coronal coverage) More contrast without contrast Clinical applications that advance MRI - Cardiac Cine IR 3D Heart Viability Imaging Cine IR Signal Intensity Amyloid Normal Quick assessment of TI (left), abnormal T1 behavior for patient with amyloid deposits compared to control (middle and right) Quick assessment of optimal TI time for MDE Detection of amyloid, vasculitis and other tissue abnormalities detectable through T1 curve Rapid, single breath hold acquisition Simple, easy to use, fast Signal Intensity Courtesy Mayo clinic, Rochester Multiphase FGRE-Cine acquisition Captures image contrast evolution at different TI time Adiabatic Inversion Recovery (IR) Myocardium suppression robust to B1 inhomogeneity No-miss myocardial tissue viability, aids in confident diagnosis GE

Coronary Artery Imaging 3D Heart Excellent anomalous coronaries, aorta & cardiac chamber assessment- wout radiation, contrast media or US limitations High SNR and contrast, high spatial

0T) Enhanced 3D FIESTA with more SNR & less artifacts Multi-slab acquisition for increased inflow effect More CNR with Special fat-sat & T2 prep Improved Navigator with algorithm

Surgical Oncology Radiation Oncology Non-radiation Based treatment MR Breast System MR Surgical Suite MR Oncology Package MR guided FUS Sedation-free robust CHD and coronaries assessment

Excellent soft tissue contrast Multi-parametric imaging: anatomical, functional, metabolic, MRA Complements CT for treatment planning Treatment follow-up and assessment Prostate, GYN,

Therapy CT Image Acquisition Spatial accuracy Tissue Density CT MRI MRCT Fusion MRI CT Virtual Simulation & Treatment Planning GE MR Surgical Suite Extending surgical vision and helping

7 Coronary Artery Imaging 3D Heart Excellent anomalous coronaries, aorta & cardiac chamber assessment- wout radiation, contrast media or US limitations High SNR and contrast, high spatial resolution Reduced motion averaging Easy prescription No anesthesia needed (free breathing) Fat sat FIESTA (1.5T) & IR-Prep FGRE (3.0T) Enhanced 3D FIESTA with more SNR & less artifacts Multi-slab acquisition for increased inflow effect More CNR with Special fat-sat & T2 prep Improved Navigator with algorithm optimization Prospective motion correction with slice tracking MR Enabled Therapies One MR with numerous clinical capabilities Multi-use Workflow HD Image Quality Biopsy Guidance Surgical Oncology Radiation Oncology Non-radiation Based treatment MR Breast System MR Surgical Suite MR Oncology Package MR guided FUS Sedation-free robust CHD and coronaries assessment Screen Diagnose Stage Treatment Plan Monitor MR for Radiation Therapy Planning Helping to improve tumor targeting accuracy MR Strengths for Radiation Therapy Planning MR advantages Excellent soft tissue contrast Multi-parametric imaging: anatomical, functional, metabolic, MRA Complements CT for treatment planning Treatment follow-up and assessment Prostate, GYN, Brain, H&N, Spine Large FOV Diffusion Tensor Imaging Spectroscopy Prostate imaging Dynamic Contrast Imaging Screen Diagnose Stage Treatment Plan Monitor MR CT Workflow for Radiation Therapy CT Image Acquisition Spatial accuracy Tissue Density CT MRI MRCT Fusion MRI CT Virtual Simulation & Treatment Planning GE MR Surgical Suite Extending surgical vision and helping to improve outcomes in neurosurgery MR Soft Tissue Metabolic & Functional Utilizing updated MR images for CT fusion may assist in more accurate delineation of pathology and improved localization of adjacent critical structures. Plan Verification Treatment Delivery GE

Simplicity in design Multi-Functional Patient Transport Single transfer board between prep, OR, MR and recovery Fully compatible with standard

0T GE MR Engineered for maximum utilization of OR and MR assets Lower infrastructure cost versus other high field imri systems Integration with

to improve intra-operative surgical navigation and outcomes.

Flexible multi-room design offers uncompromised surgical freedom while maximizing MR productivity.

enhance surgical decisionmaking prior to concluding surgery GE imri 3T HDxt Meningioma Case Study Pre-operative imaging Intra-operative imaging

intra-operative imaging T1 post gadolinium T1 +- C SV Spectroscopy Pre-surgical tractography 6 channel flexible coils Time of Flight Courtesy of

8 Simplicity in design Multi-Functional Patient Transport Single transfer board between prep, OR, MR and recovery Fully compatible with standard diagnostic 1.5 and 3.0T GE MR Engineered for maximum utilization of OR and MR assets Lower infrastructure cost versus other high field imri systems Integration with strategic partner s solutions GEHC Aestiva5 BrainLab VectorVision Sky Navigation Station InVivo Precess Wireless MR Safe Patient Monitor Helping to improve intra-operative surgical navigation and outcomes. Integrates multiple GE and industry leading strategic partners to improve surgical outcomes and workflow. Flexible multi-room design offers uncompromised surgical freedom while maximizing MR productivity. Mayfield Integra Skull Clamp MRX-Ray compatible Maquet Surgical Tables Intra-operative 6 Channel Flex Coil Intra-operative MR (imri) scans enhance surgical decisionmaking prior to concluding surgery GE imri 3T HDxt Meningioma Case Study Pre-operative imaging Intra-operative imaging Demonstrating successful resection Innovative open design allows for flexible coil placement Coils provide exquisite high resolution imaging for intra-operative imaging T1 post gadolinium T1 +- C SV Spectroscopy Pre-surgical tractography 6 channel flexible coils Time of Flight Courtesy of UVN, Dept of Neurosurgery, Central Military Hospital, Prague, Czech Republic GE imri Surgical Suite Enhancing Neurosurgery Helping to improve outcomes Uncompromised OR and MR suites Simplified Integration between OR and MR Integrated with OR industry leading strategic partners Cost effective asset maximizing solution ExAblate 2000 Excellence. Experience. ExAblate. Non-invasive targeted treatment for uterine fibroids using MR guided Focused Ultrasound GE

destroys targeted tissue, noninvasively.

tumors, and provides temperature monitoring of the treated tissue in real time.

the focal point an effect similar to a magnifying glass used to focus the sun s energy on a

Because it provides you with: Imaging in 3 orientations for precise tumor targeting and

thermometry for real-time temperature feedback allowing you to see temperature changes in the

0T 2004 Benign Indications: Uterine Fibromas Women Health Care 2005-2007 Other Brain

Soft Tissue Treatment In soft tissue: In bone tissue: Narrow, point-shaped focus is required

9 How does ExAblate work? MR guided focused ultrasound combines: High intensity focused ultrasound that heats and destroys targeted tissue, noninvasively. Magnetic Resonance Imaging system (MRI) which allows the physician to identify and target tumors, and provides temperature monitoring of the treated tissue in real time. Fibroid Focused Ultrasound generates heat by focusing ultrasound waves, ablating tissue only at the focal point an effect similar to a magnifying glass used to focus the sun s energy on a Focused Ultrasound single point. Why is MR important for guidance and control? Because it provides you with: Imaging in 3 orientations for precise tumor targeting and accurate identification of pathology Beam path visualization for controlled treatment MR thermometry for real-time temperature feedback allowing you to see temperature changes in the tumor during treatment Post treatment contrast imaging for precise treatment validation To improve accuracy in treatment! MRgFUS current and future Milestones CE FDA Approval 2004 Product 1.5T & 3.0T 2004 Benign Indications: Uterine Fibromas Women Health Care Other Brain Indications: Oncology Oncology After Bone vs. Soft Tissue Treatment In soft tissue: In bone tissue: Narrow, point-shaped focus is required Wide Beam Approach High energy density at focal point Low energy usage Shorter Treatment Time Uterine Fibroids Before Bones After Ablated Tissue Bone Breast Acoustic Beam Cutting-edge technology without the cutting! Prostate Typical Sonication Energy 2500J Transducer Typical Sonication Energy 1000J Liver Conformal Bone system ExAblate 2100 Bone - system overview Patient Table Transducer Water System Equipment Cabinet GE

10 MRgFUS for Breast Cancer The positioner is used as an interface for the breast treatment in MRgFUS. A breast MR coil is embedded into it as well as a cooling device. MRgFUS for Breast Cancer Table Setup Cooling device Breast coil Positioner MRgFUS for Breast Cancer ExAblate for Prostate Probe Water pipes Transducer Neck Voltage cables Balloon Transducer Shell Coil Transducer is inside a balloon filled with cooled degassed water. Transducer frequency: 2.3MHz (higher than in the body system) Positioner and Probe Treatment Demonstration Probe Pitch In-Out, Left-Right Supine head first Trans-rectal transducer is inserted and then fixed Balloon is inflated with cold circulating water Work in Progress Company Confidential GE

11 Closed Loop Treatment Concept Trans Cranial MR guided Focused Ultrasound Surgery Clinical Research Helmet-like Transducer Patient Setup Patient in MR Offer your patients cutting edge technology.without the cutting Trans Cranial MR guided Focused Ultrasound Surgery Thank You SIMPLY POWERFULL POWERFULL Y SIMPLE GE

GE Healthcare. Signa * HDxt 1.5T. Optima * Edition See More, Do More. The next generation in High-Definition MR.

GE Healthcare. Signa * HDxt 1.5T. Optima * Edition See More, Do More. The next generation in High-Definition MR. GE Healthcare Signa * HDxt 1.5T Optima * Edition 16.0 See More, Do More The next generation in High-Definition MR. 2 GE Healthcare Signa HDxt 1.5T Optima Edition Expect More You ve been heard. When you