FieldStrength Publication for the Philips MRI Community Issue 40 May 2010 MRI scanner at Manipal Hospital gets a new lease on life New coils and upgrade to release 12 bring Manipal Hospital s aging Intera 1.5T scanner right up to date This article is part of Field Strength issue 40, May 2010
MRI scanner at Manipal Hospital gets a new lease on life New coils and upgrade to release 12 bring Manipal Hospital s aging Intera 1.5T scanner right up to date Nageswara Rao Tummala, MD Manipal Hospital, Vijayawada, in the Southern Indian state of Andhra Pradesh was the first hospital in the country to install a Philips Intera 1.5T MRI scanner. Since that was nearly 10 years ago, the system was in need of an upgrade and following the advice of the local Philips sales organization, it received a major makeover with the installation of Philips Value Pack upgrade to release 12 for the Intera and the new SENSE Body coil and SENSE Head/Neck coil. According to Chief of Radiology, Nageswara Rao Tummala, MD, the new system is more than living up to expectations, enabling the department to expand its range of applications and referrals, and once again provide first-class service to patients in its area. We now regularly use DWIBS instead of nuclear imaging for oncological staging and followup studies. We were very happy with the old Intera system but as time went on, we started to realize its limitations, mainly because many of the features we were missing were simply not available at the time we bought it, explains Dr. Tummala. For example, in recent years we had to outsource breast exams and certain body exams because we didn t have the necessary hardware. We also used to perform a lot of coronary angio studies but found that this too dropped off after the introduction of 64-slice CT. The system s operating environment and scanning tools had also become outdated, and the radiologists wanted to have a dedicated workstation for MR for which their existing EasyVision workstation was unsuitable. System upgrade the most cost-effective solution Obviously something needed to change and after consultation with Philips, it was decided that the most effective approach would be a complete upgrade with Philips Value Pack Release 12 for the Intera, plus the SENSE Body coil, SENSE Head/Neck coil and the breast imaging support, opening the door to the latest MRI functionality and imaging techniques. At the same time the existing EasyVision workstation was upgraded to the ViewForum advanced 3D visualization and analysis workstation. 24 FieldStrength Issue 40 May 2010
PCA Vascular malformation of upper lip The MIP of the PCA scan shows an excellent area of coverage, enabled by the SENSE Head/Neck coil. The vascular malformation extends from the upper lip into the nose. Both images show that the AVM is predominantly supplied by ECA territory bilaterally and the right image shows that it is also supplied from intracranial feeders. Stretch injury As far as imaging of the posterior triangle is concerned, the improvement can only be described as phenomenal. The STIR MIP image shows diffuse sheath edema on left side. Right side is normal. There is an associated fracture of the clavicle and soft tissue injury. FieldStrength 25
Manipal is one of the very few centers in that part of the country performing a lot of abdominal imaging, particularly liver imaging. If you plan properly, the results are excellent, Dr. Tummala stresses. In fact, most of their abdominal studies, which were formerly performed with CT, are being converted to MR, including bowel pathology. There are also many cases where they mix CT and MRI but Dr. Tummala is convinced that in future MR will take over body imaging completely from CT in their center. Suspected biliary colic Single shot MRCP image acquired in one breath hold after administering oral gadolinium to suppress signal from stomach and duodenum. Scan time 8 seconds, SENSE Body coil, TR 8000 ms. Filling defects noted in terminal common bile duct suggestive of calculi. Normal pancreatic duct visualized throughout its course. Major improvements in image quality and speed Following the upgrade, Dr. Tummala and his colleagues immediately appreciated the benefits, not only in the clearly higher image quality but also in reduced scan times. The results in breast imaging are excellent, he says. We see markedly improved image quality and reduced scan times, plus the added advantage of being able to evaluate both sides of the breast to immediately compare the abnormal with the normal anatomy. The comfort level of the patients is also greatly improved which means we get much better cooperation from them during a scan. This helps to reduce scanning time even further and reduces the number of rescans needed. Dr. Tummala and his colleagues have also noticed big improvements in body imaging, again with much better image quality and shorter scan times. We re particularly impressed with the system s whole body imaging capabilities and we think the DWIBS sequences are superb, he says. This was something entirely new to us but we now regularly use DWIBS instead of nuclear imaging for oncological staging and follow-up studies after treatment, since we believe that it s not only more sensitive but also more specific. The results are available instantly and we can also perform ADC mapping. Initially the SENSE Head/Neck coil was not part of the upgrade package but the department decided it would be a worthwhile investment. The angio imaging with this new coil is very good with better area coverage and higher resolution than we ever had before, stresses Dr. Tummala. Also as far as imaging of the posterior triangle is concerned, the improvement can only be described as phenomenal. In the past, interpreting the images to determine whether an abnormality was present due to spinal trauma could easily take me up to an hour. Now, with the benefit of DWIBS and the new coil, it rarely takes more than ten minutes. This is a fantastic improvement. Dr. Tummala and his colleagues are also making extensive use of other advanced imaging tools that have become available to them with the upgrade, including CLEAR, spectroscopy, Balanced FFE sequences for angio and cardiac function studies and the latest version of MobiTrak with its enhanced capabilities that have resulted in significant improvements to their peripheral angio imaging. Occluded right ICA Post by-pass noncontrast MRA shows complete occlusion of the ICA on the right side with parotid artery graft. Image also shows excellent patency of parotid graft (arrows) with normal Circle of Willis. 26 FieldStrength Issue 40 May 2010
Smoother, easier workflow Dr. Tummala has found that workflow has improved dramatically since the upgrade with a 25% increase in throughput due not only to increases in scanning speed, but also to the availability of powerful new tools such as SmartExam and ExamCards and to the new ViewForum workstation. With SmartExam we find that our work is so much easier than before. We now use it in around 50% of our examinations and really appreciate the excellent reproducibility it provides, he explains. I believe that SmartExam and ExamCards are particularly valuable for developing countries like India where technologists don t always have sufficient training to handle the high-end applications. For every clinical problem, we stick to some basic tailor-made ExamCards, so that even an average technologist can perform the scan quickly addressing most of the problems even in the absence of the radiologist. The ViewForum workstation offers major benefits in allowing processing off-line, freeing up the scanner and leading to further increase in patient throughput. With the exception of hardcopy printing, which I must say I found quite flexible on the EasyVision station, I think the ViewForum workstation is excellent. We do all our postprocessing on it, as well CD or DVD writing and onscreen reporting. And we can send the reports directly from the workstation to the patients physicians. Tuberculous spondylytis T2-weighted STIR image with MobiView covering the entire spine of a patient with tuberculous spondylytis. Image shows involvement of D7, 8 and 9 vertebras with subligamentous abscess anteriorly. Scan duration 5.25 min. With SmartExam we find that our work is so much easier than before. Growing reputation for high-quality MRI Since the upgrade, the hospital has seen a marked increase in MRI referrals, especially for oncological, whole-spine, breast and spectroscopy examinations. Moreover, because of its new growing reputation for high-quality MRI, the hospital is also seeing an increase in referrals for other imaging modalities, particularly CT and ultrasound. There s no question that this was a very worthwhile upgrade which has brought our 10-year-old system right up to date, concludes Dr. Tummala. It s resulted in a significant reduction not only in scan time but also in interpretation time thanks to the greater diagnostic confidence we now have due to the enhanced lesion visualization. FieldStrength 27