Section outline

  • Dr. Narenda Shet  Dr. Narendra Shet

    Welcome to the exciting world of Body MR! This rapidly evolving field can seem daunting at times but has a plethora of applications in kids and is particularly appealing since MR is radiation-free. For example, we can use dynamic MR to perform multiphase evaluation of a lesion, to know whether it enhances in the arterial, portal venous, and/or late phases; multiphase CT, while sometimes used in the adult population, carries a lot of potential risks to the developing pediatric body. We can use MR to evaluate for a wide variety of structures and organ systems; for example, we can use MR to evaluate pediatric abdominal masses, but we can also use MR in the acute setting to assess for appendicitis or osteomyelitis. We can optimize MR to evaluate structures that might have poor intrinsic signal on MR, such as by filling the bowel with fluid during MR enterography in order to get rid of air signal and better visualize mural architecture and enhancement. 

    While there are quite a few things to be learned on the MR rotation, the overarching goals are to:

    1. Be a consultant for referring clinicians and direct them toward the right test (and right modality – sometimes MR is not the best choice!)
    2. Learn the basics of MR physics and sequences, and choose the right protocol for an exam
    3. Understand normal and abnormal appearances of structures on MR, depending on the sequence
    4. Create accurate and succinct reports for clinicians, using Powerscribe templates as a basic framework

    It may be difficult to achieve goals #1-3 for rotating residents due to limited time on the MR service, but we will do our best to introduce you to pediatric body MR and spark your interest in spending more time with us! Since fellows have a more longitudinal experience on the service, the following goals/objectives are expected to be achieved at various timepoints.

    Quarterly Goals/Objectives:

    July-September:

      • Develop understanding of workflow on CT/MR rotation – what studies are to be read
      • Learn how to protocol in Radnet with supervision, including how to order contrast
      • Learn basic protocol options for commonly encountered body MR studies (e.g., MR enterography)
      • Learn how to open MR study in PACS, including various series
        • Contact IT if you would like assistance in adjusting your hanging protocols
      • Go over what to look for when doing QA for a study
      • Know the MR appearance of various normal organs on common pulse sequences such as T2 and know the classic appearance of acute abnormalities such as appendicitis
      • Draft reports for MR studies using Powerscribe templates

    October-December:

      • Protocol studies in Radnet, at the start of the workday and when contacted by MR technologists
        • With guidance from your attending, know when to select gadolinium-based contrast agents other than Dotarem
      • Select protocols for commonly encountered body MR studies (e.g., MR enterography) in Radnet
      • Perform study QA for common body MR studies when contacted by MR technologists, with attending guidance
      • Know the MR appearance of various normal organs on common pulse sequences such as T2 and characterize acute and non-acute abnormalities
      • Draft reports for MR studies using Powerscribe templates; be sure to include correct sequences used (these may differ from template)

    January-March:

      • Protocol studies in Radnet, at the start of the workday and when contacted by MR technologists
      • Select protocols in Radnet for commonly and uncommonly encountered body MR studies
      • Perform study QA for common and uncommon body MR studies when contacted by MR technologists, with decreasing attending guidance (if OK’d with your attending, can perform QA independently, but attending should notify technologist that fellow QA is acceptable, to avoid confusion)
      • Know the MR appearance of various normal organs on common pulse sequences such as T2 and characterize acute and non-acute abnormalities
      • Review uncommon body MR studies such as whole-body MRI
      • Draft reports for MR studies using Powerscribe templates; be sure to include correct sequences used (these may differ from template)

    April-June:

      • Protocol studies in Radnet, at the start of the workday and when contacted by MR technologists
      • Select protocols in Radnet for all body MR studies
      • Perform study QA for common and uncommon body MR studies when contacted by MR technologists, with little attending guidance
      • Know the MR appearance of various normal organs on common pulse sequences such as T2 and characterize acute and non-acute abnormalities
      • Review any body MR studies encountered while on service
      • Draft reports for MR studies using Powerscribe templates; be sure to include correct sequences used (these may differ from template)

    Resources:

    Cases:

    a. In PACS, under username nshet, cases under Teaching Cases/Body MR

    Textbooks:

    a. The Physics of Clinical MR Taught Through Images – Runge, Nitz, Schmeets (2005)

    b. Pediatric Body MRI: A Comprehensive, Multidisciplinary Guide – Lee, Liszewski, Gee, Daltro, Restrepo (2020)

    · If you have access, use this resource; however, the field is so quickly developing that articles are often the most up to date and accurate for clinical practice.

    Articles:

    a. MR Physics, Sequences, and Techniques: ·

    Moore MM, Chung T. Review of key concepts in magnetic resonance physics (2017)

    Jo S et al. Musculoskeletal MRI Pulse Sequences: A Review for Residents and Fellows (2019)

    Jaimes C et al. Fast, free-breathing and motion-minimized techniques for pediatric body magnetic resonance imaging (2018)

    Kozak BM et al. MRI Techniques to Decrease Imaging Times in Children (2020)

    b. MR Contrast: ·

    Ayyala RS et al. Intravenous gadolinium-based hepatocyte-specific contrast agents (HSCAs) for contrast-enhanced liver magnetic resonance imaging in pediatric patients: what the radiologist should know (2019) ·

    Blumfeld et al. Gadolinium-based contrast agents — review of recent literature on magnetic resonance imaging signal intensity changes and tissue deposits, with emphasis on pediatric patients (2019) ·

    Farmakis SG et al. Safety of gadoterate meglumine in children younger than 2 years of age · Ponratana S et al. Safety issues related to intravenous contrast agent use in magnetic resonance imaging (2021)

    c. MR Findings/Interpretation: ·

    Moore MM et al. MRI for Clinically Suspected Pediatric Appendicitis: Case Interpretation (2014) ·

    Mollard BJ et al. Pediatric MR Enterography: Technique and Approach to Interpretation--How We Do It (2015)

    Chan, BY et al. MR Imaging of Pediatric Bone Marrow (2016) ·

    Navarro OM et al. Pediatric Soft Tissue Tumors and Pseudotumors: MR Imaging Features with Pathologic Correlation. Part 1. Imaging Approach, Pseudotumors, Vascular Lesions, and Adipocytic Tumors (2009) ·

    Pediatric Soft Tissue Tumors and Pseudotumors: MR Imaging Features with Pathologic Correlation. Part 2.  Tumors of Fibroblastic/Myofibroblastic, So-called Fibrohistiocytic, Muscular, Lymphomatous, Neurogenic, Hair Matrix, and Uncertain Origin (2009) ·

    Shet NS et al. Use of Eovist in Pediatric Patients: Pearls and Pitfalls (2020) ·

    Dickerson EC et al. Pediatric MR Urography: Indications, Techniques, and Approach to Review (2015) ·

    Gottumukkala RV et al. Current and Emerging Roles of Whole-Body MRI in Evaluation of Pediatric Cancer Patients (2019) ·

    Acharya PT et al. Pediatric Mediastinal Masses: Role of MR Imaging as a Problem-Solving Tool (2019)

    d. MR Safety/Quality · Artunduaga M et al. Safety challenges related to the use of sedation and general anesthesia in pediatric patients undergoing magnetic resonance imaging examinations (2021)