Cardiac MRI basics

Amy Fiona Suresh Kumar

MSc. CIET, AIIMS New Delhi
Class Outline
• MRI basics
• Generation of MR signal
• Challenges in Cardiac Imaging
• Patient Preparation
• Cardiac MR protocol
• ECG gated acquisition
• Planning views in Cardiac Imaging
Magnetic
Magnets
MRI basics
• MR active nuclei that have a net charge and are also spinning in
motion, automatically acquires a magnetic moment and can align
with external magnetic field
• The isotope of the Hydrogen nucleus called Protium is the MR active
nucleus used in clinical MRI
Why only Hydrogen?
1. Hydrogen is very abundant in the human body
2. Solitary proton gives a relatively large magnetic moment
Precession
• Each Hydrogen atom is spinning in its own axis
• The influence of B₀ produces an additional wobble/spin
• This secondary spin is called Precession and causes the
magnetic moments to follow the circular path around it
• This path is called the Precessional path and the speed at
which the NMV wobbles is called the Precessional
frequency (MHz)
Larmor Equation
• The value of the Precessional frequency is given by the Larmor
equation
• The Larmor equation states that:

• The gyromagnetic ratio of Hydrogen is 42.57 MHz

Alignment and NMV
• When patient is not under the magnetic field, nuclei spin randomly
• When Magnetic field is applied, lower energy protons align parallel to
the magnetic field whereas higher energy protons align anti parallel
to magnetic field
Resonance
Resonance
• Resonance occurs when an object is exposed to an oscillating
perturbation that has a frequency close to its own natural frequency
of oscillation
• The nucleus gains energy from the external force and resonates
• If any other frequency is given, resonance does not occur
• The application of an RF pulse that causes Resonance to occur is
called ‘Excitation’
Flip angle
• Flip angle: The angle at which the NMV moves out of alignment on
the application of an RF pulse
• The magnitude of Flip angle depends upon the amplitude and
duration of the RF pulse applied
Phase

• Phase is the position of each magnetic moment on the precessional

path around B₀
• Magnetic moments that are in phase (coherent) are in the same place
on the Precessional path around B₀
• Magnetic moments that are out of phase (incoherent) are not in the
same place on the Precessional path around B₀
• When resonance occurs, all the magnetic moments move to the same
precessional path and are in phase
Imaging
The MR signal
• Faraday’s law of Electromagnetic induction: states that if a receiver coil or
any conductive loop is placed in an area of a moving magnetic field i.e
the magnetization precessing in the Transverse plane, a voltage is
induced in the receiver coil
• The MR signal is produced when the coherent (in phase)
magnetization cuts across the coil
• Moving transverse magnetization produces magnetic field
fluctuations induce an electrical voltage in the coil
• This voltage constitutes the MR signal
• The frequency of the signal is the Larmor frequency and the
magnitude of the signal depends upon the amount of magnetization
present in the Transverse plane
Free Induction Decay (FID)
• When the RF pulse is switched off, the NMV is again influenced by B₀
and it tries to realign with it
• To do so, the Hydrogen nucleus must lose the energy given to it by
the RF pulse
• The process by which it loses this energy is called Relaxation
• As a result, amount of magnetization in the longitudinal plane
increases (T1 recovery) and amount of magnetization in the
transverse plane decreases (T2 decay)
• The induction of reduced signal is called Free Induction Decay
FID
Magnitude of Transverse
magnetization decreases

Magnitude of voltage
induced in the receiver coil
decreases

Resulting signal: FID, a

dampened sine wave
T1 Recovery

• T1 recovery is caused by the nuclei

giving up their energy to the
surrounding environment or lattice,
and it is termed spin-lattice
relaxation
• Recovery of magnetization on in the
longitudinal plane
• The rate of recovery is an exponential
process, with a recovery time
constant called the T1 relaxation time
• This is the time it takes 63% of the
longitudinal magnetization to recover
in the tissue
T2 decay
• T2 decay is caused by the magnetic
fields of neighbouring nuclei
interacting with each other hence
termed spin-spin relaxation
• Decay or loss of magnetization in
the transverse plane
• The rate of decay is also an
exponential process, so that the T2
relaxation time of a tissue is its time
constant of decay.
• It is the time it takes 63% of the
transverse magnetization to be lost
(37% remains)
Pulse Timing Parameters
• The magnitude and timing of the RF pulses form part of pulse
sequences, which are the basis of contrast generation in MRI.
• A simple pulse sequence is a combination of RF pulses, signals and
intervening periods of recovery
• TR = Time of repetition
Time from the application of first RF pulse to the application of next
RF pulse.
• TE= Time of Echo
From the application of first RF pulse to the peak of signal received
Cardiac MRI
Challenges in Cardiac Imaging
• Imaging a dynamic organ: Breathing and cardiac motion make
evaluation difficult
• No T1/T2 weighted sequences as in conventional studies: Instead Spin
Echo, Gradient Echo and their variations
• No Axial/Coronal/Transverse scanning: Instead Cardiac planes such as
four-chamber(4C), two-chamber(2C), short axis (SAX), LVOT stc
• Different protocols for different pathologies: Study needs to be
tailored to the clinical question, to ensure optimal scan times
Clinical Indications
• For the assessment of heart failure
• Assessment of right and left ventricular function and size with
precise quantification
• Determination of aetiology - ischemic vs. non-ischemic
cardiomyopathy
• Vasospasm
• For the evaluation of ischaemic heart disease
• Viability assessment prior to treatment (e.g. revascularisation)
• Assessment of location and extent of infarct
• For the assessment of cardiac masses
• For the characterisation, extent and invasion of masses
• For the assessment of pericardial disease
• Constrictive pericarditis
• Pericardial effusion
• For the assessment of cardiomyopathies
• Arrhythmogenic right ventricular cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathies
• Dilated cardiomyopathy
• Myocarditis
• For the assessment of valvular disease
• Detection, quantification, serial effect on ventricular function
• Valve masses
• For the assessment of congenital heart disease
• Intracardiac shunts with shunt fraction quantification
• Coronary artery origin evaluation for anomalies
• Cardiac and great vessel morphology
• Diagnosis and treatment monitoring
• For the assessment of aorta and great vessels diseases
• Intramural haematoma
• Aortic aneurysm
• Aortic dissection
• For the assessment of myocardial infarction complications
• For the assessment of ventricular function
• For the assessment of atrial arrhythmias
• For anomalous coronary arteries
• Thrombus formation
• Aneurysms
Patient Preparation
• A satisfactory written consent form must be taken from the patient
before entering the scanner room
• Ask the patient to remove all metal objects including keys, coins,
wallet, cards with magnetic strips, jewellery, hearing aid and hairpins
• Ask the patient to undress and change into a hospital gown
• Instruct the patient to hold their breath for the breath hold scans and
breathe gently for the gated scans (its advisable to coach the patient
two to three times before starting the scan)
• Request the patient to use the rest room before procedure
• If the chest is covered with hair it is necessary to shave the required
area before placing the ECG electrodes
• Thoroughly clean the ECG contact area with an abrasive gel
• Claustrophobic patients may be accompanied into the scanner room
e.g. by staff member or relative with proper safety screening
• Offer headphones for communicating with the patient and ear
protection
• Explain the procedure to the patient and answer questions
• Note the height & weight of the patient
Patient positioning
Routine Sequences
1. TRUFI LOCALIZER 11. TSE_T1 SA 21. PSIR MOCO LGE SA
2. TRUFI 2 CHAMBER 12. TSE_T2 SA 22. PSIR MOCO LGE 2CH
3. TRUFI 4 CHAMBER 13. T1MAP_LONGT1 SA 23. PSIR MOCO LGE 4CH
14. T2MAP_SA 24. T1 MAP (POST CONTRAST)
4. TRUFI SA
15. DYNAMIC_ TRUFI (2CH AT 10 MIN
5. TRUFI 2 CHAMBER_T 25. PSIR MOCO FW
4CH SA)
6. TRUFI 4 CHAMBER_T 16. T1 VIBE 26. PSIR MOCO DB
7. TRUFI SA_T 17. TI- SCOUT SA (AT 5MIN)
8. CINE 2CH 18. PSIR LGE 2CH
9. CINE 4CH 19. PSIR LGE 4CH
10. CINE SA 20. PSIR LGE SA
Data acquisition
• Segmented Imaging: Data obtained over multiple heart beats.
• This is the most commonest method of scanning. This allows for
evaluation of cardiac function
• Single shot imaging: Data obtained over single heart beat. This is
mainly used with real-time acquisition. MRI sequences generate
enough data to produce single image with just one excitation
ECG gating
• Retrospective triggering: (Used routinely)
• Data is acquired over multiple cardiac phases and then interpolated, It
acquires the whole cardiac cycle asynchronous to the patient’s R-R interval
• The data is then reconstructed and sorted into different cardiac phases after
acquisition
• Prospective triggering:
• Especially useful with high and irregular heart rate
• Fixed acquisition duration
• Misses end-diastole
• Functional evaluation not possible
• Real time-subset of Prospective triggered Cine. Instead of segmented
acquisition, each frame is acquired as a single shot
• Low spatial and temporal resolution
• No breath-hold required, faster scan
ECG gating summary

Retrospective Prospective
• Acquisition throughout cardiac • Acquisition only at selected
cycle phase of cardiac cycle
• Functional evaluation can be • Functional evaluation cannot be
performed performed
• Routinely used for Cine Images • To be used in arrhythmia where
R-R interval is variable
Views in Cardiac Imaging

2 Chamber 4 Chamber Short Axis

Additional views

LVOT
RVOT
Localiser
• An initial three-plane SSFP (TrueFISP, B-FFE, or FIESTA) localizer scan is
required for localization and sequence planning.
• These fast single-shot localizers have an acquisition time of under 25
seconds, making them excellent for localizing chest structures.
Localiser planning
• Plan the axial localizer on the coronal plane and position the block so
as to cover the entire heart from the aortic arch to the diaphragm
(usually 3-4 slices)
• Plan the sagittal localizer on the coronal plane and position the block
parallel to the chest so as to encompass the entire heart from right to
left (usually 3-4 slices)
• Plan the coronal localizer on the axial plane and position the block
across the chest as indicated. The slices must encompass the entire
heart from the sternum to the thoracic aorta (usually 3-4 slices).
• Confirm the position in the other two planes
2 Chamber localiser planning
Short Axis localiser
4 Chamber localiser
2 Chamber Cine
4 Chamber
Short Axis Cine
LVOT Cine
RVOT Cine
Gadolinium Enhanced Imaging
• Predominantly done for myocardial tissue characterisation, mass
differentiation
• Gadolinium injection (0.1-0.2 mmol/kg) is administered and after 10
mins, images are obtained using same views (SA/2C/4C)
• This is mainly done on using PSIR (Phase Sensitive Inversion Recovery)
sequences
• Very important to obtain adequate nulling of the myocardium
TI scout
• The TI scout is a segmented K-space inversion recovery gradient echo pulse
sequence obtained over 2-3 heartbeats, each segment representing a
different TI value.
• The optimal TI value is crucial for nullifying normal myocardium signal
intensity in images. Typically, TI values range from 185 to 515 ms, assessed
by radiographers.
• We must ensure that the signal intensity of normal myocardium is nearly
null and the left ventricular cavity's signal intensity is lower than the
infarcted region.
• Incorrect selection of the optimal null time can result in lower contrast and
may reduce the visibility of the hyper-enhanced area, leading to an
underestimation of the extent of infarction
TI scout
Determining the correct TI
PSIR sequences
• The PSIR Sequence is a 2D single-shot steady-state free precession
(SSFP) image with phase-sensitive inversion recovery preparation.
• An appropriate TI value, chosen from the look locker, should be used
to nullify the normal myocardium (usually 250-330 ms).
• Gadolinium washes in and out of the normal myocardium in a matter
of minutes.
• The areas of delayed enhancement in the image indicate infarction or
inflammation.
PSIR
STIR Imaging
• The STIR sequence is sensitive to increased myocardial water content,
allowing delineation of myocardial edema
• This is useful in myocardial ischaemia, myocarditis and trauma,
though T2 mapping is now considered a better alternative to STIR
imaging
Parametric Imaging
• T1 mapping: Mapping the T1 value
of the myocardium
• Increased in fibrosis/infiltration and
decreased with fat deposition and iron-
overload
• Native T1 mapping is obtained prior to
contrast administration and for ECV
measurement, post T1 mapping is done
• T2 mapping: Mapping the T2 value
of the myocardium
• Increased in Edema
Thankyou :)
Bibliography and further reading
• https://mrimaster.com/plan-cardic/
• https://radiologykey.com/the-fundamentals-of-cardiovascular-
magnetic-resonance/
• https://ajronline.org/doi/10.2214/AJR.10.7231