Magnetom flash 45

MAGNETOM Flash
The Magazine of MR

Issue Number 3/2010
RSNA Edition

Clinical
Tumor staging in case
of Wilms tumor
Page 6

syngo SWI case reports
Page 18

Neurography
Page 26

Spine and tumor
imaging at 3T
Page 48

How I do it
Whole spine imaging
Page 30

Liver imaging with
dynaVIBE
Page 66

Editorial

Matthias Lichy, M.D.

Dear MAGNETOM user,
Each new technology, evolution or revolution A few years ago this was simply not possible
to existing ones, changes the way how we because of limitations in coil and MR
deliver healthcare to our patients. Good sequence technology.
examples how MRI in combination with latest Taking into account the life cycle of a typical
advantages in coil technology and image MR scanner and the fast progress of MR tech-
sequences can deliver all required clinical nology and its clinical applications, Siemens
information at highest quality and replace MR is committed to offering access to the
and / or complement existing imaging in a latest developments e.g. by system upgrades.
meaningful way can be found in this issue of You will therefore find in this issue informa-
MAGNETOM Flash. tion on liver imaging with software version
The impact of higher field-strength and open- syngo MR B17 or an article on how to use the
bore technology can be seen in the articles Tim Planning Suite for performing whole-
by Weber et al. (Heidelberg University) deal- spine examinations on your system.
ing with complex pathologies of the spine
and with young patients, exemplary cases MAGNETOM Flash and additional, clinically
show how the latest 3T MR technology adds relevant information is available online at
important clinical information and how this www.siemens.com/magnetom-world.
also increases the confidence in treatment
decision of the referring physicians. Enjoy reading this issue of MAGNETOM Flash!
Another good example can be found in the
case report by Schneider et al. (Homburg
University): whole-body imaging for tumor
staging in pediatrics with diffusion-weighted
imaging is now reality in clinical routine. Matthias Lichy, M.D.

2 MAGNETOM Flash · 3/2010 · www.siemens.com/magnetom-world

Editorial

The Editorial Team
We appreciate your comments.
Please contact us at magnetomworld.med@siemens.com

Antje Hellwich Okan Ekinci, M.D. Peter Kreisler, Ph.D. Heike Weh,
Associate Editor Center of Clinical Competence – Collaborations & Applications, Clinical Data Manager,
Cardiology, Erlangen, Germany Erlangen, Germany Erlangen, Germany

Bernhard Baden, Ignacio Vallines, Ph.D., Wellesley Were Milind Dhamankar, M.D.
Clinical Data Manager, Applications Manager, MR Business Development Sr. Director, MR Product
Erlangen, Germany Erlangen, Germany Manager Marketing, Malvern, USA
Australia and New Zealand

Michelle Kessler, US Gary R. McNeal, MS (BME) Dr. Sunil Kumar S.L.
Installed Base Manager, Advanced Application Specialist, Senior Manager Applications,
Malvern, PA, USA Cardiovascular MR Imaging Canada
Hoffman Estates, USA

MAGNETOM Flash · 3/2010 · www.siemens.com/magnetom-world 3

Content Content

Content 6
Tumor Staging
18
syngo SWI Case Reports
30 30
xxxxxSAR in pTx Spine Imaging
Full
48
MSK Imaging at 3T

Further clinical information Clinical Clinical Technology Product News
Visit the MAGNETOM
Pediatric Imaging Orthopedic Imaging 60 Image Quality Improvement 76 VIBE for Liver Imaging
of Composed MR Images by with syngo MR B17
World Internet pages at 6 MR Tumor Staging for Treatment 26 3T MR Imaging of Peripheral Applying a Modiﬁed Homomor- Agus Priatna,
www.siemens.com/ Decision in case of Wilms Tumor Nerves Using 3D Diffusion- phic Filter Stephan Kannengiesser
magnetom-world G. Schneider, P. Fries Weighted PSIF Technique
for further clinical Vladimir Jellus, et al.
12 Cerebral Arterio-Venous Malforma- Avneesh Chhabra, et al.
information and talks
tion detected by syngo TWIST MRA 30 How I do it: Full Spine Imaging
by international
experts. Ali Yusuf Oner, et al. utilizing the Tim User Interface
Clinical
James Hancock Abdomen / Pelvis
Clinical 38 How I do it: Knee Imaging with 66 Value of Automated Retrospective
Neurology 4-Channel Flex Coils. The Influence
of Patient Positioning and Coil
Correction of Contrast-Enhanced
Dynamic Liver MRI. Initial Clinical
14 Case Report: Imaging of Cerebral Selection on Image Quality Experience
Amyloid Angiopathy (CAA) using Birgit Hasselberg, Marion Hellinger H.-P. Schlemmer, et al.
Susceptibility-Weighted Imaging
43 Case Report: Knee MR Imaging 71 How I do it: Non Rigid 3D-Regis-
(syngo SWI)
of Haemarthrosis in a Case of tration for Accurate Subtraction
Markus Lentschig
Haemophilia A of Dynamic Liver Images for
18 Case Report: Susceptibility-Weighted M. A. Weber; J. K. Kloth Improved Visualization of Liver
Imaging (syngo SWI) at 3T Lesions with syngo dynaVIBE
Kate Negus, Peter Brotchie 48 Advantages of MSK Imaging Matthias P. Lichy, et al.
at 3 Tesla with special focus
on Spine and Tumor Imaging
Marc-André Weber

The information presented in MAGNETOM Flash is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine.
Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This
material does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard. The treating physician bears the sole
responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly
followed when operating the MR System. The source for the technical data is the corresponding data sheets.

4 MAGNETOM Flash · 3/2010 · www.siemens.com/magnetom-world MAGNETOM Flash · 3/2010 · www.siemens.com/magnetom-world 5

Clinical Pediatric Imaging Pediatric Imaging Clinical

MR Tumor Staging for 1A 1B

Treatment Decision in Case
of Wilms Tumor
G. Schneider, M.D., Ph.D.; P. Fries, M.D.

Dept. of Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg/Saar, Germany

1C 1D

Introduction Patient history
Nephroblastoma – also known as Wilms
tumor – is the most frequent renal
Europe or COG (Children’s Oncology
Group) in North America. Therapy
A 4-year-old girl presented with a large
palpable mass in the left upper quadrant
*
malignancy in childhood with the high- includes primary surgery (COG), pre- and unspecific abdominal pain. Ultra-
est incidence of this tumor within the
fourth year of life. 80% of patients are
operative chemotherapy (SIOP), and/or
adjuvant chemotherapy. If not treated,
sound had already revealed a large
tumor of the left hemiabdomen with
+
less than 5 years old, however it is a rare prognosis of a Wilms tumor is poor. mass effect towards the liver. The
condition in neonates (<1%). Independent of prognostic factors such patient was referred to our MRI depart-
In general, there are no known risk fac- as stage and grading, the overall out- ment because of suspicion of Wilms
tors for the development of nephroblas- come is good and approximately 90% of tumor.
toma, but it may be associated with rare all children will be cured.
conditions like Denys-Drash (triad of Questions for imaging are: a) supporting MRI protocol
congenital nephropathy, Wilms tumor the suspicion of a Wilms tumor for initia- MRI was conducted using a 1.5 Tesla
and intersex disorders), WAGR (also tion of therapy, b) evaluation of tumor MAGNETOM Aera with the combination 1E 1 Transversal high-resolution T2w images showing the
called Wilms tumor-aniridia syndrome) volume, c) contralateral tumor manifes- of the 18-channel body coil and the inte- Wilms tumor (*) and multiple lung metastases (arrows).
and Beckwidth-Wiedeman (giantism tation and d) lymph nodes metastasis grated spine coil. For the MRI procedure Due to the space occupying aspect of the large tumor, the
associated with tumors and malforma- or infiltration of neighboring structures the patient received an intravenous residual kidney is swollen (+) and also slight edema of the
tions) syndrome. The incidence is
approx. 1: 100,000 for western coun-
e.g. diaphragm or liver.
Tumor staging has to include at least the
sedation using propofol. The imaging
protocol included diffusion-weighted
* liver hilum can be seen (arrowheads).

tries including the US, while a lower whole abdomen and thorax (lung filiae imaging (DWI, syngo REVEAL), acquired
incidence is reported for Asian countries. are the most common presentation of during free breathing, and transversal
If not associated with a syndrome, clini- metastatic disease). Imaging modalities T2w TSE and HASTE sequences with
cal symptoms – if present at all – are used are ultrasound, MRI, and CT in case navigator triggering.
very often unspecific and abdominal of lung metastases. Depending on final A single-shot echo planar diffusion
pain and palpable tumor can be the only tumor histology, a bone (often scinti- imaging with Stejskal-Tanner diffusion
findings at the time of diagnosis. gram) and brain MRI scan have to be encoding scheme was applied. For
MRI is considered the imaging modality performed in case of CCSK (clear cell sar- fat saturation, an inversion recovery
of choice for tumor staging and subse- coma) and RTK (rhabdoid tumor of the technique was used. The sequence
quent treatment planning. If imaging is kidney), too. MRI is recommended inde- parameters were:
conclusive, often no biopsy is performed pendent of the above-mentioned reasons
prior to initiation of therapy. Clinical in any case where a) a caval vein tumor
treatment is according to protocols of thrombus, b) infiltration of liver and dia-
SIOP (Society of Pediatric Oncology) in phragm, or c) continuous tumor exten-
sion into the thoraxic cavity is suspected.
Continued on page 10



2 5A 5B

2 Rotating MIP based on high b-value images.
5C 5D

3A 3B 3C 3D

3E 3F 3G

5E 5F

3 (A) Coronal DWI MIP. Original b-value images at 0 and 800 s/mm2 (B, C and E, F) as well as calculated b-value at b 1400 s/mm2 (D, G) are
shown. (Arrows pointing to lung metastases.)

4A 4B

*

* *
5 Based on ADC maps and high b-value images (b 1400 s/mm2 is shown), a clear differentiation between residual but swollen kidney
4 Calculated ADC map (A) and corresponding T2w image (B) demonstrating the tumor heterogeneity. The area marked by the arrows has a clear tissue (arrows) and the Wilms tumor (arrowhead) is possible. Both types of tissue differ in their cellular density, however, on T2w images
restriction in diffusibility but based on T2w imaging alone, no differentiation between this area and the one marked with * is possible. While the no clear differentiation is possible in this case (compare Fig. 1). Nevertheless, not all areas of the tumor are characterized by high signal
high signal area on T2w and high ADC values may represent cysts or calceal dilation, the area with the high restriction of diffusion represents a on the very high b-value images, demonstrating well the tumor heterogeneity. (A, B) ADC maps. (C, D, E) b 1400 s/mm2 images. (F) Coro-
very densely packed areal e.g. mucous tumor cells. nal thick-slice MPR based on b 1400 s/mm2 images (* spleen).



6A 6B 7A 7B
7 Follow-up
examination with
CT (A) still showing
a small residual
lung metastasis
(arrow), which can
also be visualized
by MRI (B). The
main tumor is also
clearly reduced
in its mass after
first cycle of
chemotherapy
(C–F) in caudo-
cranial sorting.

7C 7D

6 Corresponding images of the initial ultrasound examination of the Wilms tumor in sagittal (A) and transversal (B) orientation are shown.

Continued from page 6

Imaging ﬁndings
TR 15400 ms, TE 75 ms, TI 180 ms, PAT A large occupying tumor deriving from displaced spleen is also within normal
factor of 2, 3-scan trace (averaged), FOV the lower pole of the left kidney with age-related range.
309 x 380, matrix 208 x 128 (interpo- compression of the residual kidney and On a follow-up study after chemotherapy
lated to 208 x 256), slice thickness 5 mm, mass effect towards the liver and espe- and before surgery a tremendous reduc- 7E 7F
no gap, 4 averages. Real voxel size was cially the left liver lobe is shown. Due to tion of tumor size can be noticed. Only
1.5 x 3 x 5 mm3. Two b-values at b 0 and the mass effect, slight edema of the liver small residual tumor tissue of one lung
b 800 s/mm2 were acquired. ADC maps hilus can be seen. However, the border metastases is visible on CT and MRI.
and additional high b-value images at of the mass is well circumscribed and no
b 1400 s/mm2 were calculated auto- evidence of diffuse tumor infiltration of Conclusion
matically by the scanner software, based the liver, spleen or diaphragm can be Whole-body imaging in staging of Wilms
on linear signal decay. DWI covered the seen. Since no encasement of retroperi- tumor can replace CT imaging and gives
whole body trunk from skull base toneal vessels or other structures is seen all necessary information for therapy
towards upper lower extremities. Acqui- DD of neuroblastoma can be ruled out. planning. With the help of newer imag-
sition time was approx. 15 min. For pre- Also the lumen of the abdominal aorta is ing modalities in MRI, especially DWI,
sentation and fast overview about tumor regular and neither a tumor infiltration the prediction of tumor response needs
spread, a rotating maximum intensity of the large vessels nor a tumor-throm- to be evaluated. This can easily be done
projection (MIP) based on b 800 s/mm2 bus can be visualized. The right kidney by correlating histological data with
was generated. and the other abdominal organs are free imaging data from patients enrolled in
For detailed morphology and assess- of metastases. However, already well prospective clinical trials. As preopera-
ment of tumor infiltration, navigator visualized by the MIP DWI, a large tumor tive chemotherapy is only part of the
triggered T2w TSE was applied for the mass at the right lung hilum can be seen SIOP studies such investigations can pre- References
Contact
1 Kaste, S.C., Dome, J.S., Babyn, P.S., Graf, N.M.,
abdomen including the lower thorax and with compression of central lung struc- dominantly be performed in Europe. PD Dr. Dr. Günther Schneider
Grundy, P., Godzinski, J., Levitt, G.A., Jenkinson,
mediastinum. Sequence parameters were tures and edema of the depending lung H. 2008 Wilms tumour: Prognostic factors, stag-
Dept. of Diagnostic and Interventional
TR 3508 ms, TE 102 ms, 2 averages. tissue. In addition, at least four addi- Radiology
ing, therapy and late effects Pediatric Radiology
Saarland University Hospital
PAT factor 2, FOV 188 x 250 mm2, matrix tional lung metastases are detected. 38 (1), pp. 2-17.
Kirrberger Strasse
269 x 512, slice thickness 6 mm, 20% No evidence for bone metastases. The 2 Graf, N., Tournade, M.-F., De Kraker, J. 2000 The
66421 Homburg/Saar
role of preoperative chemotherapy in the manage-
gap, acquisition time was approx. 8 min. bright signal of the bone marrow on Germany
ment of Wilms’ tumor: The SIOP studies. Urologic
high b-value images has to be con- dr.guenther.schneider@uks.eu
Clinics of North America 27 (3), pp. 443-454.
sidered as age related. The size of the



Cerebral Arterio-Venous 1A 1B

Malformation detected
by syngo TWIST MRA
Ali Yusuf Oner; Turgut Tali; Nil Tokgoz

Gazi University, School of Medicine, Department of Radiology, Ankara, Turkey

Patient history Sequence details Conclusion
A 17-year-old patient suffering from All images were acquired using a 3T Anomalies of neuronal migration and
untractable epilepsy was referred to our MAGNETOM Verio with software version vascular malformations are two impor-
institution for imaging evaluation. He syngo MR B17 and the standard head tant and relatively frequent causes of 1 T2-weighted image in the axial plane (A) and inverted STIR image (B) in the coronal plane show right parietal polymicrogyric cortex (arrows)
underwent an initial brain MRI on a 3T matrix coil. epilepsy. However their coexistence, as with indistinct gray-white matter interface. Note the small vascular flow voids, raising suspicion of a possible accompanying AVM arrowhead.
MAGNETOM Verio, which showed a right in the presented case, is less usual.
parietal polymicrogyric focus with a Axial TSE T2W: TR 4000 ms, TE 107 ms, Although their diagnosis is straight
suspected neighboring arterio-venous FOV 220 x 220 mm2, matrix 410 x 512, forward by MRI and TOF MRA, 4D MRA
2 3
malformation (AVM) not readily depicted 2 averages, iPAT factor of 2, slice thick- techniques following contrast injection
by time-of-flight (TOF) MR angiography ness 5 mm, gap 1.5 mm. such as syngo TWIST can be the
(MRA). A second contrast enhanced problem-solving tool in cases with low
syngo TWIST MRA succesfully showed Coronal T2W TIRM: TR 9000 ms, flow AVM’s.
the AVM nidus and the patient was TE 94 ms, FOV 200 x 220 mm2, matrix
referred for stereotactic radiosurgery. 232 x 256, 1 average, iPAT factor of 2,
slice thickness 5 mm, gap 2 mm.
Imaging ﬁndings
T2-weighted turbo spin-echo (TSE) 3D TOF MRA: TR 21 ms, TE 3.60 ms,
images in the axial plane and coronal FOV 181 x 200 mm2, matrix 331 x 384,
Contact
TIRM images show right pariteal shallow 1 average, iPAT factor of 2. Ali Yusuf Oner, M.D.
sulci, with indistinct gray-white matter Gazi University
interface, lined by polymicrogyric cortex syngo TWIST MRA: TR 2.79 ms, School of Medicine
(Fig. 1). On the T2-weighted images TE 1.01 ms, FOV 350 x 400 mm2, matrix Department of Radiology
2 Coronal maximum intensity projection (MIP) of a 3D 3 Highly temporal resolved post-contrast 4D MRA in the coronal
Ankara
small vascular flow voids are noted. The 245 x 384, iPAT factor of 2, slice thick- TOF MRA fails to demonstrate the AVM nidus. plane shows a low-flow AVM mostly fed by the anterior arterial
Turkey
AVM nidus goes undetected on a 3D TOF ness 2.5 mm, 25 measurments with a system, with a central drainage (arrows).
Phone: +90 312 202 5163
MRA due to its low flow status (Fig. 2), temporal resolution of 1.09 seconds per yusufoner@gazi.edu.tr
whereas a post-contrast syngo TWIST single slab.
MRA readily shows the AVM nidus fed
by the anterior system, together with
the early central draining veins (Fig. 3).


Clinical Neurology Neurology Clinical

Case Report:
Cerebral Amyloid Angiopathy (CAA) 1A 1B

using Susceptibility-Weighted Imaging
(syngo SWI)
Markus Lentschig

MR, Nuclear Medicine and PET/CT Center Bremen Mitte, Bremen, Germany

Background
With the development of a 3D gradient- technique is available which enables magnitude images and the finally post-
echo (GRE) based susceptibility- either the direct visualization or quanti- processed SWI are available for image
weighted imaging sequence (syngo fication of the amyloid deposits. But as analysis. Also, a thick-slice MPR (multi-
SWI), a neuroimaging MR technique is an indirect sign, typically microhemor- planar reconstruction) which is gener- 1 DarkFluid (FLAIR) images of a patient with cerebral amyloid angiopathy.
now available in clinical routine which rhages within and around the arteriole ated Inline is available.
maximizes tissue magnetic susceptibility vessel wall lobar microbleeds are found DarkFluid (FLAIR): TR 9000 ms, TE 94
and makes use of these differences to and related to CAA. Usually CAA is ms, FOV 230 / 84 %, Matrix 256 / 95 %
generate a unique contrast, different involving the cortex and subcortical (interpolated to 512), SL 5 mm, TA 2:26 2A 2B

from that of proton density, T1, T2, and white matter within the frontal and pari- min:s, voxel size 1.0 x 0.9 x 5 mm
conventional T2* imaging we are used etal lobes. In contrast, hypertensive or
so far in clinical routine. Compared to atherosclerotic microangiopathy shows Imaging ﬁndings
other imaging techniques syngo SWI – a microhemorrhages in a deep or infraten- Multiple T2w hyperintense isolated foci
long TE flow compensated gradient echo torial location. in the periventricular white matter are
imaging providing enhanced contrast shown on DarkFluid (FLAIR) images
with the combination of phase and mag- Sequence details (arrows figure 1A). In addition, dorsal of
nitude information – has already pro- A 68-year-old patient with suspicion of the posterior horn and lateral ventricle
vided superior results in clinical studies TIA (transient ischemic attack) has been converging hyperintense periventricular
in detecting intracranial bleeding but referred to our institution for imaging T2w hyperintense areas are shown,
also in depicting minute intracranial vas- and to rule out further diseases of the which can be interpreted as age-related
cular malformations. brain. All images were acquired at 3 Tesla periventricular gliosis (arrowheads fig-
using a MAGNETOM Verio with the stan- ure 1). However, also in the temporal
Cerebral Amyloid Angiopathy dard 12-channel head coil. Sequence lobe cortical and subcortical T2 hyperin-
Cerebral amyloid angiopathy (CAA) is a parameters for shown images were: tense spots with only slightly increased
small vessel disease which is character- T1 SE: TR 500 ms, TE 8.4 ms, FOV 230, signal can be visualized by DarkFluid
ized by deposition of amyloid protein matrix 256 / 95 % (interpolated to 512), (FLAIR) imaging (arrows figure 1B). In
within the cerebral arterioles. It is known SL 5 mm, TA 1:53 min:s, voxel size 1.0 x addition, there is a widening of the
that there is a clear association of CAA 0.9 x 5 mm internal and external cerebral fluid inter-
with the following aging, dementia, syngo SWI: TR 27 ms, TE 20 ms, FOV spaces. On native T1w MRI, no hyperin-
Alzheimer’s disease, postradiation 230 / 75 %, Matrix 256 / 95 % (interpo- tense signal can be demonstrated; only 2 Corresponding native T1-weighted images.
necrosis, and spongiform encephalo- lated to 512), SL 2.5 mm, TA 2:48 min:s, in the case of the largest periventricular
pathies. But so far, no in vivo imaging voxel size 0.9 x 0.9 x 2,5 mm. Phase and white-matter foci, a corresponding


Clinical Neurology

3A 3B
Try them on your system
Trial licenses for most of the applications featured in this 4
issue of MAGNETOM Flash are available free of charge for a
period of 90 days: Please contact your local Siemens repre-
sentative for system requirements and ordering details or
visit us online* at www.siemens.com/discoverMR for further
details, product overviews, image galleries, step-by-step
videos, case studies and general requirement information.

1

3 syngo SWI showing multiple cortical and subcortical bleedings.

hypointense lesion can be found. How- tive to iron accumulation in the brain; 4 Schrag M, McAuley G, Pomakian J, Jiffry A, Tung 1 syngo TWIST (page 13).
S, Mueller C, Vinters HV, Haacke EM, Holshouser
ever, SWI looked completely different: this is observed in ageing process,
B, Kido D, Kirsch WM. Correlation of hypointensi-
multiple smallest cortical and subcorti- reflection of brain damage, diseases of 2
ties in susceptibility-weighted images to tissue
cal bleedings were visualized in the tem- iron metabolism and haemorrhages. histology in dementia patients with cerebral amy-
poral, parietal and less prominent in the Iron involvement is already accepted in loid angiopathy: a postmortem MRI study. Acta
frontal lobe (figure 3). Hallervorden-Spatz disease, neuroferri- Neuropathol. 2009 Nov 25. [Epub ahead of print]

In conclusion the findings in our patient tinopathy, aceruloplasminemia, Fried-
are a mixture of unspecific vascular / age reich’s Ataxia. However, larger studies
related findings (periventricular gliosis, are still needed to determine the role of Contact
reduced brain volume, microinfarcts) SWI in iron measuring especially in neu- Markus G. Lentschig, M.D.
and CAA. However, extent and severity rodegenerative diseases (Alzheimer’s MR and PET/CT Imaging Center Bremen
Mitte
of CAA is only visualized by syngo SWI in disease, Parkinson, ALS, and in Multiple
Sankt-Jürgen-Str. 1
detail and would have been clearly Sclerosis). 28177 Bremen
underestimated based on conventional Germany
MRI only. www.mr-bremen.de

References
Conclusion 1 Haacke EM, Mittal S, Wu Z, Neelavalli J, Cheng
syngo SWI has shown in this case to be a YC.Susceptibility-weighted imaging: technical
aspects and clinical applications, part 1. AJNR Am
sensitive tool for precise assessment of 2 syngo SWI, susceptibility-weighted imaging (page 23). 4 syngo Composing (page 63).
J Neuroradiol. 2009 Jan;30(1):19-30. Epub 2008
CAA. In general, SWI can provide useful Nov 27. Review.
additional information in the evaluation 2 Mittal S, Wu Z, Neelavalli J, Haacke EM. Suscepti-
3
of various pediatric and adult neurologic bility-weighted imaging: technical aspects and
conditions and can be incorporated eas- clinical applications, part 2. AJNR Am J Neuroradi-
ol. 2009 Feb;30(2):232-52. Epub 2009 Jan 8.
ily into the routine imaging assessment.
Review.
It is known that SWI is more sensitive in 3 Haacke EM, DelProposto ZS, Chaturvedi S, Sehgal
detection of small bleedings and small V, Tenzer M, Neelavalli J, Kido D. Imaging cerebral
vascular malformations than conven- amyloid angiopathy with susceptibility-weighted
*Direct link for US customers:
tional T2* imaging and that it is an imaging. AJNR Am J Neuroradiol. 2007
Feb;28(2):316-7.
www.siemens.com/WebShop
imaging technique which is highly sensi-
Direct link for UK customers:
www.siemens.co.uk/mrwebshop
16 MAGNETOM Flash · 3/2010 · www.siemens.com/magnetom-world 3 Tim Planning Suite (page 33). MAGNETOM Flash · 3/2010 · www.siemens.com/magnetom-world 17


Case Reports: 1A 1B

Susceptibility-Weighted
Imaging (syngo SWI) at 3T
Kate Negus; Peter Brotchie, MBBS, Ph.D.

Barwon Medical Imaging, The Geelong Hospital, Geelong, Victoria, Australia

Introduction
This is a pictorial review of susceptibil- The phase images can be windowed to The resolution is high enough to diag-
1C 1D
ity-weighted imaging (syngo SWI) using see contrast between iron deposition nose clinically relevant lesions and the
a MAGNETOM Trio system with software and normal tissue and also to visualize sequence short enough to include in all
version syngo MR B15 and a 32-channel gyral pattern to anatomically orientate protocols that would benefit from this
head coil at The Geelong Hospital, lesions more accurately. The SWI sliding new technique, without a time penalty.
Victoria, Australia. minIP is useful to visualize change in tis- Whole brain coverage of our sequence
syngo SWI is a 3D FLASH sequence that sue susceptibility caused by structures means that lesions in unexpected loca-
is flow compensated in slice, read and such as veins that cross many slices. tions would not be missed due to lack of
phase directions. The data received con- coverage.
tains a combination of phase and mag- SWI sequence details for all case studies:
nitude information. The susceptibility- swi3d1r, transverse plane, TR 28 ms, Case 1: Thrombosis and
weighted images are produced by first TE 20 ms, flip angle 15, bandwidth 120 Associated Venous Infarct
filtering the phase images of unwanted Hx/px, FOV 220 (FOV phase 84.4%), res-
Patient history
field inhomogeneities and then weight- olution 199 x 256, slice thickness 3 mm,
ing the magnitude images with this 48 slices, voxel size 0.9 x 0.9 x 3 mm, A 65-year-old male presented to our
phase mask. Two maps are automati- 1 average, acquisition time 2:19 min. emergency department with dysphagia,
cally calculated; phase mask multiplied word-finding difficulty and right sided
magnitude images and SWI minIP (mini- Since SWI is more sensitive to haemor- weakness.
mum intensity projection of 8 images rhage than conventional T2* gradient
on a sliding scale). In addition, the echo imaging, we replaced the T2* gra- Imaging ﬁndings
1 A) Native CT scan. B) T2* GRE at 1.5 Tesla. C) T2w TSE with syngo BLADE at 3 Tesla. D) Corresponding syngo SWI at 3 Tesla.
phase and magnitude images can also dient echo sequence with syngo SWI in Non-contrast CT identified a hypodense
be produced by modifying the recon- all of our brain protocols. In order to do mass lesion in the left thalamus with a
struction tab card. this without increasing scan time, the hyperdense border. Contrast CT and CT
The SWI images are T2*-weighted and SWI sequence as provided by the stan- venogram demonstrated a segment of
are enhanced by flow compensation dard protocol tree with the software ver- non-filling likely due to thrombosis in
and phase masking, so there is exquisite sion syngo MR B15 was modified by the left internal cerebral vein with asso- Discussion
detail of areas of susceptibility due to increasing the voxel size from 0.8 mm x ciated venous infarct in the left thala- foci of restricted diffusion in the left The patient was recalled to our Siemens SWI nicely demonstrated the venous
venous blood, haemorrhage and iron 0.7 mm x 1.2 mm (resolution 256 x 384 mus. MRI was obtained to confirm the centrum semiovale likely related to the 3T MAGNETOM Trio scanner the follow- tributaries of the left internal cerebral
storage. and 1.2 mm slice thickness) to 0.9 mm x vein thrombosis and extent of infarction. venous infarction, but no definite ing day. The sequences performed vein with signal dropout due to the
0.9 mm x 3 mm (resolution 199 x 256 Initial MRI on our Philips Edge 1.5T sys- restricted diffusion involving the left included axial T2w, T1w, Diffusion- presence of deoxyhaemoglobin in the
and slice thickness 3 mm), giving us tem confirmed a non-filling section of thalamus or the left basal ganglia. MR Weighted Imaging (DWI), Susceptibility- vessels. Signal dropout is also seen in
lower resolution but allowing us to image the left internal cerebral vein in keeping spectroscopy of the basal ganglia region Weighted Imaging (syngo SWI) and MR the thrombosed internal cerebral vein
the whole brain rather than only a sec- with thrombosis, extending to the vein showed an increased lactate peak sug- venography. This imaging confirmed the and within the thalamic haemorrhage,
tion of it, in half the time of the standard of Galen. There was an area of suscepti- gestive of ischaemia. left internal cerebral vein thrombosis and demonstrating the high sensitivity but
sequence. The 3 mm slice thickness also bility artefact in the gradient echo associated venous infarct. low specificity of this sequence.
correlates to our other brain sequences images in the left thalamus represent-
allowing direct comparison to be made. ing haemorrhage. There were 2 small



Case 2: Amyloid Angiopathy Case 3: Cerebral haemorrhage in case of AVM
2A 2B 3A 3B 3C

3D 3E 3 A) Initial SWI scan at 3Tesla.
B) Follow up T2* at 1.5 Tesla three
months later.
C) Corresponding T2w TSE at
1.5 Tesla.
D, E) 3T MRI performed in the
same month as figures B and C;
D) conventional T2* GRE,
E) syngo SWI.

2 All images acquired at 3 Tesla. A) T2w TSE. B) syngo SWI.

Patient history Imaging ﬁndings Discussion Patient history Imaging ﬁndings
An 83-year-old male presented for MRI Haemosiderin staining over the cortical The SWI demonstrated signal loss due to A 33-year-old male with a known brain A collection of serpiginous flow-voids within the left parietal lobe, measuring
from the memory clinic query fronto- surface of the frontal and parietal lobes haemorrhage which was not appreciable arterio-venous malformation (AVM) pre- was evident within the left superior 2.0 x 1.5 x 3.0 cm in size. On the
temporal dementia versus Alzheimers was evident on the SWI, consistent with on the routine imaging. Micro haemor- sented to our emergency department parietal lobule, similar in appearance to previous imaging from 3 months prior,
Disease with frontal features. previous subarachnoid haemorrhage, rhages in the arterioles of the grey with a history of 5 minutes of motor the patient’s previous study. However a small focus of hypointensity at this
most likely secondary to amyloid matter may lead to vascular dementia problems in his right hand. MRI was per- there was a region of hypointense sig- site was evident measuring 1 x 1 x 1 cm
Sequence details angiopathy. associated with amyloid angiopathy. formed to rule out cerebral haemorrhage. nal present within the region of the in diameter.
The standard dementia protocol was syngo SWI may provide useful informa- vascular malformation that was not visi-
performed: T1 volume, axial T2, FLAIR, tion in the imaging of dementia. Sequence details ble on the SWI from a previous study Discussion
syngo SWI, DWI whole brain images T1 volume, axial T2, FLAIR, field-echo performed on the patient 3 months The SWI appearance indicated the
with PRESS 30 MR spectroscopy of the whole brain images, 3D Time-of-Flight prior. This was suspicious for acute development of haemorrhage into the
parietal grey matter. (TOF) and contrast-enhanced MR haemorrhage. vascular malformation within the left
angiography and MR venography The patient was recalled for SWI at 3 parietal lobe, which had occurred since
sequences were performed on our Tesla, so we could have a direct compar- the previous study. The signal dropout
Siemens 1.5T MAGNETOM Avanto ison with the previous imaging that was on the SWI shows the margin of the
system. also performed on our 3T scanner. This haemorrhage and the associated anom-
demonstrated the development of a alous vessels more accurately than
region of hypointensity situated cen- other routine sequences.
trally within the vascular malformation



Case 4: Traumatic haemorrhage Case 5: Cerebral metastases in case of oesophageal adenocarcinoma
4A 4D 5A 5B
Patient history 5 A) T2w TSE at
3 Tesla.
48-year-old female presented to our B) T2w FLAIR at
3 Tesla.
emergency department with vomiting
C) syngo SWI at
and headache after previously discharg- 3 Tesla: cavernous
ing herself following a diagnosis of cor- haemangioma
tical vein thrombosis. marked by arrow,
DVA marked by
Sequence details asterisk, hemor-
rhagic metastases
Pre and post contrast T1 whole brain marked by arrow-
images, axial T2, DWI, syngo SWI whole head.
brain images with MR venogram. D) Follow-up after
one month with
Imaging ﬁndings a conventional
T2* sequence at
syngo SWI demonstrated a number of 1.5 Tesla.
hypointense foci within the sulci of the
4B 4E
frontal lobes bilaterally and a number of
extra-axial locations. These were associ-
ated with a number of small foci of 5C 5D
restricted diffusion within the cerebral
cortex. The history of recent head
trauma, subsequently elicited from the
patient, indicated that the appearance
was most likely due to regions of extra-
axial haemorrhage and small cortical
contusions. *
Discussion
SWI is more sensitive to very small areas
of traumatic haemorrhage because of
its higher resolution and better sensitiv-
ity to blood products than the routine
4C 4F
sequences.

Patient history Imaging ﬁndings Discussion
A 48-year-old male with oesophageal No evidence of orbital mass or mass The patient returned for a follow-up
adenocarcinoma presented with right within the paranasal sinuses was dem- scan on our 1.5T MAGNETOM Avanto
retro orbital pain for 8 weeks and was onstrated. scanner 1 month later and standard T2*
scanned for query cerebral metastases. Numerous T2 hypointense lesions with gradient echo imaging was performed.
marked signal dropout on SWI were Compared to the 3T SWI, the standard
Sequence details evident throughout the left cerebral gradient echo imaging at 1.5T is not as
Pre- and post contrast T1 volume, axial hemisphere. However, some of these sensitive to the multiple haemorrhagic
4 All images acquired at 3 Tesla. A, D) DWI B, E) T2w TSE 4 C, F) syngo SWI.
T2, FLAIR, DWI, syngo SWI whole brain were unaltered in appearance from areas, failing to show some of the
images, coronal T1, fat sat T2, post the previous study from 2 years earlier smaller lesions evident on the 3T SWI
contrast fat sat T1 images of orbits and and were consistent with cavernous sequence.
paranasal sinuses. haemangiomas. The others represent
haemorragic metastases.


Clinical Neurology

Case 6: Haemorrhagic component of MCA infarction
6A 6B 6C
Don’t miss the talks of
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experts covering a broad
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Jörg Barkhausen, M.D.
University Hospital Essen

6 All images acquired at 3 Tesla. A) DWI B) T2w TSE C) syngo SWI Dynamic 3D MRA – Clinical Concepts
(syngo TWIST)

Patient history Case study discussion References
1 syngo SWI powered by Tim. Hot Topic by Siemens
John A. Detre, M.D.
A 48-year-old female presented to our syngo SWI has allowed smaller suscepti- Healthcare. Available online at www.siemens. University of Pennsylvania
emergency department with sudden bility lesions to be demonstrated than com/magnetom-world (go to Publications > Hot
onset of left face, arm and leg weak- previously possible, in cases of vascular Topics). Clinical Applications of Arterial Spin Labeling
2 Susceptibility Weighted Imaging, Opening new
ness. CT brain was reported as right malformation, tumor, stroke, trauma doors to clinical applications of Magnetic Reso-
(syngo ASL)
middle cerebellar artery infarction. MRI and dementia. nance Imaging – E. Mark Haacke PhD Comment:
was performed to confirm this finding. In many cases cited in the literature, MRM, 2004 Sep;52(3):612-618.
SWI was the only imaging sequence to 3 Susceptibility-weighted MR imaging: a review of
Sequence details show the abnormality due to its clinical applications in children. Tong KA, Ashwal Tammie L. S. Benzinger, M.D., Ph.D.
S, Obenaus A, Nickerson JP, Kido D, Haacke EM.
Pre- and post contrast volume T1, axial increased sensitivity to iron content. AJNR Am J Neuroradiol. 2008 Jan;29(1):9-17.
Washington University School of Medicine
FSE T2, FLAIR, syngo SWI, DWI images In all 6 of our cases the SWI sequence Epub 2007 Oct 9. Review.
of the whole brain and 3D TOF MRA demonstrated increased detail of the 4 Susceptibility-weighted imaging to visualize Clinical Applications of Diffusion-Tensor Imaging
circle of Willis. pathology compared with the routine blood products and improve tumor contrast in (syngo DTI)
the study of brain masses. Sehgal V, Delproposto
imaging sequences. In cases 2, 4 and 5,
Z, Haddar D, Haacke EM, Sloan AE, Zamorano LJ,
Imaging ﬁndings some lesions appeared to be too small Barger G, Hu J, Xu Y, Prabhakaran KP, Elangovan
Abnormal signal was seen within the to see on other imaging sequences, IR, Neelavalli J, Reichenbach JR. J Magn Reson
right caudate head and lentiform nucleus indicating how the sensitivity of syngo Imaging. 2006 Jul;24(1):41-51. John F. Nelson, M.D.
5 Reliability in detection of hemorrhage in acute Battlefield Imaging
with significant susceptibility artefact SWI may benefit diagnosis.
stroke by a new three-dimensional gradient
within these structures that was most The increased signal and susceptibility recalled echo susceptibility-weighted imaging
consistent with the presence of blood effects at 3T enhance the use of syngo technique compared to computed tomography: Breast Cancer Management –
products. The pathology is contained SWI, allowing full brain coverage in a a retrospective study. Wycliffe ND, Choe J, Cross Modality Approach
within the middle cerebral artery distribu- short amount of time. Holshouser B, Oyoyo UE, Haacke EM, Kido DK. J
Magn Reson Imaging. 2004 Sep;20(3):372-7.
tion and appearances on syngo SWI are
most consistent with a cerebral infarction
with haemorrhagic transformation.
John A. Carrino, M.D., M.P.H.
Discussion Contact
Johns Hopkins University, School of Medicine
Kate Negus Assoc. Prof. Peter Brotchie, MBBS, Ph.D.
The SWI sequence demonstrated the full MRI Supervising Technologist Director MRI
extent of the haemorrhagic component Barwon Medical Imaging Barwon Medical Imaging MRI in Sports Medicine
of the infarction better than any of the The Geelong Hospital The Geelong Hospital
PO Box 281 Geelong, 3220, Victoria, Australia
Visit us at
routine sequences. The presence of
haemorrhage with stroke is important
Geelong, 3220, Victoria, Australia Phone: +61 3 5226 7032 www.siemens.com/magnetom-world
Phone: +61 3 5226 7070 peterbr@barwonhealth.org.au
to demonstrate as it changes treatment katen@barwonhealth.org.au
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