G a s t r o i n t e s t i n a l I m a g i n g R ev i ew

Sandrasegaran et al.
Pancreatic MRI

FOCUS ON:

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Gastrointestinal Imaging
Review

Kumaresan Sandrasegaran1
Chen Lin
Fatih M. Akisik
Mark Tann
Sandrasegaran K, Lin C, Akisik FM, Tann M

State-of-the-Art Pancreatic MRI

OBJECTIVE. The purpose of this article is to discuss the most current techniques used
for pancreatic imaging, highlighting the advantages and disadvantages of state-of-the-art and
emerging pulse sequences and their application to pancreatic disease.
CONCLUSION. Given the technologic advances of the past decade, pancreatic MRI protocols have evolved. Most sequences can now be performed in one or a few breath-holds; 3D sequences with thin, contiguous slices offer improved spatial resolution; and better fat and motion
suppression allow improved contrast resolution and image quality. The diagnostic potential of
MRCP is now almost as good as ERCP, with pancreatic MRI as the main imaging technique to
investigate biliopancreatic pain, chronic pancreatitis, and cystic pancreatic tumors at many institutions. In addition, functional information is provided with secretin-enhanced MRCP.

Keywords: MRCP, MRI, pancreas, secretin

DOI:10.2214/AJR.10.4421
Received February 9, 2010; accepted after revision
March 30, 2010.
The Department of Radiology and Imaging Science,
Indiana University School of Medicine receives research
grants from Siemens Healthcare.
1

All authors: Department of Radiology and Imaging

Science, Indiana University School of Medicine, 550 N
University Blvd., UH 0279, Indianapolis, IN 46202.
Address correspondence to K. Sandrasegaran
(ksandras@iupui.edu).

AJR 2010; 195:4253

0361803X/10/195142
American Roentgen Ray Society

42

n the past few years, MRI scanners

have become more sophisticated.
Current MRI scanners have more
than 100 integrated coil elements
and more than 30 independent radiofrequency
channels. Shorter scanners with wider bores allow scanning of obese and claustrophobic patients. Higher field strength (3 T) scanners are
increasingly used. Several new sequences have
been introduced for performing pancreatic MRI,
and 3D T1-weighted and MRCP sequences are
routinely used. Secretin-enhanced MR cholangiopancreatography (S-MRCP) protocols have
been developed for a more complete assessment
of pancreatic ducts and glandular function.
These improvements result in fast sequences
with excellent diagnostic quality. We have noted
that, with improved image quality and diagnostic accuracy, the volume of pancreatic MRI cases has substantially increased over the past few
years. MRI is used as a problem-solving tool in
patients with elevated liver function tests, acute
pancreatitis, and pancreatic cancer. In our practice, it is used as the primary investigation for
suspected biliopancreatic pain, staging chronic
pancreatitis, and diagnosis and follow-up of
cystic pancreatic tumors. In this article, we discuss the sequences that form state-of-the-art
MRI examination of the pancreas.
MRI Sequences
To fully evaluate the pancreatic parenchyma and the pancreaticobiliary ductal system, it

is necessary to obtain the following sequences: T1-weighted gradient-echo; T2-weighted axial and coronal sequences, usually turbo spin-echo (TSE) or a variant of TSE; 2D
and 3D MRCP; and T1-weighted 3D gradientecho before and after gadolinium. S-MRCP
is a useful optional sequence. Tables 1 and 2
give the MRI parameters for these sequences on 1.5- and 3-T scanners, respectively. For
most patients, it is possible to complete the
core sequences and S-MRCP within 20 minutes. In the following sections, we discuss different methods of performing these sequences, while being as vendor-neutral as possible.
Patient Preparation
In our practice, patients fast for 4 hours
before the MRI examination so that the
gallbladder is distended and it is possible to
adequately assess the exocrine response to
secretin. Negative oral contrast is useful to
reduce the signal from overlying stomach
and duodenum. Pineapple and blueberry
juice have been used as oral contrast agents
[13]. The manganese content of these juices results in increased signal on T1-weighted images and reduced signal on T2-weighted images. We prefer the use of 300 mL of
proprietary silicone-coated superparamagnetic iron oxide particle suspension (ferumoxsil, GastroMark, Mallinckrodt Medical) (Fig. 1) taken orally a few minutes
before the MRI examination.

AJR:195, July 2010

Pancreatic MRI
TABLE 1: Parameters for Pancreatic Imaging on 1.5-T MRI Scanner
Parameter

3D SPGR Dixon

T2 2D SSFSE

T2 2D STIR

Axial

Axial

Axial

Coronal

Coronal

Coronal

Coronal

Axial

TR/TE (msec)

7.47/4.76 (in), 2.38 (out)

1,100/90

2,900/132 (TI 150)

1,100/90

2,000/755

2,500/691

2,000/756

5.17/2.52

Flip angle ()

10

13050

180

130

180

Variable

12

ST/SG (mm)

3.4/

4.0/4.0

4.0/4.0

40

1/

40

3.0/

290

475

250

476

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Plane of
acquisition

NEX
RBW (Hz/pixel)
Phase direction

T2 2D SSFSE MRCP 2D Slab MRCP 3D MRCP Secretin

Anterior to posterior Anterior to posterior Anterior to posterior Right to left

Echo-train length
Matrix
Field of view (mm)
Respiration

3D SPGR FS

300

372

300

300

Right to left

Right to left

Right to left

Anterior to posterior

160

33

192

320

189

256

256 120

256 192

256 180

256 192

256 256

384 346

256 256

256 144

400

360

360

360

290

350

290

360

Breath-hold

Breath-hold

Breath-hold

Fat saturation

No

No

Inversion recovery

Breath-hold Breath-hold

Navigator

Breath-hold

Breath-hold

Fat sat

Fat sat

Fat sat

Fat sat

Concatenation

Parallel imaging

No

No

No

No

No

Scan time (min:s)

0:12

0:44

0:58

0:31

0:18

3:55

0.03 (9:58)

0:18 (3:28)

No

NoteThese are guidelines for use on a Magnetom Avanto 1.5-T MRI scanner (Siemens Healthcare). The names of the sequences and parameter values may vary with other
scanners. Where parallel imaging is used, the number given is the acceleration factor. Parallel imaging is typically performed with GRAPPA (generalized autocalibrating
partially parallel acquisition). The scan time given in parentheses is the total scan time for performing the secretin-enhanced MRCP series and the three gadoliniumenhanced series. 3D SPGR Dixon = 3D nonfat-saturated spoiled gradient-echo sequence for chemical shift imaging, SSFSE = half single-shot fast spin-echo sequence, 3D
SPGR FS = fat-saturated 3D spoiled gradient-echo T1-weighted sequence for contrast-enhanced imaging, ST/SG = slice thickness and slice gap (2D MRCP and secretin
MRCP slabs are single slabs of 40-mm thickness; 3D sequences do not have slice gap), NEX = number of excitations, RBW = receiver bandwidth, FOV = field of view,
Navigator = navigator-monitored respiratory triggering, Fat sat = spectral selective fat saturation, Concatenation = number of interleaved acquisitions or number of
breath-holds.

TABLE 2: Parameters for Pancreatic Imaging on 3-T MRI Scanner

Parameter
Plane of acquisition

3D SPGR Dixon

T2 2D SSFSE

MRCP 3D

MRCP Secretin

3D SPGR FS

Axial

Axial

T2 2D SSFSE MRCP 2D Slab

Coronal

Coronal

Coronal

Coronal

Axial

TR/TE (msec)

5.45/2.45 (in), 3.68 (out)

2,000/96

2,000/97

4,500/622

2,400/719

4,500/746

4.19/1.47

Flip angle ()

150

150

160

Variable

180

ST/SG (mm)

4.0/

5/5.2

4/4.4

40/

1.2/

40/

2.6/

NEX
RBW (Hz/pixel)

500 or 780

780

780

383

318

161

350

Phase direction

Anterior to posterior

Anterior to posterior

Right to left

Right to left

Right to left

Right to left

Anterior to posterior

Echo-train length
Matrix
Field of view (mm)
Respiration
Fat saturation

168

256

307

101

288

320 224

320 224

320 256

384 306

380 380

384 306

308 210

400

380

350

300

380

300

400

Breath-hold

Breath-hold

Navigator

Breath-hold

Navigator

Breath-hold

Breath-hold

No

SPAIR

No

Fat sat

SPAIR

Fat sat

SPAIR

Concatenation

Parallel imaging

Scan time (min:s)

0:16

1.08

1:50

0:36

3:54

0.04 (9.56)

0:19 (3:19)

NoteThese are guidelines for use on Magnetom Verio 3-T MRI scanner (Siemens Healthcare). The names of sequences and parameter values may vary with other
scanners. Where parallel imaging is used, the number given is the acceleration factor. Parallel imaging is typically performed with GRAPPA (generalized autocalibrating
partially parallel acquisition). The scan time given in parentheses is the total scan time for performing the secretin-enhanced MRCP series and the three gadoliniumenhanced series. 3D SPGR Dixon = 3D nonfat-saturated spoiled gradient-echo sequence for chemical shift imaging, SSFSE = half single-shot fast spin-echo sequence, 3D
SPGR FS = fat-saturated 3D spoiled gradient-echo T1-weighted sequence for contrast-enhanced imaging, ST/SG = slice thickness and slice gap (2D MRCP and secretin
MRCP slabs are single slabs of 40-mm thickness; 3D sequences do not have slice gap), NEX = number of excitations, RBW = receiver bandwidth, FOV = field of view,
Navigator = navigator-monitored respiratory triggering, SPAIR = spectral adiabatic inversion recovery, Fat sat = spectral selective fat saturation, Concatenation =
number of interleaved acquisitions or number of breath-holds.

AJR:195, July 2010

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Sandrasegaran et al.

Fig. 163-year-old woman with known branch-type intraductal papillary mucinous neoplasm.
A, Coronal T2-weighted turbo spin-echo 2D slab image from examination performed at outside institution
without oral contrast shows stomach contents (arrowhead) are bright and overlie body and tail of pancreas,
obscuring main duct. There is 2.5-cm cystic mass (solid arrow) in pancreatic body. There is also N/2 ghosting
of stomach (dashed arrows) projected over right hepatic lobe. This artifact is due to filling of k-space over two
respiratory cycles. Ghost signal is shifted by one half length of field of view (FOV) in phase-encoding direction
(or FOV/4 if parallel imaging with acceleration factor of 2 is used). It is less likely to occur with variable flip-angle
techniques.
B, Single-shot fast spin-echo image from examination performed at our institution with negative oral contrast
administration shows good visualization of cystic mass (arrow) and main pancreatic duct.

quences, including gradient-echo, TSE, or

balanced steady-state free precession [9].
Compared with two-point Dixon techniques,
three-point Dixon techniques are less affected by field inhomogeneities and can assess
fat content of more than 50%, but they also
have longer acquisition times. A recent study
found no significant differences in hepatic fat
content measured by the two techniques [10].
At the time of this writing, three-point Dixon techniques are not commercially available
with all major vendors.

T1-Weighted Sequences
T1-weighted sequences are useful for assessing hemorrhage, such as within inflammatory collections in acute pancreatitis (Fig. 2),
and pancreatic fat. Estimation of pancreatic
fat is currently not considered part of routine
MRI assessment. However, studies in animals
and humans have shown that fatty pancreas
is associated with increased severity of acute
pancreatitis or higher incidence of postoperative complications [46]. Thus, accurate assessment of pancreatic fat content may be
useful. Traditionally, 2D gradient-echo sequences with two TEs have been used. This
sequence yields images in which water and
fat protons have the same or opposing phases
(Fig. 2). Fat content may be estimated by assessing the signal drop-off on opposed-phase

images; 3D two-point Dixon techniques (Fig.

3), which acquire thinner, contiguous slices within a breath-hold, are preferable to 2D
gradient-echo sequences. The signal in twopoint Dixon images is adversely affected by
magnetic field (B0) and radiofrequency (B1)
inhomogeneity, either intrinsic to the system
or due to the presence of tissue iron. Threepoint Dixon techniques correct for T2* decay by using the data from a third echo. The
most commonly used three-point Dixon technique is iterative decomposition of water and
fat with echo asymmetry and least-squares
estimation (IDEAL), which maps field inhomogeneities and uses asymmetric sampling
(unevenly spaced echoes) for maximum signal-to-noise ratio (SNR) [7, 8]. The IDEAL
technique is compatible with many pulse se-

T2-Weighted Sequences
Multishot fast spin-echo (TSE) and single-shot fast spin-echo (SSFSE) sequences
are the most commonly used T2-weighted
sequences for pancreatic (and liver) imaging. We use both of these sequences. An alternative technique is balanced steady-state
free precession. Respiratory-gated TSE has
been shown to be superior to breath-hold
TSE and respiratory-gated SSFSE in detecting solid liver lesions, such as metastases [11,
12]. SSFSE sequences have a long echo-train
length, which reduces the contrast-to-noise
ratio (CNR) of solid liver lesions (which have
short T2) because of magnetization transfer
effect and T2-filtering produced by multiple 180 refocusing pulses [12, 13]. On the
other hand, the image quality of SSFSE sequence is superior to TSE sequences. SSFSE
sequences are used to obtain T2-weighted
sequences, with a TE of about 100 milliseconds, and MRCP, with a TE of about 600
milliseconds (Tables 1 and 2). Fat is bright
on these sequences, and fat suppression may
be required. In addition, T2-weighted sequences are too long to be acquired within
one breath-hold. They may be concatenated

Fig. 233-year-old woman with acute pancreatitis with sudden drop in hematocrit.
A, Axial T2-weighted image shows large fluid collection (arrow) with low-signal material (arrowhead) in dependent aspect.
B and C, Axial T1-weighted in-phase (B) and opposed-phase (C) images show high signal (arrowhead) in dependent aspect of cyst (arrow) indicating blood. Patient was
diagnosed with hemorrhagic pseudocyst. Angiography (not shown) did not reveal pseudoaneurysm. In addition, there is reduced liver signal (dashed arrow) on opposedphase image compared with in-phase image, indicating hepatic steatosis.

44

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Pancreatic MRI
Fig. 359-year-old man with postprandial pain who
underwent mesenteric CT angiography.
A, Axial CT image shows mild reduced density
and irregular outline of pancreatic head (arrow),
considered worrisome for pancreatic neoplasm.
B and C, In-phase (B) and opposed-phase (C) images
from 3D T1-weighted MRI show signal loss on
opposed-phase in anterior aspect of pancreatic head
(arrows).
D, Using in- and opposed-phase images, it is possible
to derive fat-only or water-only images. On fat-only
image, pancreatic head shows focal increased signal
(arrow). Appearances are consistent with fatty
infiltration of pancreatic head, simulating tumor.

over two or three breath-holds. Alternatively,

the sequences may be performed during free
breathing with motion correction techniques
that will be explained later.

difference in T1 relaxation times between fat

and water. By using an inversion time (TI) of
150170 milliseconds at 1.5-T MRI, the fat
signal can be selectively suppressed. In general, IR techniques have more homogeneous
fat suppression and better CNR compared
with spectral fat saturation techniques. On
the other hand, they have lower spatial resolution, with other MR parameters being the
same, or longer acquisition times (Fig. 4).
In the conventional implementation of IR fat
suppression, the inversion pulse has a wide frequency bandwidth to invert both fat and water
spins. Therefore, the water signal is also partially suppressed at the TI of fat. This results in
a lower SNR, which may affect lesion conspicuity. SPAIR (spectral adiabatic inversion recovery) is a newly developed IR fat suppression
technique. In this sequence, the inversion pulse

Fat Suppression
Two different approaches are traditionally used for fat suppression. Chemical shift
fat suppression is based on the difference of
resonance frequency between fat and water.
Before the main sequence, a spectrally selective radiofrequency pulse tuned to the fat frequency is applied, followed by spoiler gradient pulses. The frequency of precession of fat
protons is dependent on the magnetic field.
Therefore, this technique is adversely affected by magnetic field inhomogeneity. Another
approach is inversion recovery (IR) fat suppression, such as STIR, which is based on the

is spectrally selective and affects only the fat

protons. The adiabatic inversion is also insensitive to B1 inhomogeneity. The benefits of adiabatic inversion recovery over conventional IR
include better SNR and reduced susceptibility
artifact, especially at 3 T [14] (Fig. 5). The specific absorption rate (SAR) is higher with adiabatic inversion recovery compared with conventional IR sequences.
In addition to the two techniques of fat
suppression discussed, i.e., chemical shift selective saturation and inversion recovery, T2weighted Dixon techniques are being evaluated. Three-point Dixon techniques with
IDEAL may be used with TSE sequences but
require a long acquisition time [15]. A prototype three-point Dixon technique in which
each TSE readout gradient is replaced with
three readout gradient pulses with differFig. 436-year-old man with primary sclerosing
cholangitis.
A and B, Comparison of axial T2-weighted images
with spectral fat saturation (A) and inversion
recovery (B) show that with inversion recovery, fat is
more uniformly suppressed. Contrast-to-noise ratio
is better on B, with depiction of lacy reticular fibrosis
(arrow, B) in posterior right liver. In A, posterior right
liver merely shows mild increased signal (arrow,
A). On the other hand, spatial resolution is better
in A compared with B, with clearer depiction of
main pancreatic duct (arrowheads). In our current
practice, conventional inversion recovery has been
superseded by selective saturation of fat with
adiabatic inversion recovery.

A
AJR:195, July 2010

B
45

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Sandrasegaran et al.
Fig. 541-year-old man with chronic pancreatitis
who underwent 3-T MRI.
A and B, Line diagrams show conventional inversion
recovery (A) and spectral adiabatic inversion
recovery (SPAIR) (B) sequences. Gray lines show
signal from fat and dashed lines, signal from water.
There is reduced water signal in conventional
inversion recovery sequence compared with SPAIR.
C and D, Comparison of axial images from
conventional inversion recovery (C) and SPAIR (D).
Susceptibility artifact from bowel gas, seen as dark
band in anterior abdomen on inversion recovery
image (arrowheads), is not evident on SPAIR
sequence.

Fig. 6Navigator monitoring of respiratory motion.

A, In this technique, coronal 2D low-resolution
gradient-echo images with small flip angle (to prevent
magnetization saturation) are acquired in about 100
milliseconds [62]. These images sample, in real time,
motion of right hemidiaphragm.
B, This respiratory trace allows synchronization of
data acquisition with patients respiratory cycle.
On initial respiratory cycles, range of motion is
determined (large boxes, arrows). On subsequent
respiratory cycles, data acquisition is triggered
when diaphragm is relatively stationary (small boxes,
arrowheads).

Fig. 736-year-old woman with unexplained

abdominal pain.
A and B, T2-weighted axial images obtained freebreathing without motion correction technique,
BLADE (Siemens Healthcare) (A) and with BLADE
(B) show substantially improved image quality with
BLADE. Currently we use navigatorecho technique
for free-breathing sequences, although BLADE is
likely to be used more in the future.

46

90

90
Water

Water
Fat

Fat
180

180

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Pancreatic MRI

Fig. 852-year-old woman with chronic

pancreatitis. Axial motion correction technique,
BLADE (Siemens Healthcare) image shows streaky
artifacts (arrowhead) that degrade image quality.
These artifacts arise in process of gridding data
acquired from oblique trajectory in k-space and
may be improved by oversampling of k-space. In our
experience, spatial resolution is lower with BLADE
compared with navigatorecho sequence.

Fig. 971-year-old man with multiple cystic pancreatic lesions seen for follow-up.
A and B, Coronal images of free-breathing 3D MRCP performed at 3-T MRI using constant flip angle (single-shot
fast spin-echo [SSFSE]) (A) and variable refocusing flip angles (sampling perfection with application optimized
contrasts using different flip-angle evolutions [SPACE]) (B). Both sequences show side-branch intraductal
papillary mucinous neoplasm (arrowheads). SPACE sequence suggests irregularity of main pancreatic duct
(arrow) that was not evident on conventional SSFSE sequence. Specific absorption rate of SPACE sequence
was 52% lower than that of conventional SSFSE sequence.

ent fatwater phase shifts may, in the future,

provide high-quality, fat-suppressed, breathhold T2-weighted images [16, 17].

duced motion artifacts (Fig. 7). Because of the

redundancy in k-space data, these techniques
require longer scanning times than conventional rectilinear data acquisition. However,
the oversampling in the center of the k-space
also improves the SNR. Because blade motion correction is based on the assumption of
rigid body motion, it is not as effective in correcting elastic motion for organs, such as liver and pancreas, and also does not correct for
through-plane motion. With rotatory k-space
filling techniques, image quality is best with
wider blades, longer echo train lengths, and
oversampling of k-space [20]. Inadequate kspace sampling may result in streak artifacts
(Fig. 8). Increasing echo-train length also im-

proves flow suppression. Studies have shown

the improved diagnostic quality of upper abdominal organs with rotatory k-space filling
technique sequences compared with conventional breath-hold and navigator-corrected T2weighted SSFSE sequences [18, 21].

Motion Suppression
Techniques of motion suppression during
free breathing include the use of respiratory
triggering, respiratory monitoring with navigator pulse, and rotatory k-space sampling. Most
T2-weighted SSFSE and 3D MRCP sequences
are too long to be performed within a breathhold and require respiratory triggering. Traditionally, this has been performed using pneumatic bellows placed around the lower chest to
detect respiratory motion. The use of 2D navigator pulses is a more recent development. The
most commonly used navigator technique is
2D PACE (prospective acquisition correction
encoding) (Fig. 6). This technique is further
discussed under the section on MRCP.
Rotatory filling of k-space allows inherent motion correction capabilities. With these
techniques, named PROPELLER (periodically rotated overlapping parallel lines with enhancement reconstruction) or BLADE (Siemens Healthcare), the entire k-space is covered
by multiple rectangular regions shaped like
blades rotated around the center [18, 19]. Each
blade consists of a small number of phase-encoding lines that can be filled with a multiple
echo acquisition after a single excitation. Any
in-plane motion that occurs between the acquisitions of the two blades can be determined by
comparing the k-space data in the overlapping
part of two blades and may be corrected. After repeating the process for all the blades, the
full k-space can be created from motion-corrected blades to reconstruct an image with re-

AJR:195, July 2010

Flip-Angle Modulation Techniques

A limitation of 3D constant flip angle T2weighted sequences at 3 T is the high radio
frequency energy deposition. Newer 3D TSE
techniques use variable flip angles. Such techniques are termed SPACE (sampling perfection with application optimized contrasts using different flip-angle evolutions), XETA
(extended echo-train acquisition), or CUBE

Fig. 1054-year-old man with abdominal pain.

A, Single-shot fast spin-echo (SSFSE) axial image shows apparent filling defect in distal common bile duct
(CBD) (arrowhead). This finding simulates choledocholithiasis but is artifactual and due to sensitivity of this
sequence to biliary flow. Flow void is also seen in superior mesenteric vein (arrow).
B, Balanced SSFP image at same level shows normal appearance of CBD (arrowhead). Because balanced SSFP
is not sensitive to flow voids, vessels appear bright (arrow) on this sequence. This sequence is susceptible to
off-resonance effects because it accumulates signal between adjacent TRs. Variation in phases from adjacent
TR results in destructive interference that is typically responsible for black-boundary effect seen around
organs on balanced SSFP images.

47

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Sandrasegaran et al.

Fig. 112D MRCP in 67-year-old woman with intraductal papillary mucinous neoplasm (IPMN).
A, Positioning of 40-mm MRCP slabs is performed on axial single-shot fast spin-echo sequence. In our practice, six coronal oblique slabs are used to ensure that entire
pancreaticobiliary ductal system is included. C and B indicate slabs.
B, 2D MRCP coronal image, corresponding to slab B on image A, shows that cystic lesion in downstream body (arrowhead) communicates with main duct. Duct in
pancreatic tail (solid arrow) is not well visualized on this image. Note divisum anatomy (dashed arrow).
C, 2D MRCP coronal image, corresponding to slab C on image A, does not optimally show main ductal communication of IPMN in pancreatic body (arrowhead) but shows
cystic masses in pancreatic tail (arrow). Dashed arrow indicates divisum anatomy.
Fig. 1274-year-old woman with intraductal
papillary mucinous neoplasm.
A and B, Coronal image from 2D MRCP (A) and
coronal maximum-intensity-projection image from
3D MRCP (B) show that duct in pancreatic tail
(arrowhead) and posterior branch of right hepatic
duct (arrow) are better visualized on 3D sequence.
We perform both 2D and 3D MRCP because 2D may
have better image quality in patients with irregular or
rapid respiratory cycles.

(GE Healthcare). Variable refocusing flip-angle techniques can maintain higher signal intensity in a long echo-train to produce higher
SNR [22]. The SAR may be reduced by about
70% at 3 T by using a varying flip angle [23].
A study comparing traditional constant flipangle 3D MRCP with variable refocused flipangle MRCP in healthy volunteers imaged on a
3-T MR scanner found significantly better image quality of intrahepatic bile ducts with the
latter sequence [22] (Fig. 9). The superiority of
image quality with the variable refocused flipangle technique has also been found in healthy
subjects scanned at 1.5 T [24], where energy
deposition is not a major consideration. This
finding may be due to the shorter echo spacing, and thus less image blurring, that is possible with variable refocusing flip angles. The
advantages and disadvantages of flip-angle
modulation techniques over constant flip-angle
techniques are shown in Table 3 [25].

imaging, balanced steady-state free precession sequences (SSFP), such as FIESTA (fast
imaging employing steady-state acquisition),
trueFISP (fast imaging with steady-state precession) or balanced FFE (fast-field echo) may
be used. Balanced SSFP sequences have high
SNR. Contrast in these sequences is determined by a ratio of T2/T1. By keeping the TR
and TE very short, T1 remains constant, and
the principal component of image contrast is

Steady-State Free Precession Sequences

Although TSE and SSFSE are the most
commonly used sequences for T2-weighted

48

T2. Balanced SSFP techniques are insensitive

to flow voids and do not show artificial filling
defects in bile ducts because of flow (Fig. 10).
Vessels are bright in these sequences. This
may be an advantage in pancreatic imaging,
showing the proximity of tumor to blood vessels, but it also may mask small cystic lesions
adjacent to splenic vessels. Balanced SSFP
sequences are prone to susceptibility artifact.
The TR needs to be kept short and shim per-

TABLE 3: Advantages and Disadvantages of Flip-Angle Modulation

Techniques With Constant Flip Angle Turbo Spin-Echo
T2-Weighted Sequences
Advantages

Disadvantages

Reduced specific absorption rate, especially at 3 T

Longer acquisition times

Reduced echo space, less blurring

Longer acquisition times

Reduced N/2 ghosting artifacts

Longer acquisition times

Isotropic acquisition, allowing multiplanar reconstructions

Altered contrast, with partial T1 weighting

Improved flow suppression

Increased B1 inhomogeneity artifact

NoteFlip-angle modulation techniques include sampling perfection with application optimized contrasts
using different flip-angle evolutions. Variable flip-angle techniques may fill the entire k-space partition in a
respiratory cycle. Constant flip-angle 3D techniques may fill the k-space partition in two breathing cycles. If
the diaphragmatic positions in the two cycles are different, N/2 ghosting artifacts may occur [25] (Fig. 1).

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Pancreatic MRI
Fig. 1348-year-old woman with abdominal pain.
AD, MRCP images at 0 (A), 3 (B), 7 (C), and 10 (D)
minutes after IV secretin injection. Patient has
reverse divisum with ventral duct (arrowhead, B)
entering minor papilla. Diagnosis is easier to make on
postsecretin images. Reverse divisum may result in
isolated ventral chronic pancreatitis. Note progress
filling of duodenum (solid arrows, BD) and proximal
small bowel loops (dashed arrow, D) with high-signal
fluid.

formed to reduce this artifact. Studies on liver

lesions have not found a significant difference
in diagnostic ability between balanced SSFP
and SSFSE sequences [26, 27].

to ensure that the entire pancreatic ductal

system has been imaged (Fig. 11).

MRCP
MRCP refers to the acquisition of heavily T2-weighted images, with variants of TSE
sequences. These sequences consist of a single 90 pulse followed by multiple constant
refocusing pulses. The refocusing pulses typically have been 180 pulses, although pulses
of 130 to 160 are often used to reduce energy deposition, especially at 3-T MRI. Very
long echo-trains may be required to acquire
all data in a slice within a single TR. However, long echo pulses cause some blurring of
the images. The commonly used sequences
use partial Fourier technique, in which between 50% and 60% of the k-space is filled
by data. The remainder of the k-space is filled
by extrapolation using the symmetry of the kspace. Sequences that acquire the entire data
set within one TR and use partial Fourier
technique are called SSFSE or HASTE; 2D
MRCP has long been performed using coronal SSFSE slabs. We prefer to acquire 40mm slabs in multiple coronal oblique planes

AJR:195, July 2010

3D MRCP
The 3D TSE sequence can produce highspatial-resolution MRCP images (Fig. 12).
Thin sections without a slice gap allow better assessment of small stones, side branches of the main pancreatic duct, and intrahepatic bile ducts [28, 29]. Three-dimensional
TSE MRCP may be performed as a series of
breath-holds or during free breathing. We
acquire 12 mm, contiguous slices during
free breathing and use the navigator-echo
technique to reduce motion effects. The
main disadvantage of this technique is the
relatively long acquisition time. In addition,
navigator-based triggering requires uniform
and regular breathing cycles for optimal image quality. If the patient has rapid or irregular breathing, the image quality may be impaired. An alternative method of producing
3D MRCP images is to use a TSE sequence
with a 90 flip-back pulse. This sequence is
called FRFSE (fast recovery fast spin-echo),
DRIVE, or RESTORE. The unique feature
of this sequence is that after a long echotrain, the residual transverse magnetization

is refocused into a final spin-echo and then

flipped along the z-axis by a 90 fast recovery pulse [29, 30]. This accelerates relaxation
of the longitudinal magnetization, leading to
a reduction in TR without a loss of SNR. It
is possible to perform breath-hold 3D MRCP
with this sequence. However, the number of
slices that may be obtained is substantially
less than with respiratory-triggered versions
of 3D MRCP.
Secretin-Enhanced MRCP
Secretin is a polypeptide hormone secreted by duodenal mucosa in response to luminal acid [31]. It induces pancreatic secretion of water and bicarbonate. In the first 57
minutes, the tone of the sphincter of Oddi is
increased. These effects result in temporary
distention of the pancreatic ducts. Synthetic
human secretin (ChiRhoStim, ChiRhoClin,
Inc.) is given IV over 1 minute to avoid potential abdominal pain that may occur with a
bolus injection. An adult dose of 16 g (0.2
g/kg body weight in children) is used. At
the commencement of injection, a baseline
scan is obtained, followed by coronal SSFSE
images (2-second scanning time) every 30
seconds for 10 minutes. In healthy subjects,

49

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Sandrasegaran et al.
our practice, we use secretin even in patients
with mild acute pancreatitis but avoid its use
in severe pancreatitis. The major drawbacks
of S-MRCP are the 10 minutes of acquisition
time and the cost of secretin (estimated to be
$300 per adult dose).

the maximal effect of IV secretin is between

710 minutes (Fig. 13).
Although S-MRCP is used routinely in
all patients undergoing MRCP at our institution, a more selective use may be considered.
Secretin is useful in assessing complex ductal anomalies, such as annular pancreas (Fig.
14) and anomalous pancreaticobiliary junction [32]. In patients with pancreas divisum,
S-MRCP increases the confidence of diagnosis (Fig. 14), although in many instances the
diagnosis is suspected on nonsecretin MRCP.
Conventional MRCP is not sensitive to the diagnosis of mild chronic pancreatitis. S-MRCP
helps in assessing early side branch dilation
of this condition [3336] (Fig. 15). With SMRCP, it is possible to quantitatively or semiquantitatively assess the exocrine functional
reserve of the pancreas (Figs. 1315). Quan-

titative measurements of exocrine response to

secretin have been performed using volumetric or signal intensity measurements of fluid
released into duodenum after secretin injection [3740]. We prefer a semiquantitative
description of exocrine function [41]. If the
maximum output only fills the duodenal bulb,
pancreatic exocrine function is considered to
be poor. Filling of the bulb and second part of
the duodenum is considered suboptimal function. Filling of the entire duodenum or loops
of small bowel is considered normal function.
In addition, S-MRCP may show pancreatic
leak after severe pancreatitis, pancreatic surgery, or blunt trauma [42, 43] (Fig. 16).
We have performed more than 4,000 SMRCP examinations since 2003 and are
aware of only two cases of acute pancreatitis that resulted shortly after secretin use. In

Contrast-Enhanced Sequences
If the only indication for the MRI examination is evaluation of choledocholithiasis,
contrast enhancement may not be necessary.
For most other indications, the acquisition of
gadolinium-enhanced sequences is advisable.
The sequence of choice for unenhanced and
gadolinium-enhanced series is 3D fat-suppressed spoiled gradient-echo. This sequence
has many names, such as VIBE (volume interpolated breath-hold F-GRE), LAVA (liver acquisition with volume acceleration) and
THRIVE (T1-weighted high-resolution isotropic volume examination), and allows the
acquisition of 2- to 5-mm contiguous slices
within a 20-second breath-hold.
Typically, gadolinium is injected at 2 mL/s
using a power injector and followed with a 20mL saline flush administered at the same rate.
It is usual to acquire the entire liver (and pancreas) in multiple phases. Timing of the scan
may be performed using fixed time delays, realtime bolus tracking, or a test bolus. Traditionally, empirical timing has been used with the arterial, venous, and delayed phases acquired 25,
60, and 180 seconds, respectively, after commencement of contrast infusion (Fig. 17).
Bolus tracking has been primarily used in
MR angiography but is used increasingly in
abdominal imaging. The delay from onset
of infusion to arrival of contrast material in
the distal aorta varies from 12 to 30 seconds,
with a mean of 1718 seconds [44, 45]. Thus,

Fig. 1446-year-old woman with annular pancreas and chronic pancreatitis.

A, Presecretin image shows normal-appearing annular duct (arrowhead). Apparent filling effect at common
hepatic duct (arrow) is due to crossing vessel.
B, Postsecretin image at 7 minutes after injection shows irregular caliber of annular duct (black arrowhead)
with side-branch dilation. Chronic pancreatitis is predominantly confined to annulus, with normal main
pancreatic duct (white arrowhead). There is divisum anatomy, with main pancreatic duct crossing common bile
duct to enter minor papilla (black arrow). This anatomic variant was not obvious on presecretin image. Despite
normal-appearing main duct, exocrine function is considered to be suboptimal because volume of pancreatic
fluid is only sufficient to fill duodenal bulb (dashed arrow) and second part of duodenum (white arrow).

Fig. 1552-year-old woman with suspected chronic pancreatitis.

A, Presecretin MRCP image shows apparently normal pancreatogram and postcholecystectomy cholangiogram. Ventral duct (dashed arrow) is not well assessed.
B, Image obtained 8 minutes after secretin shows side-branch dilation (arrowheads), indicating mild chronic pancreatitis (diagnosed by dilation of three or more
side branches). Exocrine response to secretin is poor, with fluid only filling duodenal bulb (solid arrow). In our experience, exocrine functional deficiencies may be
substantially worse than anatomic abnormalities of ducts. Curved ventral duct (dashed arrow) is better visualized after secretin.
C, ERCP image confirms findings of chronic pancreatitis with early side-branch dilation (arrowheads).

50

AJR:195, July 2010

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Pancreatic MRI

Fig. 1624-year-old woman with suspicion of pancreatic ductal disruption after motor vehicle accident.
A, Presecretin MRCP image shows probable ductal injury with focal segment of stenosis (solid arrow) and upstream duct dilation (dashed arrow).
B, After secretin, there is leakage of exocrine output into large collection (arrowhead).
C, ERCP image obtained on same day confirms ductal disruption (arrowhead). In our experience, secretin may be useful to show large ductal leakage postsurgically or
after blunt abdominal trauma. However, pressure within pancreatic duct after secretin may not be sufficient to show small leak, and potential leaks may be obscured by
surrounding collections. ERCP is superior to secretin MRCP for showing ductal leaks.

it may be expected that bolus tracking would

be superior to using fixed delays. In patients
without cardiovascular comorbidity, fixed
time delays may be satisfactory [46]. However, when delaying with patients with cirrhosis or hypertension, bolus tracking gives
a more reliable arterial phase [44].
There is no consensus on the optimal bolus tracking technique. We prefer to monitor
the distal aorta at the diaphragmatic hiatus
with a bolus tracking sequence and real-time
reconstructions. As soon as contrast material
arrives, the bolus tracking scan is stopped,
and the patient is given breathing instructions. The arterial phase is started 8 seconds
later. For a satisfactory arterial phase, there
should be good contrast in the aorta, superior mesenteric artery, and portal vein and no
contrast in the hepatic veins. Lack of contrast
in the portal vein suggests that the phase was
acquired too early, the most common reason for not obtaining a good arterial phase.
The timing of the contrast bolus may be less
stringent with venous and delayed phases.
The contraindications to the use of gadolinium are severe allergy, pregnancy, and re-

A
AJR:195, July 2010

nal dysfunction. When the estimated glomerular filtration rate (eGFR) is more than 60
mL/min/1.73 m2, we use the standard dose
of gadolinium (0.1 mmol/kg). With an eGFR
of 3060 mL/min/1.73 m2, we use a reduced
dose, typically one half of the standard dose.
We tend not to use gadolinium when the
eGFR is less than 30 mL/min/1.73 m2.
1.5- Versus 3-T MRI
In the previous sections, we have alluded
to sequences that tend to be more useful in
3-T MRI, such as variable flip-angle techniques for reducing SAR. The main advantage of scanning at 3 T is the higher SNR.
Parallel imaging is a technique used more
often in 3-T MRI than at 1.5 T. It allows the
production of images with adequate field of
view and spatial resolution using fewer kspace lines. This is possible because the spatial sensitivity information from independent
receiver coils may be used to overcome the
aliasing effect of acquiring a reduced number of phase encoding lines [47, 48]. As a
result, a shorter scanning time, often by a
factor of two, may be achieved. Other advan-

tages of parallel imaging include the ability

to produce breath-hold images or multiphasic studies in a short period of time. In addition, parallel imaging techniques can be used
to reduce T2 blurring in TSE techniques and
reduce SAR and susceptibility effects by allowing shorter echo-trains [49].
The main limitation of parallel imaging
is the associated reduction in SNR, which is
usually not an issue at 3 T, where the overall
SNR is higher. Parallel imaging may cause
artifacts that sometimes manifest as lines
or bands in the middle of images. There are
two main types of parallel imaging: image
domainbased techniques such as sensitivity encoding (SENSE), and k-space-based
techniques such as generalized autocalibrating partially parallel acquisition (GRAPPA).
Details of these techniques are discussed
elsewhere [48, 50, 51].
The improved availability of radiofrequency coils that are optimal for 3 T has reduced
many of the limitations of this technique, such
as increased chemical shift and susceptibility artifacts and artifacts due to interference
of radiofrequency waves. Studies comparing

Fig. 1772-year-old woman seen for assessment of

cystic mass in pancreas.
A, Axial T2-weighted image shows possible softtissue component (arrowhead) in 2.5-cm cystic mass.
B, Axial gadolinium-enhanced image shows
enhancing mural nodules (arrowheads), raising
concern for malignant change within cystic lesion.
Patient underwent radical pancreaticoduodenectomy
and was found to have intraductal papillary mucinous
neoplasm with carcinoma in situ.

51

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Sandrasegaran et al.
1.5- and 3-T abdominal MRI suggest that 3
T does not offer substantial improvement in
image quality for unenhanced images [52
59]. However, the SNR of contrast-enhanced
images is thought to be superior at 3 T, compared with 1.5 T [60, 61]. It is probable that
future improvements in hardware and imaging sequences will make 3-T MRI the system
of choice for imaging the pancreas.
Conclusions
As a result of rapid technologic improvements, the current pancreatic MRI protocol
is very different from the one used a decade
ago. Most sequences can be performed in one
or a few breath-holds, and 3D sequences with
thin, contiguous slices offer good spatial resolution. Better fat and motion suppression allows improved contrast resolution and image
quality. The diagnostic potential of MRCP is
now almost as good as ERCP, eliminating the
need for most diagnostic ERCP studies.
Looking to the future, it is probable that increased functional assessment of the pancreas
will be performed. S-MRCP gives information on the exocrine function of the pancreas. Diffusion-weighted MRI, MRI perfusion,
and MR elastography are currently research
tools. In the future, they may become part of
the MR protocol for specific indications, such
as assessing the malignant potential of cystic
pancreatic tumor or evaluating the severity of
chronic pancreatitis. The future of pancreas
MRI appears to be exciting.
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