INTRODUCTION

Magnetic resonance imaging (MRI) produces high quality images of the body in cross section and in three-dimension. It detects the effects of induced changes in the nuclei of specific elements within the body and is particularly useful for the imaging of soft tissues, providing greater contrast between different types of soft tissue than computerised tomography (CT). It is the technique of choice for many neurological, cardiovascular, oncological and musculoskeletal conditions. An MRI machine uses a powerful magnetic field to align the magnetization of some atoms in the body, and radio frequency fields to systematically alter the alignment of this magnetization. This causes the nuclei to produce a rotating magnetic field detectable by the scannerand this information is recorded to construct an image of the scanned area of the body.[1]:36 Strong magnetic field gradients cause nuclei at different locations to rotate at different speeds. 3-D spatial information can be obtained by providing gradients in each direction. MRI provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain, muscles, the heart, and cancers compared with other medical imaging techniques such as computed tomography (CT) or X-rays. Unlike CT scans or traditional X-rays, MRI uses no ionizing radiation.

HISTORY
In the 1950s, Herman Carr reported on the creation of a one-dimensional MR image. Paul Lauterbur expanded on Carr's technique and developed a way to generate the first MRI images, in 2D and 3D, using gradients. In 1973, Lauterbur published the first nuclear magnetic resonance image and the first cross-sectional image of a living mouse was published in January 1974. Nuclear magnetic resonance imaging is a relatively new technology first developed at the University of Nottingham, England. Peter Mansfield, a physicist and professor at the university, then developed a mathematical technique that would allow scans to take seconds rather than hours and produce clearer images than Lauterbur had.

Raymond Damadian's "Apparatus and method for detecting cancer in tissue." In a 1971 paper in the journal Science, Dr. Raymond Damadian, an Armenian-American physician, scientist, and professor at the Downstate Medical Center State University of New York (SUNY), reported that tumors and normal tissue can be distinguished in vivo by nuclear magnetic resonance ("NMR"). He suggested that these differences could be used to diagnose cancer, though later research would find that these differences, while real, are too variable for diagnostic purposes. Damadian's initial methods were flawed for practical use, relying on a point-by-point scan of the entire body and using relaxation rates, which turned out to not be an effective indicator of cancerous tissue. While researching the analytical properties of magnetic resonance, Damadian created the world's first magnetic resonance imaging machine in 1972. He filed the first patent for an MRI machine, U.S. patent #3,789,832 on March 17, 1972, which was later issued to him on February 5, 1974. As the National Science Foundation notes, "The patent included the idea of using NMR to 'scan'

the human body to locate cancerous tissue." However, it did not describe a method for generating pictures from such a scan or precisely how such a scan might be done. Damadian along with Larry Minkoff and Michael Goldsmith, subsequently went on to perform the first MRI body scan of a human being on July 3, 1977. These studies performed on humans were published in 1977. In recording the history of MRI, Mattson and Simon (1996) credit Damadian with describing the concept of whole-body NMR scanning, as well as discovering the NMR tissue relaxation differences that made this feasible.

2003 Nobel Prize

Reflecting the fundamental importance and applicability of MRI in medicine, Paul Lauterbur of the University of Illinois at Urbana-Champaign and Sir Peter Mansfield of the University of Nottingham were awarded the 2003 Nobel Prize in Physiology or Medicine for their "discoveries concerning magnetic resonance imaging". The Nobel citation acknowledged Lauterbur's insight of using magnetic field gradients to determine spatial localization, a discovery that allowed rapid acquisition of 2D images. Mansfield was credited with introducing the mathematical formalism and developing techniques for efficient gradient utilization and fast imaging. The actual research that won the prize was done almost 30 years before, while Paul Lauterbur was at Stony Brook University in New York. The award was vigorously protested by Raymond Vahan Damadian, founder of FONAR Corporation, who claimed that he invented the MRI and that Lauterbur and Mansfield had merely refined the technology. An ad hoc group, called "The Friends of Raymond Damadian", took out full-page advertisements in the New York Times and The Washington Post entitled "The Shameful Wrong That Must Be Righted", demanding that he be awarded at least a share of the Nobel Prize. Also, even earlier, in the Soviet Union, Vladislav Ivanov filed (in 1960) a document with the USSR State Committee for Inventions and Discovery at Leningrad for a Magnetic Resonance Imaging device, although this was not approved until the 1970s. In a letter to Physics Today, Herman Carr pointed out his own even earlier use of field gradients for one-dimensional MR imaging.

THE PHYSICS OF MAGNETIC RESONANCE IMAGING

MRI relies on the fact that some atoms within the human body possess an odd unpaired proton. The proton nucleus of the hydrogen atom is one of the most abundant examples, being a major constituent of water. It responds particularly well to the application of an external magnetic field and is therefore one of the simplest atom to use for MRI. Another example is phosphorus, which as a component of adenosine triphosphate, allows for many metabolic processes to be studied. These nuclei possess a spin that results in a local magnetic field because of their charge, allowing them to act like small magnets. The alignment of these nuclei is usually random (Figure A), however when a strong electromagnetic field is applied to the body they align themselves with that field. (Figure B)

These nuclei can be turned out of alignment with the magnetic field by applying brief bursts of radiofrequency energy, creating an electromagnetic field perpendicular to the first magnetic field. When the electromagnetic field is removed, the radio-frequency energy taken up by the nuclei is released slowly as they relax back into alignment. The rate at which realignment takes place depends on the type of nucleus, or element being measured, and thus the emitted signal depends on the molecular properties of the tissue.1 This low radiofrequency radiation that is emitted induces an electrical signal within a set of three orthogonal gradient coils in the MRI machine. They are positioned in the transverse (X and Y) and longitudinal (Z) planes allowing for encoding of spatial information. The detected signals are therefore able to form a three-

dimensional image of the body. It is these gradient coils that are rapidly turned on and off during an MRI study that is responsible for the loud banging noises

Different tissues within the body have different relaxation rates. T refers to the relaxation time constant, and images may be T1 weighted (generated a few milliseconds after the electromagnetic field is removed) or T2 weighted (generated later than T1), depending on the characteristics of the tissue you wish to look at. Nuclei in hydrogen take a long time to decay to their original position, so fluid will appear dark (minimal signal) in a T1 weighted (early) image (Figure 1), but white in the later T2 image as the signal appears.3 (Figure 2)

Because the signal that makes up the final MR image is very weak, any external radiofrequency sources can greatly interfere with its detection by the gradient coils. To prevent this the MRI machine is contained within a radiofrequency shield called a Faraday cage. This is built into the

fabric of the MR room. To allow infusion lines or monitoring cables to enter the MR room, a hollow brass tube or waveguide is built into the Faraday cage passing through into the control room. The Magnetic field MRI requires strong magnetic fields between 0.2 and 3.0 Tesla that are generated by superconductors. To minimise the electrical resistance of the superconducting coils, they are immersed in liquid helium and cooled to below 4.2 Kelvin. 1 Tesla = 10 000 Gauss (Earths magnetic field = 0.5 1.0 Gauss) = 1 weber/m2 The magnetic field strength falls away exponentially from the magnet. A safety line is usually demarcated at the level of 0.5mTesla (5 Gauss) within which pacemakers will malfunction, and therefore unscreened personnel should not enter (see hazards section below). A second line is demarcated at 50 Gauss within which a significant attractive force will be encountered on all ferromagnetic objects, which risk becoming dangerous projectiles. Such items include gas cylinders, needles, watches, floor cleaners and patient trolleys. Within this line anaesthetic infusion pumps (or any electronic or mechanical equipment) may fail due to the effects of the magnetic field. While these lines of demarcation are often referred to theoretically, in practice many MRI units are simply divided into a safe zone outside the scanner, and the controlled hazardous zone within the MR examination room.

INDICATIONS FOR THE USE OF MAGNETIC RESONANCE IMAGING

MRI is usually the preferred imaging technique in the following cases: Posterior fossa and infratentorial pathology Sinus and orbit pathology, sensorineural hearing loss and cranial nerve pathology Cerebral inflammatory disease including encephalitis, myelitis and meningitis Brain abscess Acute ischaemic strokes Spinal cord soft tissue pathology including congenital, traumatic, neoplastic and vascular abnormalities and disc pathology Demyelinisation and the myelopathies Airway malformations Vascular malformations Liver vascular pathology Joint soft tissue pathology

CT scanning remains more useful for bony pathology, chest examinations, intracranial haemorrhage and abdominal and pelvic applications

Specialized MRI scans

Diffusion MRI Diffusion MRI measures the diffusion of water molecules in biological tissues. In an isotropic medium (inside a glass of water for example), water molecules naturally move randomly according to turbulence and Brownian motion. In biological tissues however, where the Reynolds number is low enough for flows to be laminar, the diffusion may be anisotropic. For example, a molecule inside the axon of a neuron has a low probability of crossing the myelin membrane. Therefore the molecule moves principally along the axis of the neural fiber. If it is known that molecules in a particular voxel diffuse principally in one direction, the assumption can be made that the majority of the fibers in this area are going parallel to that direction. The recent development of diffusion tensor imaging (DTI) enables diffusion to be measured in multiple directions and the fractional anisotropy in each direction to be calculated for each voxel. This enables researchers to make brain maps of fiber directions to examine the connectivity of different regions in the brain (using tractography) or to examine areas of neural degeneration and Magnetization Transfer MRI
Magnetization transfer (MT) refers to the transfer of longitudinal magnetization from free water protons to hydration water protons in NMR and MRI.

In magnetic resonance imaging of molecular solutions, such as protein solutions, two types of water molecules, free (bulk) and hydration (bound), are found. Free water protons have faster average rotational frequency and hence less fixed water molecules that may cause local field in homogeneity. Because of this uniformity, most free water protons have resonance frequency lying narrowly around the normal proton resonance frequency of 63 MHz (at 1.5 teslas). This also results in slower transverse magnetization dephasing and hence longer T2. Conversely, hydration water molecules are slowed down by interaction with solute molecules and hence create field inhomogeneities that lead to wider resonance frequency spectrum.

T1rho MRI T1 (T1rho): Molecules have a kinetic energy that is a function of the temperature and is expressed as translational and rotational motions, and by collisions between molecules. The moving dipoles disturb the magnetic field but are often extremely rapid so that the average effect over a long time-scale may be zero. However, depending on the time-scale, the interactions between the dipoles do not always average away. At the slowest extreme the interaction time is effectively infinite and occurs where there are large, stationary field disturbances (e.g. a metallic implant). In this case the loss of coherence is described as a "static dephasing". T2* is a measure of the loss of coherence in an ensemble of spins that include all interactions (including static dephasing). T2 is a measure of the loss of coherence that excludes static dephasing, using an RF pulse to reverse the slowest types of dipolar interaction. There is in fact a continuum of interaction time-scales in a given biological sample and the properties of the refocusing RF pulse can be tuned to refocus more than just static dephasing. In general, the rate of decay of an ensemble of spins is a function of the interaction times and also the power of the RF pulse. This type of decay, occurring under the influence of RF, is known as T1. It is similar to T2 decay but with some slower dipolar interactions refocused as well as the static interactions, hence T1T2 . Fluid Attenuated Inversion Recovery (Flair) Fluid Attenuated Inversion Recovery (FLAIR) is an inversion-recovery pulse sequence used to null signal from fluids. For example, it can be used in brain imaging to suppress cerebrospinal fluid (CSF) so as to bring out the periventricular hyperintense lesions, such as multiple sclerosis (MS) plaques. By carefully choosing the inversion time TI (the time between the inversion and excitation pulses), the signal from any particular tissue can be suppressed. Magnetic resonance angiography Magnetic resonance angiography (MRA) generates pictures of the arteries to evaluate them for stenosis (abnormal narrowing) or aneurysms (vessel wall dilatations, at risk of rupture). MRA is often used to evaluate the arteries of the neck and brain, the thoracic and abdominal aorta, the renal arteries, and the legs (called a "run-off"). A variety of techniques can be used to generate the pictures, such as administration of a paramagnetic contrast agent (gadolinium) or using a

technique known as "flow-related enhancement" (e.g. 2D and 3D time-of-flight sequences), where most of the signal on an image is due to blood that recently moved into that plane, see also FLASH MRI. Techniques involving phase accumulation (known as phase contrast angiography) can also be used to generate flow velocity maps easily and accurately. Magnetic resonance venography (MRV) is a similar procedure that is used to image veins. In this method, the tissue is now excited inferiorly, while signal is gathered in the plane immediately superior to the excitation planethus imaging the venous blood that recently moved from the excited plane. Magnetic resonance gated intracranial CSF dynamics (MR-GILD) Magnetic resonance gated intracranial cerebrospinal fluid (CSF) or liquor dynamics (MR-GILD) technique is an MR sequence based on bipolar gradient pulse used to demonstrate CSF pulsatile flow in ventricles, cisterns, aqueduct of Sylvius and entire intracranial CSF pathway. It is a method for analyzing CSF circulatory system dynamics in patients with CSF obstructive lesions such as normal pressure hydrocephalus. It also allows visualization of both arterial and venous pulsatile blood flow in vessels without use of contrast agents.

Magnetic resonance spectroscopy

Magnetic resonance spectroscopy (MRS) is used to measure the levels of different metabolites in body tissues. The MR signal produces a spectrum of resonances that correspond to different molecular arrangements of the isotope being "excited". This signature is used to diagnose certain metabolic disorders, especially those affecting the brain, and to provide information on tumor metabolism. Magnetic resonance spectroscopic imaging (MRSI) combines both spectroscopic and imaging methods to produce spatially localized spectra from within the sample or patient. The spatial resolution is much lower (limited by the available SNR), but the spectra in each voxel contains information about many metabolites. Because the available signal is used to encode spatial and spectral information, MRSI requires high SNR achievable only at higher field strengths (3 T and above).

Real-time MRI

Real-time MRI of a human heart at a resolution of 50 ms

Real-time MRI refers to the continuous monitoring (filming) of moving objects in real time. While many different strategies have been developed over the past two decades, a recent development reported a real-time MRI technique based on radial FLASH and iterative reconstruction that yields a temporal resolution of 20 to 30 milliseconds for images with an inplane resolution of 1.5 to 2.0 mm. The new method promises to add important information about diseases of the joints and the heart. In many cases MRI examinations may become easier and more comfortable for patients.

Interventional MRI
The lack of harmful effects on the patient and the operator make MRI well-suited for "interventional radiology", where the images produced by a MRI scanner are used to guide minimally invasive procedures. Of course, such procedures must be done without any ferromagnetic instruments. A specialized growing subset of interventional MRI is that of intraoperative MRI in which the MRI is used in the surgical process. Some specialized MRI systems have been developed that allow imaging concurrent with the surgical procedure. More typical, however, is that the surgical procedure is temporarily interrupted so that MR images can be acquired to verify the success of the procedure or guide subsequent surgical work.

Current density imaging Current density imaging (CDI) endeavors to use the phase information from images to reconstruct current densities within a subject. Current density imaging works because electrical currents generate magnetic fields, which in turn affect the phase of the magnetic dipoles during an imaging sequence. Magnetic resonance guided focused ultrasound In MRgFUS therapy, ultrasound beams are focused on a tissueguided and controlled using MR thermal imagingand due to the significant energy deposition at the focus, temperature within the tissue rises to more than 65 C (150 F), completely destroying it. This technology can achieve precise ablation of diseased tissue. MR imaging provides a three-dimensional view of the target tissue, allowing for precise focusing of ultrasound energy. The MR imaging provides quantitative, real-time, thermal images of the treated area. This allows the physician to ensure that the temperature generated during each cycle of ultrasound energy is sufficient to cause thermal ablation within the desired tissue and if not, to adapt the parameters to ensure effective treatment. Multinuclear imaging Hydrogen is the most frequently imaged nucleus in MRI because it is present in biological tissues in great abundance, and because its high gyromagnetic ratio gives a strong signal. However, any nucleus with a net nuclear spin could potentially be imaged with MRI. Such nuclei include helium-3, carbon-13, fluorine-19, oxygen-17, sodium-23, phosphorus-31 and xenon-129.
23 31

Na and

P are naturally abundant in the body, so can be imaged directly. Gaseous isotopes
17 19

such as 3He or 129Xe must be hyperpolarized and then inhaled as their nuclear density is too low to yield a useful signal under normal conditions.
17

O and

F can be administered in sufficient

quantities in liquid form (e.g. O-water) that hyperpolarization is not a necessity. Multinuclear imaging is primarily a research technique at present. However, potential applications include functional imaging and imaging of organs poorly seen on 1H MRI (e.g. lungs and bones) or as alternative contrast agents. Inhaled hyperpolarized 3He can be used to

image the distribution of air spaces within the lungs. Injectable solutions containing stabilized bubbles of hyperpolarized
129

13

C or

Xe have been studied as contrast agents for angiography

and perfusion imaging. 31P can potentially provide information on bone density and structure, as well as functional imaging of the brain.

HAZARDS AND SAFETY CONSIDERATIONS FOR PATIENTS AND STAFF IN THE MRI UNIT
1. The presence of a strong magnetic field The strong magnetic field poses by far the most important hazard related to anaesthesia and care of patients requiring MRI. These powerful magnetic fields are able to exert large forces on any ferromagnetic materials in close proximity. They may also induce currents in metallic objects causing local heating and may interfere with monitoring equipment. Conversely, ferromagnetic objects and electrical fields in the vicinity of the magnet will degrade the quality of the MR images produced. The safety aspects related to ferromagnetic objects as projectiles, implants, foreign bodies and as equipment will be discussed in further detail below. The human body is conductive and movement of the body within the magnetic field will induce weak electrical currents within the tissues. Movement of blood around the body will also result in the generation of electric potentials and current. These currents can cause symptoms such as nausea and vertigo as a result of excitation of the semicircular canals of the inner ear, or flashing lights due to their effects on the retina. The patient as well as the staff positioning a patient in the scanner and moving within the immediate vicinity of the magnet bore may occasionally notice these effects. There is currently no evidence that long-term repeated exposure to strong magnetic fields has a harmful effect on the human body, however current recommendations suggest that a time weighted average of 200mT over any 8-hour period should not be exceeded by healthcare personnel. Ideally all staff should vacate the MRI examination room whilst the scan is in progress.

2. Ferromagnetic objects and the projectile effect The attractive forces between the magnet and all ferromagnetic objects increase significantly as such objects are brought closer to the magnet. All ferromagnetic items brought within the 50 Gauss line will be subject to movement and may be rapidly accelerated into the magnetic field. Objects that are not fixed down therefore risk becoming dangerous projectiles and may cause injury to anyone in their path, as well as damage to equipment, and interference with the MR image generated.

All staff should be fully aware of the dangers of metal objects in the scanner, and before entering the controlled area of the examination room need to remove all ferromagnetic, metallic or conducting materials from their person. Magnetised items such as credit cards and mobile phone SIM cards are at risk of being damaged by proximity to the magnetic field. Before entering the examination room with an anaesthetised patient a careful inspection for metallic objects should be made. Items that typically might contain metals include needles, watches and jewellery, pagers, stethoscopes, anaesthetic gas cylinders, metallic trolleys, ECG electrodes, transdermal drug patches (GTN) and ventilator systems. After hours, floor polishers are particularly common projectiles.

3. Implants and foreign bodies Ferromagnetic materials may also be present inside the body and are subject to similar forces that can cause them to move or malfunction with potentially fatal consequences. Implanted ferromagnetic objects may also heat up significantly during the MR examination causing local tissue damage. Absolute contraindications to MRI include cochlear implants, intra-ocular metallic foreign bodies or shrapnel, or ferromagnetic arterial or aneurysm clips particularly neurovascular. Patients with cardiac pacemakers or implanted defibrillators must never undergo an MRI scan since these will malfunction within the Gauss line. Most modern patient implants, including metal prostheses, are non-ferromagnetic. General surgical clips, artificial heart valves and sternal wires are usually deemed safe since they are fixed by fibrous tissue. Nonetheless, no patient should ever enter an MR examination room if there is any doubt about the safely of an implanted device or foreign body. All patients therefore need to be screened prior to the MRI scan for the presence of metallic implants. This is the responsibility of the radiology staff, however all staff working within the MRI unit should be aware of these risks. The same precautions regarding foreign bodies and implanted devices apply to all hospital staff that work near the MRI scanner. Usually a standard screening questionnaire or metal check will suffice,

however X-rays may be used to search for metal implants if any doubt exists. The compatibility of any implanted devices with the MR scanner may be confirmed online via websites such as www.mrisafety.com

4. Equipment and monitoring issues All anaesthetic equipment and monitoring in the MR room should be MRI compatible. An important distinction exists between equipment that is designated MRI safe and that which is designated MRI compatible. MRI safe implies that a piece of equipment will not pose a danger to patients and staff if it enters an MRI examination room, but does not guarantee that it will function correctly or avoid degrading the image quality. MRI compatible equipment is both safe to enter the MR examination room and will operate normally within that environment without interference to the MR scanner. It is reasonable to deduce that all anaesthetic equipment used within the MRI examination room should therefore be MRI compatible. Where non-compatible equipment is used within the magnetic field they may pose serious hazards to the patient they may become projectile, cause burns if heated cables come in contact with the patient, or they may malfunction. In the past ferrous anaesthetic machines remained in the MR control room and anaesthetic breathing systems such as the co-axial Mapleson D or Bain circuit extended through the waveguide ports to the patient. MR compatible anaesthetic machines, ventilators and vaporisers are now available from most manufacturers and should be used instead. Anaesthetic breathing systems including the circle system, Bain circuit or Ayres T piece for children have all been used successfully. Piped gasses with back up cylinders made of a non-ferrous metal such as aluminium should be available. Although MR compatible equipment is likely to be more fragile and costly it is essential that minimal monitoring standards for routine anaesthesia are complied with. Suppliers often provide basic MR compatible monitors as part of the system. The anaesthetist must be aware of the fact that MR can interfere with accurate monitoring and monitors can similarly interfere with the MRI. The changing gradient fields and radiofrequency currents used for MRI can induce currents in monitoring leads. These can cause burns to the patient as well as interference with the monitoring. Fibre-optic or carbon fibre cabling should avoid this problem, however care must still be taken to avoid coiling of cables within the scanner, and padding should be placed between all leads and the patients skin. The converse applies too, and monitors should not emit radiofrequencies that might interfere with the image

quality. Mains power supply should be isolated or filtered, or battery power used. Batteries are ferromagnetic, and if used, the relevant equipment should be firmly secured. Monitoring screens should be present in the MR control room to allow for remote monitoring of the patient so that the anaesthetist can leave the MR examination room. Monitoring cables can be passed through the waveguide ports to facilitate this. All alarms should be visual because of the noise made by the MR scanner, and the view of the monitor, anaesthetic machine and patient should be unobstructed at all times. Electrocardiogram (ECG) monitoring cannot occur with standard electrodes and MR compatible electrodes are needed. They should be placed in a narrow triangle on the patients chest, and leads should be braided and short (15cm). Currents induced by blood flow through the transverse aorta will interfere with the ECG signal causing artefact in the ST-T complexes which mimics hyperkalaemia. Pulse oximeter cables should be insulated and placed as far from the scanner as possible. Finger burns have been reported with standard non compatible pulse oximeters. Non-invasive blood pressure monitoring is possible if connectors are changed to plastic, and invasive pressure monitoring is possible if the pressure transducer cabling is passed through the waveguides. MR compatible pressure transducers are available. Capnography and monitoring of airway pressures and gasses requires a longer sample tubing than is routine, this results in approximately a 20 second delay, which the anaesthetist should take into consideration. Infusion pumps may fail if close to the magnet where the magnetic field strength exceeds 50 Gauss.

5. Restricted access of the environment The MR scanner is designed to place the patient in the centre of the magnetic field within the bore of the magnet. As a result the patient is effectively enclosed within a narrow tube to which access is extremely limited. Newer designs include open C shaped magnets that are less claustrophobic for the awake patient and allow improved access, however these are only suitable for limited investigations as they do not allow such detailed investigations and the duration of the scans is longer. Not only is the patient access restricted, but also the MRI suite itself is an environment in which only suitably trained staff should be working. It is often located at a distance from the hospitals theatre facilities making readily available backup and assistance less likely.

6. High level acoustic noise Noise levels above the safe level of 85 decibels can be produced during MRI due to the rapid switching of the gradient coils. The exact magnitude of this noise depends on the sequence of images being collected and the strength of the magnetic field. Staff working in MRI units should protect themselves by remaining in the MR control room during sequence acquisition, or by wearing earplugs should they need to remain in the examination room. All patients should be given ear protection, regardless of if they are awake or anaesthetised. The anaesthetist should be aware that high ambient noise levels may mask normal auditory alerts such as monitor alarms or sound the sound of partial airway obstruction, so vigilance and attention to visual cues is essential.

7. Scavenging of anaesthetic gasses Volatile anaesthetic agents and nitrous oxide may be used for general anaesthesia in MR units. MR compatible scavenging systems are available and these gases should therefore be scavenged in the usual way to comply with the local regulations for these substances. (Control of Substances Hazardous to Health or COSHH regulations in the United Kingdom)

8. Quenching of superconducting magnets The coils used in MR magnets need to be kept cold in order to maintain superconductivity. This is achieved by immersing them in liquid coolants or cryogens, liquid helium being the most commonly used in modern MRI units. Quenching is a process involving the rapid boil-off of the cryogen that causes an immediate loss of superconductivity. This may occur spontaneously as a system error during installation, services and power ups, or may be deliberately induced in order to shutdown the magnetic field. If this happens, the magnetic field will be lost and a large volume of helium gas will be produced. This is normally vented to the outside atmosphere through a quench pipe. In the event of damage to the quench pipe, the build-up of helium within the scanning room could potentially lead to asphyxiation. Oxygen sensors must be present in the scanning room to alert the staff in the control room to a hypoxic environment. All Staff working in an MRI unit should be aware of the emergency procedures for quenching.

9. Hazards of MRI during pregnancy The MRI unit may pose hazards to the developing foetus, including exposure to strong magnetic fields, high noise levels and unscavenged anaesthetic gases. Although limited evidence exists, in the United Kingdom it is currently recommended that pregnant women should ideally not be scanned during the first trimester of pregnancy. Pregnant staff working within the MRI unit should be advised of the risks posed by this environment, and given the option of not entering the inner controlled area during their first trimester.

10. Use of contrast agents The most commonly used intravenous MR contrast agent is gadolinium dimeglumine (Gd-DTPA or Magnevist). It is used to increase the signal intensity on T1 weighted scans and reduce the signal intensity on T2 weighted scans. It is often used in contrast-enhanced MR angiography and to help identify tumours. Since it does not normally cross the blood brain barrier it may be used to demonstrate areas where it has broken down and to delineate intracranial pathology. GdDTPA is used in doses of 0.2 ml/kg and has minor side effects including nausea, vomiting an pain on injection. There are rare complications of gadolinium called nephrogenic systemi fibrosis or nephrogenic fibrosing dermopathy, seen in association with renal impairment; all patients should have an assessment of renal function before MRI, either by history or by urea and creatinine assay. There has been one incidence of anaphylactoid reaction reported.

11. Maintenance of body temperature A theoretical problem during sedation or anaesthesia of infants and neonates for MRI is the maintenance of body temperature within this cooled environment. Passive heat loss should be prevented by minimizing exposure and by returning the infant to a warm environment as soon as possible. Recent studies examining the effect of MRI on body core temperature in sedated infants and children have suggested that this problem is not as significant as once thought. Radiofrequency radiation produced by the MR scanner and absorbed by the patient causes an increase in body temperature,suggesting that active heating is unnecessary and may in fact cause hyperthermia. This rise in temperature was more profound in 3 T than in 1.5 T examinations.

PATIENT MANAGEMENT FOR MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging requires a patient to lie still in a noisy and restricted space for prolonged periods of time. By far the greater majority of patients should be able to achieve this without the intervention of an anaesthetist. Understandably this may not be possible for certain groups of patients, particularly young children. All cases referred for general anaesthesia should be evaluated and have the risks of anaesthesia weighed against the benefits of the investigation. Not all patients require general anaesthesia. For example, with regards to infants and children, other management strategies may be commonly utilized: Behavioural techniques, including reassurance, communication through informative booklets, videos and visits to the unit, rehearsal of scans and the skills of play specialists. Natural sleep techniques, including the feed and wrap method for neonates, and sleep deprivation prior to a scan for toddlers. Sedation techniques, lead by specialist and experienced nurse lead sedation services have been shown to be both highly successful and very safe.

The following groups are more likely to require general anaesthesia: Infants and children Patients with learning difficulties Patients with certain seizure or movement disorders Patients with claustrophobia Critically ill patients Patients undergoing neurological examinations, particularly where raised intracranial pressure is a concern (sedation is contraindicated as it can be potentially dangerous)

CONDUCT OF GENERAL ANAESTHESIA FOR MRI All patients for MRI should be pre-assessed by their anaesthetist and starvation guidelines should be the same as for any general anaesthetic. A metal check must be performed by the radiology staff prior to induction of anaesthesia. The choice of anaesthesia technique depends on factors such as the length of the scan, the age of the child, associated co-morbidities such as raised intracranial pressure, or the need for a breath hold as for cardiac MRI scans. Small infants <5kg that require anaesthesia are best managed by intubation and ventilation; older children may be managed by spontaneous ventilation with an LMA. Induction of anaesthesia should occur in a dedicated room adjacent to the MR examination room. This induction room should contain all standard anaesthetic equipment, monitoring, drugs and resuscitation equipment. It can also be used as a post anaesthesia recovery area if necessary. Prior to induction, patients should be placed on a non-ferrous trolley (without oxygen cylinders) so that they can be safely transferred to the MR room once they are anaesthetised. Before this transfer a brief second metal check should occur to look for loose objects such as needles, oxygen cylinders and stethoscopes etc, which may have strayed onto the patients trolley. In the MR examination room the patient can be transferred onto the MRI scanner and maintenance of anaesthesia and monitoring should be recommenced immediately. A check to ensure that the airway is secure is important since once inside the scanner, the patient will be relatively inaccessible. Patients having head scans will have a receiver coil placed over their heads, which further reduces access. Maintenance of anaesthesia may be either inhalational or intravenous. If volatiles are given, the vaporiser should be MR compatible. TIVA is an acceptable technique for MRI, but some infusion pumps may act as projectiles or malfunction close to the magnetic field. Keeping these pumps in the control room and passing the connecting lines through the waveguide will avoid this. Ear protection should be provided for the patient prior to commencing the scan, and should be removed before waking them up. The anaesthetist may then exit the MR examination room and monitor the patient from the control room if the facilities for this exist. Once the study has been completed, the patient should be removed from the scanner and be woken up and recovered in a suitable recovery area. Analgesia is unlikely to be required for MRI scanning, although paracetamol may be useful if the child has a sore throat or is complaining of headache. Many children may be managed as day cases for MRI scans, depending on their associated co-morbidities, and may be

discharged from the recovery or ward area once they meet the normal discharge criteria for day case procedures. CONSENT FOR ANAESTHESIA FOR MRI Unlike anaesthesia for invasive surgical procedures where the consent for anaesthesia is implied by the act of consenting for the surgery, and contrary to routine MRI where written consent is not required, the consent for MRI under general anaesthesia remains a complex issue. In order to obtain truly informed consent input should ideally be provided from the referring clinician who has requested the investigation, the radiologist who is performing the scan, and the anaesthetist responsible for the general anaesthesia. Recent review of this issue has suggested that it is the referring clinician who is best suited to explain the intended benefits, side effects and risks of the procedure, and thus to obtain written consent. Nevertheless it remains incumbent upon the responsible anaesthetist to review the anaesthetic plan and risks with the patient prior to the procedure.

EMERGENCIES IN THE MRI SUITE Owing to the presence of a strong magnetic field and the risk of projectiles, as well as the restricted access imposed by the MRI scanner, it is impossible to manage emergencies and resuscitation within the scanning room and Gauss line. In the event of an emergency the patient should be removed from the magnetic field as quickly as possible and transferred to the induction room, which should be close to the scanner and will contain the necessary anaesthetic and resuscitation equipment and drugs. The resuscitation team should know not to enter the Gauss line of the inner controlled area, and in the event of an emergency should be directed by radiology staff to the induction/resuscitation room.

INTENSIVE CARE PATIENTS REQUIRING MRI MRI of critically ill adults and children is becoming both an important diagnostic and prognostic tool. These patients require special expertise, planning and time to be safely examined by MR.12 One notable challenge includes the multiple drug infusions that these patients might require, inotropic therapy being of particular concern. All unnecessary infusions should be discontinued. Those that are required should be infused through extensions of adequate length, which can be passed through the waveguide to a pump remaining in the MR control room. Non-compatible

MR syringe drivers used within the MR examination room may deliver incorrect drug doses with significant patient safety dangers. If MR compatible infusion pumps exist they may be used in the MR examination room, however the anaesthetist may need to remain in the room if the pumps rate needs to be changed. Critically ill patients also require a higher standard of monitoring. All monitoring equipment should be changed to MR compatible versions within the anaesthetic induction room before entering the MR examination room. Arterial pressure transducers can be passed through the waveguide if not compatible.Pulmonary artery catheters with conductive wires in contact with heart muscle and epicardial pacing wires pose a theoretical risk of micro-shock; these should be removed prior to the examination. Central venous catheters pose no risk to the patient. All in-dwelling catheters should be disconnected from electrical connections and external accessories before entering the MR examination room. Lastly, care should be taken to ensure that no surgical interventions undertaken have left the patient with internal metal work. Often where the patients history is vague, a pre-MR X-ray screen might be required. Many tracheostomy tubes are not MR compatible and will need to be changed prior to the examination. The pilot balloons of cuffed tracheal tubes may contain a small ferromagnetic spring that will need to be taped securely away from the area being scanned.

CONCLUSION

MRI is now a routine investigation, and as the demand for MRI scans increases so will the need for general anaesthesia in this environment and for MRI scans of more challenging patients. New scanning techniques are being developed in the areas of orthopaedic soft tissue imaging and dynamic cardiac imaging. Operating theatres and intensive care units incorporating open MRI scanners are being developed and introduced. Scanners that permit access to the patient allow for perioperative scanning. This is an area of anaesthetic practice that will grow in the future, and in order to maintain the current levels of patient care and safety, all anaesthetists should remain familiar with the challenges posed by this unique environment.

REFERENCES
1. Davis PD, Kenny GNC. Basic Physics and Measurement in Anaesthesia, Fifth Edition. Butterworth Heinemann, 2002; 269 71 2. Peden CJ, Twigg SJ. Anaesthesia for magnetic resonance imaging. Continuing Education in Anaesthesia, Critical Care and Pain. 2003; 3: 97 101 3. Bricker S. The Anaesthesia Science Viva book, First edition. Greenwich Medical Media Ltd, 2004; 256 57 4. Association of Anaesthetists of Great Britain and Ireland. Provision of anaesthetic services in magnetic resonance units. May 2002. Website: www.aagbi.com 5. Roth JL, Nugent m et al. Patient monitoring during Magnetic resonance imaging. Anaesthesiology. 1985; 62: 80 83 6. Taber KH, Thompson J et al. Invasive pressure monitoring of patients during magnetic resonance imaging. Canadian Journal of Anaesthesia. 1993; 40: 1092 5 7. Sesay M, Tauzin-Fin P et al. Audibility of anaesthesia alarms during magnetic resonance imaging: should we be alarmed? European Journal of Anaesthesiology. 2009; 26: 117 122 8. Machata AM, Willschke H et al. Effect of brain magnetic resonance imaging on body core temperature in sedated infants and children. British Journal of Anaesthesia. 2009; 9. Sury MRJ, Harker H et al. The management of infants and children for painless imaging. Clinical Radiology. 2005; 60: 731 741 10. Sury MRJ, Hatch DJ et al. Development of a nurse-led sedation service for paediatric magnetic resonance imaging. The Lancet. 1999; 353:1667 71 11. Wellesly H, Chong WK, Segar P. Who should obtain written consent for magnetic resonance imaging under general anesthesia? Pediatric Anesthesia. 2009; 19: 961 63 12. Tobin JR, Spurrier EA, Wetzel RC. Anaesthesia for critically ill children during Magnetic Resonance Imaging. British Journal of Anaesthesia. 1992; 69: 482 86 13. Kampen J, Tonner PH, Scholz J. Patient safety during anaesthesia for magnetic resonance imaging. European Journal of Anaesthesiology. 2004; 21: 320 35 14. Odegard KC, DiNardo JA et al. Anaesthesia considerations for cardiac MRI in infants and small children. Paediatric Anaesthesia. 2004

MAGNETIC RESONANCE IMAGING

MADE BY: MUKUL ATTRI SEC-S 9013

SUBMITTED TO: Ms. Mallela Martha prem latha

CONTENTS

INTRODUCTION HISTORY THE PHYSICS OF MAGNETIC RESONANCE IMAGING THE INDICATIONS FOR THE USE OF RESONANCE IMAGING SPECIALIZED MRI SCANS HAZARDS AND SAFETY CONSIDERATIONS FOR

PATIENTS AND STAFF IN THE MRI UNIT PATIENT MANAGEMENT FOR MAGNETIC RESONANCE IMAGING CONCLUSION REFERENCES