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Tough New Questions Confront Radiologists in the Molecular Era

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Tough New Questions Confront Radiologists in the Molecular Era ECR TODAY DAILY NEwS fROM EUROpE’S lEADINg IMAgINg CONgRESS SUNDAY, MARCH 8, 2009 INSIDE TODAY ESR meets Sports Technology focus Switzerland Round-up on MRI See page 2 See page 5 See page 17 Tough new questions Experts speculate confront radiologists on the future of in the molecular era cardiac MR and CT By Philip Ward By Philip Ward Crystal-ball gazing reached new levels at ECR on Future magnetic resonance systems used in Saturday, when Prof. Dieter Enzmann took dele- cardiovascular imaging will inevitably operate gates on ‘a trip to radiology tomorrowland,’ as he at higher field strengths, including 7T, according referred to his W.C. Röntgen Honorary Lecture. to a leading cardiac radiologist. “Radiology is in the information business, not the “The future will be about more Tesla,” Prof. film-reading business, and that information is in Matthias Gutberlet of the cardiac imaging unit, image phenotypes, at least currently,” said Enz- department of diagnostic and interventional mann, chair at the David Geffen School of Medicine radiology, Leipzig University and Leipzig Heart at the University of California, Los Angeles. Center, Germany, told attendees at Saturday’s car- diac categorical course. Radiologists are good at gathering imaging data, Prof. Dieter R. Enzmann from Los Angeles/US Prof. Matthias Gutberlet from Leipzig/DE and they do this is because it leads to information The crucial aspects in cardiac MR are the analysis of upon which others can act. This in turn leads to future more closely resembles a network of multi- ventricular function, myocardial perfusion and via- The main advantages of 3T are its perfusion/via- Opening Ceremony a medical decision. Currently this process relies ple alternative pathways, Enzmann said. bility, and imaging of the coronary arteries, he said. bility, flow measurement, ‘tagging’/spectroscopy heavily on anatomic and physiologic information. applications, and effective imaging of the coronary Diseases are defined by the states of complex bio- Gutberlet emphasised this point by referring to arteries. Conversely, the main drawback is its high “The raison d’être of radiology is that there is a logic networks, and one of radiology’s goals is to research from the Society of Cardiovascular MR. cost and limited availability. medical decision. Without a medical decision, define the cell network and to establish its state. The SCMR asked its members: Which is the most there is not much need for radiology,” he said. important problem in your daily routine with car- In terms of image quality, all standard cardiac MR “What’s changing is that in medical decisions, “Radiology will be in the business of imaging bio- diac MR? A staggering 66% of the respondents sequences used for functional evaluation of left there are now additional factors to be considered.” logic networks and their states,” he predicted. “All replied imaging of the coronaries, whereas 17% ventricular function show an improved SNR and biological processes are driven by networks, not cited myocardial perfusion, 14% cited flow quan- contrast-to-noise ratio. In today’s molecular era, radiologists need new by simple pathways.” tification, 2% cited functional imaging, and 1% information, new imaging data, new knowledge, delayed enhancement imaging. “Image quality of MR flow measurements and and new experience. They will have to learn about Cancer is a paradigm for radiology’s network chal- myocardial tagging improves without changing integrated diagnosis by imaging phenotypes, lenges, and radiologists are uniquely positioned to Switching from 1.5T to 3T improves the image sequence parameters,” Gutberlet said. “In steady which consist of any observable physical or bio- detect and measure heterogeneity in cancer, he quality and doubles the signal-to-noise ratio state free precession (SSFP), sequence modifica- chemical characteristics of an organism. continued. In this context, it is important to regard (SNR). It reduces the acquisition time and tions are necessary.” cancer as a genetic disease that modifies the cell increases spatial resolution. Moving to 7T leads To offer an answer to any question, it is essential to network. Although this network is very complex, to further improvements in image quality by Furthermore, ‘excessive’ use of parallel ima- understand the question itself, but the questions a limited number of pathways cause abnormal increasing the SNR by around five times, i.e., ging enables improved spatial and/or temporal facing radiology are changing fast. Instead of being signaling in cancer. Therefore, cancer should be (SNR x 2) x 2.33, he explained. a straight and clearly defined road, radiology’s regarded as a signaling problem. continued on page 3 myESR.org 2 ECR TODAY 2009 HIGHLIGHTS Sunday, March 8, 2009 Swiss radiologists display their knowledge of high-field MR imaging systems By Paula Gould Switzerland is leading the way in terms of high- field MRI. The country has one of the highest densities of 3T systems in Europe, if not the world, delegates learned yesterday at the ‘ESR meets Switzerland’ session. Of the 207 MRI systems installed in Swiss hospitals and clinics, 42 are 3T units. This means that there are five 3T scanners for every million Swiss residents. In comparison, the number of 3T MRI scanners per million inhabitants is half this number in Germany. Swiss radiologists’ knowledge and expertise of high-field MRI was showcased at the 90-minute session, during which analogies were made between alpine peaks and the heights that radiologists are reaching at 3T. Presenters from four leading centres discussed the pros and cons of working at higher field strengths in a wide range of practical applications. High-field MRI is playing a key role in stroke management in Switzerland, according to Dr. Karl-Olav LØvblad, neuroradiologist at Geneva University Hospital. Because most 3T systems are sited in larger cities, air ambulances are used to transport stroke patients from remote, alpine Congress President Prof. Borut Marincek welcomes his fellow countrymen at yesterday’s ESR meets Switzerland session. locations to centres that have advanced imaging technology. better imaging. One downside, common to all Moving from 1.5T to 3T should boost diagnostic abdominal MRI at 1.5T. He then posed the “The problem with stroke imaging is that you applications, is that imaging is slower. The longer confidence when examining the knee, ankle, and question: why move to 3T at all when you can do have to do something very complex in a short T1 relaxation time means a longer TR. This shoulder, and when looking at cartilage defects. so much at 1.5T? space of time,” he said. is typically compensated for by using parallel However, returning to the mountain metaphors imaging. Some findings can also be missed on once again, Bonel observed that high-field MRI High-field MRI has traditionally presented Although CT is typically regarded as the high-field images. has yet to reach its peak. many challenges for abdominal radiologists, modality of choice when deciding which acute Weishaupt said. Issues associated with increased stroke patients should receive thrombolysis, MRI The higher spatial resolution realised at 3T has The case for 3T abdominal MRI has yet to energy deposition and acoustic noise, and greater may be a better bet. Diffusion-weighted MRI clear diagnostic advantages when imaging the be proven too, according to Prof. Dominik chemical shift artefacts are being overcome. is more sensitive to the detection of ischaemic hand and wrist, said Dr. Harald Bonel, radiologist Weishaupt, chair of radiology at Triemli He regards the major remaining problem to events. Moving from 1.5T to 3T for the scan at the University Hospital Inselspital, Bern, Hospital, Zurich. Weishaupt began his be B-field inhomogeneity and standing wave means double the signal-to-noise ratio, more who considered the topic of sports imaging. presentation by outlining the strengths of artefacts. BOLD contrast, and an increase in the effect of T1 relaxation of contrast. The benefits of 3T over 1.5T are clear-cut in a few abdominal imaging applications, Weishaupt New techniques that are under development said. For example, studies show that intrahepatic could tip the balance further in favour of MRI. bile ducts can be detected with more confidence Arterial spin labelling at 3T may remove the when MRCP is performed at 3T. The diagnosis need for contrast altogether when studying of focal liver lesions also appears to be improved revascularisation, LØvblad said. Meanwhile, when imaging with SPIO contrast is performed susceptibility-weighted imaging has been shown on a high-field system. to demonstrate haemorrhages better than standard T2* imaging sequences. The thorny issue of: ‘Is the gain worth the financial pain?’ was also debated when the “Three-T does have an impact on stroke imaging floor was opened up to questions. All speakers because by simply going beyond research stressed that the choice of whether to invest in purposes it allows clinical implementation of 3T depended critically on local circumstances. new and improved sequences,” LØvblad said. A clinic with a large neuroimaging workload, for example, would be well advised to invest Another area where high-field MRI can make in a high-field system. For departments with a a difference is myocardial perfusion imaging, mixed caseload, including a high proportion of according to Dr. Jens Bremerich, radiologist abdominal studies, the case may not be so clear- at the University Hospital in Basel. The most cut. robust protocol for perfusion MRI is first pass Dr. Harald Bonel from Berne/CH Dr. Jens Bremerich from Basel/CH contrast-enhanced imaging, he said. Other Prof. Borut Marincek, co-moderator for the options include BOLD imaging, spin labelling, session, challenged Weishaupt directly to say and magnetisation transfer, though these are what type of system he would buy next. The currently regarded as works-in-progress. Institute of Radiology at Triemli Hospital currently has just one 1.5T MRI system and Patients scheduled for 3T perfusion MRI at the the purchase of a second scanner is planned.
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