MR systems for MRI-guided interventions

Intraoperative MRI for Brain Tumors

INTRODUCTION

The use of intraoperative imaging has been a critical tool in the neurosurgeon's armamentarium and is of particular benefit during tumor surgery. This article summarizes the history of its development, implementation, clinical experience and future directions.

METHODS

We reviewed the literature focusing on the development and clinical experience with intraoperative MRI. Utilizing the authors' personal experience as well as evidence from the literature, we present an overview of the utility of MRI during neurosurgery.

RESULTS

In the 1990s, the first description of using a low field MRI in the operating room was published describing the additional benefit provided by improved resolution of MRI as compared to ultrasound. Since then, implementation has varied in magnetic field strength and in configuration from floor mounted to ceiling mounted units as well as those that are accessible to the operating room for use during surgery and via an outpatient entrance to use for diagnostic imaging. The experience shows utility of this technique for increasing extent of resection for low and high grade tumors as well as preventing injury to important structures while incorporating techniques such as intraoperative monitoring.

CONCLUSION

This article reviews the history of intraoperative MRI and presents a review of the literature revealing the successful implementation of this technology and benefits noted for the patient and the surgeon.

Percutaneous MR-guided interventions using an optical Moiré Phase tracking system: Initial results

The aim of this study was the development and evaluation of a real-time guidance support using optical Moiré Phase Tracking (MPT) for magnetic resonance (MR) guided percutaneous interventions. A gradient echo sequence, capable of real-time position updates by the MPT system, was modified to enable needle guidance based on four rigidly attached MPT markers at the back of a needle. Two perpendicular imaging planes were automatically aligned along the calibrated needle and centered at its tip. For user guidance, additional information about the needle trajectory and the tip to target distance were added as image overlay. Both, images and guiding information were displayed on the in-room monitor to facilitate MR guided interventions. The guidance support was evaluated by four experienced interventional radiologists and four novices targeting rubber O-rings embedded in a custom-made phantom on a 3T wide-bore MRI system (80 punctures). The skin to target time, user error, system error and total error were analyzed. The mean skin to target time was 146s±68s with no statistically significant difference between experts and novices. A low mean user error (0.91mm±0.43mm), system error (0.53mm±0.27mm) and total error (0.99mm±0.47mm) was reached in all directions. No statistically significant difference in user error, system error and total error could be found between experts and novices. The presented tracking and image guidance system combined with the user interface offers continuous and interactive control of the imaging plane while puncturing in the magnet enabling accurate real-time feedback for both, experienced and non-experienced users.

Motion compensation for MRI-compatible patient-mounted needle guide device: estimation of targeting accuracy in MRI-guided kidney cryoablations

Patient-mounted needle guide devices for percutaneous ablation are vulnerable to patient motion. The objective of this study is to develop and evaluate a software system for an MRI-compatible patient-mounted needle guide device that can adaptively compensate for displacement of the device due to patient motion using a novel image-based automatic device-to-image registration technique. We have developed a software system for an MRI-compatible patient-mounted needle guide device for percutaneous ablation. It features fully-automated image-based device-to-image registration to track the device position, and a device controller to adjust the needle trajectory to compensate for the displacement of the device. We performed: (a) a phantom study using a clinical MR scanner to evaluate registration performance; (b) simulations using intraoperative time-series MR data acquired in 20 clinical cases of MRI-guided renal cryoablations to assess its impact on motion compensation; and (c) a pilot clinical study in three patients to test its feasibility during the clinical procedure. FRE, TRE, and success rate of device-to-image registration were 2.71 ± 2.29 mm, 1.74 ± 1.13 mm, and 98.3% for the phantom images. The simulation study showed that the motion compensation reduced the targeting error for needle placement from 8.2 mm to 5.4 mm (p  <  0.0005) in patients under general anesthesia (GA), and from 14.4 mm to 10.0 mm (p < 1.0 × 10(−5)) in patients under monitored anesthesia care (MAC). The pilot study showed that the software registered the device successfully in a clinical setting. Our simulation study demonstrated that the software system could significantly improve targeting accuracy in patients treated under both MAC and GA. Intraprocedural image-based device-to-image registration was feasible.

Enabling Technology for MRI-Guided Intervention

The use of magnetic resonance imaging (MRI) for image-guided intervention poses both great opportunity and challenges. Although MRI is distinguished by its excellent contrast resolution and lack of ionizing radiation, it was not till the 1990s that technologic innovations allowed for adoption of MRI as a guidance modality for intervention. With advances in magnet, protocol, coil, biopsy needle, and ablation probe design, MRI has emerged as a viable, and increasingly, preferable alternative to other image guidance modalities. With the development of targeting software, augmented reality, robotic assist devices, and MR thermometry, the future of MRI-guided interventions remains promising.

Cardiac MR imaging: current status and future direction

Coronary artery disease is currently a worldwide epidemic with increasing impact on healthcare systems. Magnetic resonance imaging (MRI) sequences give complementary information on LV function, regional perfusion, angiogenesis, myocardial viability and orientations of myocytes. T2-weighted short-tau inversion recovery (T2-STIR), fat suppression and black blood sequences have been frequently used for detecting edematous area at risk (AAR) of infarction. T2 mapping, however, indicated that the edematous reaction in acute myocardial infarct (AMI) is not stable and warranted the use of edematous area in evaluating therapies. On the other hand, cine MRI demonstrated reproducible data on LV function in healthy volunteers and LV remodeling in patients. Noninvasive first pass perfusion, using exogenous tracer (gadolinium-based contrast media) and arterial spin labeling MRI, using endogenous tracer (water), are sensitive and useful techniques for evaluating myocardial perfusion and angiogenesis. Recently, new strategies have been developed to quantify myocardial viability using T1-mapping and equilibrium contrast enhanced MR techniques because existing delayed contrast enhancement MRI (DE-MRI) sequences are limited in detecting patchy microinfarct and diffuse fibrosis. These new techniques were successfully used for characterizing diffuse myocardial fibrosis associated with myocarditis, amyloidosis, sarcoidosis heart failure, aortic hypertrophic cardiomyopathy, congenital heart disease, restrictive cardiomyopathy, arrhythmogenic right ventricular dysplasia and hypertension). Diffusion MRI provides information regarding microscopic tissue structure, while diffusion tensor imaging (DTI) helps to characterize the myocardium and monitor the process of LV remodeling after AMI. Novel trends in hybrid imaging, such as cardiac positron emission tomography (PET)/MRI and optical imaging/MRI, are recently under intensive investigation. With the promise of higher spatial-temporal resolution and 3D coverage in the near future, cardiac MRI will be an indispensible tool in the diagnosis of cardiac diseases, coronary intervention and myocardial therapeutic delivery.

Occupational exposure in MRI

This article reviews occupational exposure in clinical MRI; it specifically considers units of exposure, basic physical interactions, health effects, guideline limits, dosimetry, results of exposure surveys, calculation of induced fields and the status of the European Physical Agents Directive. Electromagnetic field exposure in MRI from the static field B(0), imaging gradients and radiofrequency transmission fields induces electric fields and currents in tissue, which are responsible for various acute sensory effects. The underlying theory and its application to the formulation of incident and induced field limits are presented. The recent International Commission on Non-Ionizing Radiation Protection (ICNIRP) Bundesministerium für Arbeit und Soziales and Institute of Electrical and Electronics Engineers limits for incident field exposure are interpreted in a manner applicable to MRI. Field measurements show that exposure from movement within the B(0) fringe field can exceed ICNIRP reference levels within 0.5 m of the bore entrance. Rate of change of field dB/dt from the imaging gradients is unlikely to exceed the new limits, although incident field limits can be exceeded for radiofrequency (RF) exposure within 0.2-0.5 m of the bore entrance. Dosimetric surveys of routine clinical practice show that staff are exposed to peak values of 42 ± 24% of B(0), with time-averaged exposures of 5.2 ± 2.8 mT for magnets in the range 0.6-4 T. Exposure to time-varying fields arising from movement within the B(0) fringe resulted in peak dB/dt of approximately 2 T s(-1). Modelling of induced electric fields from the imaging gradients shows that ICNIRP-induced field limits are unlikely to be exceeded in most situations; however, movement through the static field may still present a problem. The likely application of the limits is discussed with respect to the reformulation of the European Union (EU) directive and its possible implications for MRI.

MR fluoroscopy in vascular and cardiac interventions (review)

Vascular and cardiac disease remains a leading cause of morbidity and mortality in developed and emerging countries. Vascular and cardiac interventions require extensive fluoroscopic guidance to navigate endovascular catheters. X-ray fluoroscopy is considered the current modality for real time imaging. It provides excellent spatial and temporal resolution, but is limited by exposure of patients and staff to ionizing radiation, poor soft tissue characterization and lack of quantitative physiologic information. MR fluoroscopy has been introduced with substantial progress during the last decade. Clinical and experimental studies performed under MR fluoroscopy have indicated the suitability of this modality for: delivery of ASD closure, aortic valves, and endovascular stents (aortic, carotid, iliac, renal arteries, inferior vena cava). It aids in performing ablation, creation of hepatic shunts and local delivery of therapies. Development of more MR compatible equipment and devices will widen the applications of MR-guided procedures. At post-intervention, MR imaging aids in assessing the efficacy of therapies, success of interventions. It also provides information on vascular flow and cardiac morphology, function, perfusion and viability. MR fluoroscopy has the potential to form the basis for minimally invasive image-guided surgeries that offer improved patient management and cost effectiveness.

Magnetic resonance-guided interventions of large and small joints

Magnetic resonance (MR)-guided interventions of large and small joints are feasible and safe procedures offering several advantages compared with standard guiding techniques. Nevertheless, MR-guided interventions are not routinely performed in daily practice apart from a few centers. Accurate injections are crucial for clinical outcome in diagnostic arthrography as well as therapeutic joint injections. In particular, palpatory joint puncture was shown to be inaccurate or uncertain in a substantial percentage of injections of the shoulder, the hip, and the knee. Magnetic resonance imaging offers respective merits of a cross-sectional technique with high soft-tissue contrast. Exact depiction of structures, which should be preserved, such as the labrum, should be aimed for. Areas with complex anatomy can be approached by adapting the right imaging plane(s) because of multiplanar capacity. Lack of ionizing radiation for patients is of growing interest particularly in young patients with repeated interventions. Magnetic resonance guidance alone allows an "all-in-one" MR arthrography combining precise targeting with high-field-strength imaging. Modern short-bore and open-bore high-field-strength systems offer a good comfort for patients as well as clinicians and enhance patient positioning options such as supine or prone position. Thus, a tailored approach such as a posterior technique for suspected anterior lesions in shoulder MR arthrography is possible.In this article, we describe the advantages and limitations of MR guidance in joint interventions with focus on shoulder and hip interventions. We review the requirements for needle material and MR sequences, discuss several different techniques developed to date, and present current results in clinical outcome.

Evolution from active surveillance to focal therapy in the management of prostate cancer

Organ-preserving therapies are widely accepted in many facets of medicine and, more recently, in oncology. For example, partial nephrectomy is now accepted as a preferred alternative over radical nephrectomy for small (up to 4 cm or T1) tumors. Focal therapy (FT) is another organ-preserving strategy applying energy (cryotherapy, laser ablation and/or high-intensity focused ultrasound) to destroy tumors while leaving the majority of the organ, surrounding tissue and structures unscathed and functional. Owing to the perceived multifocality of prostate cancer (PCa) technology limitations, in the past PCa was not considered suitable for FT. However, with the rise of active surveillance for the management of low-risk PCa in carefully selected patients, FT is emerging as an alternative. This is owing to technology improvements in imaging and energy-delivery systems to ablate tissue, as well as the realization that many men and clinicians still desire tumor control. With the postulated ability to ablate tumors with minimal morbidity, FT may have found a role in the management of PCa; the aim of FT a being long-term cancer control without the morbidity associated with radical therapies. Data for FT in PCa have been derived from case series and small Phase I trials, with larger cohort studies with longer follow-up having only just commenced. More data from large trials on the safety and efficacy of FT are required before this approach can be recommended in men with PCa. Importantly, studies must confirm that no viable cancer cells remain in the region of ablation. FT might eventually prove to be a ‘middle ground’ between active surveillance and radical treatment, combining minimal morbidity with cancer control and the potential for retreatment.

Interventional MRI using multiple 3D angiography roadmaps with real-time imaging

PURPOSE

To enhance real-time magnetic resonance (MR)-guided catheter navigation by overlaying colorized multiphase MR angiography (MRA) and cholangiopancreatography (MRCP) roadmaps in an anatomic context.

MATERIALS AND METHODS

Time-resolved MRA and respiratory-gated MRCP were acquired prior to real-time imaging in a pig model. MRA and MRCP data were loaded into a custom real-time MRI reconstruction and visualization workstation where they were displayed as maximum intensity projections (MIPs) in distinct colors. The MIPs were rendered in 3D together with real-time multislice imaging data using alpha blending. Interactive rotation allowed different views of the combined data.

RESULTS

Fused display of the previously acquired MIP angiography data with real-time imaging added anatomical context during endovascular interventions in swine. The use of multiple MIPs rendered in different colors facilitated differentiation of vascular structures, improving visual feedback during device navigation.

CONCLUSION

Interventional real-time MRI may be enhanced by combining with previously acquired multiphase angiograms. Rendered as 3D MIPs together with 2D slice data, this technique provided useful anatomical context that enhanced MRI-guided interventional applications.

A long arm for ultrasound: a combined robotic focused ultrasound setup for magnetic resonance-guided focused ultrasound surgery

PURPOSE

Focused ultrasound surgery (FUS) is a highly precise noninvasive procedure to ablate pathogenic tissue. FUS therapy is often combined with magnetic resonance (MR) imaging as MR imaging offers excellent target identification and allows for continuous monitoring of FUS induced temperature changes. As the dimensions of the ultrasound (US) focus are typically much smaller than the targeted volume, multiple sonications and focus repositioning are interleaved to scan the focus over the target volume. Focal scanning can be achieved electronically by using phased-array US transducers or mechanically by using dedicated mechanical actuators. In this study, the authors propose and evaluate the precision of a combined robotic FUS setup to overcome some of the limitations of the existing MRgFUS systems. Such systems are typically integrated into the patient table of the MR scanner and thus only provide an application of the US wave within a limited spatial range from below the patient.

METHODS

The fully MR-compatible robotic assistance system InnoMotion (InnoMedic GmbH, Herxheim, Germany) was originally designed for MR-guided interventions with needles. It offers five pneumatically driven degrees of freedom and can be moved over a wide range within the bore of the magnet. In this work, the robotic system was combined with a fixed-focus US transducer (frequency: 1.7 MHz; focal length: 68 mm, and numerical aperture: 0.44) that was integrated into a dedicated, in-house developed treatment unit for FUS application. A series of MR-guided focal scanning procedures was performed in a polyacrylamide-egg white gel phantom to assess the positioning accuracy of the combined FUS setup. In animal experiments with a 3-month-old domestic pig, the system's potential and suitability for MRgFUS was tested.

RESULTS

In phantom experiments, a total targeting precision of about 3 mm was found, which is comparable to that of the existing MRgFUS systems. Focus positioning could be performed within a few seconds. During in vivo experiments, a defined pattern of single thermal lesions and a therapeutically relevant confluent thermal lesion could be created. The creation of local tissue necrosis by coagulation was confirmed by post-FUS MR imaging and histological examinations on the treated tissue sample. During all sonications in phantom and in vivo, reliable MR imaging and online MR thermometry could be performed without compromises due to operation of the combined robotic FUS setup.

CONCLUSIONS

Compared to the existing MRgFUS systems, the combined robotic FUS approach offers a wide range of spatial flexibility so that highly flexible application of the US wave would be possible, for example, to avoid risk structures within the US field. The setup might help to realize new ways of patient access in MRgFUS therapy. The setup is compatible with any closed-bore MR system and does not require an especially designed patient table.

Origins of intraoperative MRI

Neurosurgical diagnosis and intervention has evolved through improved neuroimaging, allowing better visualization of anatomy and pathology. This article discusses the various systems that have been designed over the last decade to meet the requirements of neurosurgical patients and opines on the potential future developments in the technology and application of intraoperative MRI. Because the greatest amount of experience with intraoperative MRI comes from its use in brain tumor resection, this article focuses on the origins of intraoperative MRI in relation to this field.

Research design issues for the use of magnetic resonance imaging machines in brain studies of psychological/psychiatric variables

The magnetic resonance imaging (MRI) machine itself has an impact on the likelihood of obtaining successful measurements of brain size in certain groups of subjects. The differential selection and attrition in both cross-sectional and longitudinal designs, therefore, indicate that the MRI coincidentally serves as a screen for the anatomical structure of the brains that are successfully scanned. This screening effect introduces confounds in experiments whose very hypotheses are focused on comparing anatomical differences in subjects who differ, for example, in their reactions to anxiety-inducing situations. Here, behavioral interventions and possible statistical models are presented in order to reduce attrition and other effects of the confounds introduced by the MRI measurement process in research. Child and adolescent research-particularly in the attention-deficit/hyperactivity disorder research area-is used as an example to clarify and delineate the general research principles presented in the present article.

Origins of intraoperative MRI

Neurosurgical diagnosis and intervention has evolved through improved neuroimaging, allowing better visualization of anatomy and pathology. This article discusses the various systems that have been designed over the last decade to meet the requirements of neurosurgical patients and opines on the potential future developments in the technology and application of intraoperative MRI. Because the greatest amount of experience with intraoperative MRI comes from its use in brain tumor resection, this article focuses on the origins of intraoperative MRI in relation to this field.