Physiological effects of fast oscillating magnetic field gradients

Experimental validation of a PNS-optimized whole-body gradient coil

PURPOSE

Peripheral nerve stimulation (PNS) limits the usability of state-of-the-art whole-body and head-only MRI gradient coils. We used detailed electromagnetic and neurodynamic modeling to set an explicit PNS constraint during the design of a whole-body gradient coil and constructed it to compare the predicted and experimentally measured PNS thresholds to those of a matched design without PNS constraints.

METHODS

We designed, constructed, and tested two actively shielded whole-body Y-axis gradient coil winding patterns: YG1 is a conventional symmetric design without PNS-optimization, whereas YG2's design used an additional constraint on the allowable PNS threshold in the head-imaging landmark, yielding an asymmetric winding pattern. We measured PNS thresholds in 18 healthy subjects at five landmark positions (head, cardiac, abdominal, pelvic, and knee).

RESULTS

The PNS-optimized design YG2 achieved 46% higher average experimental thresholds for a head-imaging landmark than YG1 while incurring a 15% inductance penalty. For cardiac, pelvic, and knee imaging landmarks, the PNS thresholds increased between +22% and +35%. For abdominal imaging, PNS thresholds did not change significantly between YG1 and YG2 (-3.6%). The agreement between predicted and experimental PNS thresholds was within 11.4% normalized root mean square error for both coils and all landmarks. The PNS model also produced plausible predictions of the stimulation sites when compared to the sites of perception reported by the subjects.

CONCLUSION

The PNS-optimization improved the PNS thresholds for the target scan landmark as well as most other studied landmarks, potentially yielding a significant improvement in image encoding performance that can be safely used in humans.

Influence of peripheral axon geometry and local anatomy on magnetostimulation chronaxie

Objective.Rapid switching of magnetic resonance imaging (MRI) gradient fields induces electric fields that can cause peripheral nerve stimulation (PNS) and so accurate characterization of PNS is required to maintain patient safety and comfort while maximizing MRI performance. The minimum magnetic gradient amplitude that causes stimulation, the PNS threshold, depends on intrinsic axon properties and the spatial and temporal properties of the induced electric field. The PNS strength-duration curve is widely used to characterize simulation thresholds for periodic waveforms and is parameterized by the chronaxie and rheobase. Safety limits to avoid unwanted PNS in MRI rely on a single chronaxie value to characterize the response of all nerves. However, experimental magnetostimulation peripheral nerve chronaxie values vary by an order of magnitude. Given the diverse range of chronaxies observed and the importance of this number in MRI safety models, we seek a deeper understanding of the mechanisms contributing to chronaxie variability.Approach.We use a coupled electromagnetic-neurodynamic PNS model to assess geometric sources of chronaxie variability. We study the impact of the position of the stimulating magnetic field coil relative to the body, along with the effect of local anatomical features and nerve trajectories on the driving function and the resulting chronaxie.Main results.We find realistic variation of local axon and tissue geometry can modulate a given axon's chronaxie by up to two-fold. Our results identify the temporal rate of charge redistribution as the underlying determinant of the chronaxie.Significance.This charge distribution is a function of both intrinsic axon properties and the spatial stimulus along the nerve; thus, examination of the local tissue topology, which shapes the electric fields, as well as the nerve trajectory, are critical for better understanding chronaxie variations and defining more biologically informed MRI safety guidelines.

Peripheral nerve stimulation informed design of a high-performance asymmetric head gradient coil

PURPOSE

Peripheral nerve stimulation (PNS) limits the image encoding performance of both body gradient coils and the latest generation of head gradients. We analyze a variety of head gradient design aspects using a detailed PNS model to guide the design process of a new high-performance asymmetric head gradient to raise PNS thresholds and maximize the usable image-encoding performance.

METHODS

A novel three-layer coil design underwent PNS optimization involving PNS predictions of a series of candidate designs. The PNS-informed design process sought to maximize the usable parameter space of a coil with <10% nonlinearity in a 22 cm region of linearity, a relatively large inner diameter (44 cm), maximum gradient amplitude of 200 mT/m, and a high slew rate of 900 T/m/s. PNS modeling allowed identification and iterative adjustment of coil features with beneficial impact on PNS such as the number of winding layers, shoulder accommodation strategy, and level of asymmetry. PNS predictions for the final design were compared to measured thresholds in a constructed prototype.

RESULTS

The final head gradient achieved up to 2-fold higher PNS thresholds than the initial design without PNS optimization and compared to existing head gradients with similar design characteristics. The inclusion of a third intermediate winding layer provided the additional degrees of freedom necessary to improve PNS thresholds without significant sacrifices to the other design metrics.

CONCLUSION

Augmenting the design phase of a new high-performance head gradient coil by PNS modeling dramatically improved the usable image-encoding performance by raising PNS thresholds.

Magneto-stimulation limits in medical imaging applications with rapid field dynamics

Objective. The goal of this work is to extend previous peripheral nerve stimulation (PNS) studies to scenarios relevant to magnetic particle imaging (MPI) and low-field magnetic resonance imaging (MRI), where field dynamics can evolve at kilo-hertz frequencies. Approach. We have constructed an apparatus for PNS threshold determination on a subject’s limb, capable of narrow and broad-band magnetic stimulation with pulse characteristic times down to 40 μs. Main result. From a first set of measurements on 51 volunteers, we conclude that the PNS dependence on pulse frequency/rise-time is compatible with traditional stimulation models where nervous responses are characterized by a rheobase and a chronaxie. Additionally, we have extended pulse length studies to these fast timescales and confirm thresholds increase significantly as trains transition from tens to a few pulses. We also look at the influence of field spatial distribution on PNS effects, and find that thresholds are higher in an approximately linearly inhomogeneous field (relevant to MRI) than in a rather homogeneous distribution (as in MPI). Significance. PNS constrains the clinical performance of MRI and MPI systems. Extensive magneto-stimulation studies have been carried out recently in the field of MPI, where typical operation frequencies range from single to tens of kilo-hertz. However, PNS literature is scarce for MRI in this fast regime, relevant to small (low inductance) dedicated MRI setups, and where the resonant character of MPI coils prevents studies of broad-band stimulation pulses. This work advances in this direction.

Evaluation of Peripheral Electrostimulation Thresholds in Human Model for Uniform Magnetic Field Exposure

The external field strength according to the international guidelines and standards for human protection are derived to prevent peripheral nerve system pain at frequencies from 300-750 Hz to 1 MHz. In this frequency range, the stimulation is attributable to axon electrostimulation. One limitation in the current international guidelines is the lack of respective stimulation thresholds in the brain and peripheral nervous system from in vivo human measurements over a wide frequency range. This study investigates peripheral stimulation thresholds using a multi-scale computation based on a human anatomical model for uniform exposure. The nerve parameters are first adjusted from the measured data to fit the peripheral nerve in the trunk. From the parameters, the external magnetic field strength to stimulate the nerve was estimated. Here, the conservativeness of protection limits of the international guidelines and standards for peripheral stimulation was confirmed. The results showed a margin factor of 4-6 and 10-24 times between internal and external protection limits of Institute of Electrical and Electronics Engineers standard (IEEE C95.1) and International Commission on Non-Ionizing Radiation Protection guidelines, with the computed pain thresholds.

Gradient waveform design for tensor-valued encoding in diffusion MRI

Diffusion encoding along multiple spatial directions per signal acquisition can be described in terms of a b-tensor. The benefit of tensor-valued diffusion encoding is that it unlocks the 'shape of the b-tensor' as a new encoding dimension. By modulating the b-tensor shape, we can control the sensitivity to microscopic diffusion anisotropy which can be used as a contrast mechanism; a feature that is inaccessible by conventional diffusion encoding. Since imaging methods based on tensor-valued diffusion encoding are finding an increasing number of applications we are prompted to highlight the challenge of designing the optimal gradient waveforms for any given application. In this review, we first establish the basic design objectives in creating field gradient waveforms for tensor-valued diffusion MRI. We also survey additional design considerations related to limitations imposed by hardware and physiology, potential confounding effects that cannot be captured by the b-tensor, and artifacts related to the diffusion encoding waveform. Throughout, we discuss the expected compromises and tradeoffs with an aim to establish a more complete understanding of gradient waveform design and its impact on accurate measurements and interpretations of data.

Experimental comparison of four nonlinear magnetic detection methods and considerations on clinical usability

Superparamagnetic iron oxide nanoparticles (SPIONs) are promising for clinical applications, because they have a characteristic nonlinear magnetic response when an external magnetic field is applied. This nonlinearity enables the distinct detection of SPIONs and makes measurements less sensitive to the human body and surgical steel instruments. In clinical applications, only a limited field strength for the magnetic detection is allowed. The signal to noise ratios (SNRs) of four nonlinear magnetic detection methods are compared. These methods include differential magnetometry and three variations of magnetic particle spectroscopy: frequency mixing, second harmonic detection and third harmonic detection. All methods were implemented on the same hardware and experimentally compared for various field strengths. To make the comparison fair, the same power was supplied to the excitation coil each time. In general, the SNR increases with increasing field strength. The SNR per drive field of all methods stabilizes or even decreases for field strengths above 6 mT. The second harmonic detection has the best SNR and the most room for improvement.

The response of the neuronal activity in the somatosensory cortex after high-intensity intermediate-frequency magnetic field exposure to the spinal cord in rats under anesthesia and waking states

Novel technologies using the intermediate-frequency magnetic field (IF-MF) in living environments are becoming popular with the advance in electricity utilization. However, the biological effects induced by the high-intensity and burst-type IF-MF exposure used in the wireless power transfer technologies for electric vehicles or medical devices, such as the magnetic stimulation techniques, are not well understood. Here, we developed an experimental platform using rats, that combined an 18 kHz, high-intensity (Max. 88 mT), Gaussian-shaped burst IF-MF exposure system with an in vivo extracellular recording system. In this paper, we aimed to report the qualitative differences in stimulus responses in the regions of the somatosensory cortex and peripheral nerve fibers that were induced by the IF-MF exposure to the rat spinal cord. We also report the modulation of the stimulus responses in the somatosensory cortex under anesthesia or waking states. Using this experimental platform, we succeeded in the detection of the motor evoked potentials or the neuronal activity in the somatosensory cortex that was induced by the IF-MF exposure to the spinal cord in rats. Compared to the state of anesthesia, the neuronal activities in the somatosensory cortex was enhanced during the waking state. On the other hand, these neuronal responses could not be confirmed by the IF-MF exposure-related coil sound only. Our experimental results indicated the basic knowledge of the biological responses and excitation mechanisms of the spinal cord stimulation by the IF-MF exposure.

Investigating cardiac stimulation limits of MRI gradient coils using electromagnetic and electrophysiological simulations in human and canine body models

Purpose:

Cardiac stimulation (CS) limits to gradient coil switching speed are difficult to measure in humans; instead, current regulatory guidelines (IEC 60601–2-33) are based on animal experiments and electric field–to-dB/dt conversion factors computed for a simple, homogeneous body model. We propose improvement to this methodology by using more detailed CS modeling based on realistic body models and electrophysiological models of excitable cardiac fibers.

Methods:

We compute electric fields induced by a solenoid, coplanar loops, and a commercial gradient coil in two human body models and a canine model. The canine simulations mimic previously published experiments. We generate realistic fiber topologies for the cardiac Purkinje and ventricular muscle fiber networks using rule-based algorithms, and evaluate CS thresholds using validated electrodynamic models of these fibers.

Results:

We were able to reproduce the average measured canine CS thresholds within 5%. In all simulations, the Purkinje fibers were stimulated before the ventricular fibers, and therefore set the effective CS threshold. For the investigated gradient coil, simulated CS thresholds for the x-, y-, and z-axis were at least one order of magnitude greater than the International Electrotechnical Commission limit.

Conclusion:

We demonstrate an approach to simulate gradient-induced CS using a combination of electromagnetic and electrophysiological modeling. Pending additional validation, these simulations could guide the assessment of CS limits to MRI gradient coil switching speed. Such an approach may lead to less conservative, but still safe, operation limits, enabling the use of the maximum gradient amplitude versus slew rate parameter space of recent, powerful gradient systems.

Prediction of peripheral nerve stimulation thresholds of MRI gradient coils using coupled electromagnetic and neurodynamic simulations

PURPOSE

As gradient performance increases, peripheral nerve stimulation (PNS) is becoming a significant constraint for fast MRI. Despite its impact, PNS is not directly included in the coil design process. Instead, the PNS characteristics of a gradient are assessed on healthy subjects after prototype construction. We attempt to develop a tool to inform coil design by predicting the PNS thresholds and activation locations in the human body using electromagnetic field simulations coupled to a neurodynamic model. We validate the approach by comparing simulated and experimentally determined thresholds for 3 gradient coils.

METHODS

We first compute the electric field induced by the switching fields within a detailed electromagnetic body model, which includes a detailed atlas of peripheral nerves. We then calculate potential changes along the nerves and evaluate their response using a neurodynamic model. Both a male and female body model are used to study 2 body gradients and 1 head gradient.

RESULTS

There was good agreement between the average simulated thresholds of the male and female models with the experimental average (normalized root-mean-square error: <10% and <5% in most cases). The simulation could also interrogate thresholds above those accessible by the experimental setup and allowed identification of the site of stimulation.

CONCLUSIONS

Our simulation framework allows accurate prediction of gradient coil PNS thresholds and provides detailed information on location and "next nerve" thresholds that are not available experimentally. As such, we hope that PNS simulations can have a potential role in the design phase of high performance MRI gradient coils.

Real-time detection of stimulus response in cultured neurons by high-intensity intermediate-frequency magnetic field exposure

Threshold values of neuronal stimulation and modulation associated with exposure to time-varying electromagnetic fields contribute to establishing human protection guidelines and standards. However, biological evidence of threshold values in the intermediate-frequency range is limited. Additionally, although it is known that dendrites, a type of unmyelinated neuronal fibre, play an important role in information processing in the central nervous system, the stimulus threshold in dendrites has not been sufficiently investigated. We evaluated the excitation site-specific stimulus response of rat brain-derived cultured neurons by using a 20 kHz high-intensity intermediate-frequency magnetic field (hIF-MF) exposure system, a non-conductive fibre-optic imaging (NCFI) system, combined with a micro-patterning technique. Our hIF-MF exposure and NCFI system permitted real-time detection of the intracellular calcium ([Ca2+]i) spikes in neuronal cell bodies or unmyelinated neuronal fibres during exposure to a 20 kHz, 70 mT (peak), burst-type sinusoidal wave hIF-MF. Dosimetry of the induced electric fields intensities in the extracellular solution indicated that about 50% of unmyelinated neuronal fibres respond at about 147 V m-1. In contrast, the threshold of the [Ca2+]i spikes in neuronal cell bodies were lower than that in unmyelinated neuronal fibres. Our results provide a basis for understanding site-specific differences in the responses of cultured neurons to hIF-MFs.

Effects of a High-Protein Diet Including Whole Eggs on Muscle Composition and Indices of Cardiometabolic Health and Systemic Inflammation in Older Adults with Overweight or Obesity: A Randomized Controlled Trial

Age-related increases in intermuscular adipose tissue (IMAT) impair muscle quality, decrease functional capacity, and promote several cardiometabolic and inflammatory disorders. Whether these age-related alterations in muscle composition improve by consuming a high-protein (HP) diet with whole eggs are unclear. This parallel-design, randomized-controlled trial assessed the effects of a 12-week eucaloric HP diet with three whole eggs per day (1.4 g protein kg⁻¹ day⁻¹) versus a normal-protein diet void of eggs (NP, 0.8 g protein kg⁻¹ day⁻¹) on muscle composition (IMAT), cardiometabolic health, and systemic inflammation in older adults with overweight or obesity (12 men and 10 women; age 70 ± 5 years, BMI 31.3 ± 3.2 kg/m², mean ± SD). No changes in muscle composition were observed over time, independent of protein intake. Total body weight was reduced in both groups (−3.3 ± 1.2%) and lean mass was preserved only with the HP diet. LDL concentration and hip circumference decreased only with the NP diet, while MCP-1 and HsCRP concentrations increased over time in both groups. A HP diet with whole eggs promotes lean mass retention with modest weight loss, but does not positively influence muscle composition, cardiometabolic health or systemic inflammation, compared to a NP diet void of eggs.

Induced Current Magnetic Resonance Electrical Conductivity Imaging With Oscillating Gradients

In this paper, induced current magnetic resonance electrical impedance tomography (ICMREIT) by means of current induction due to time-varying gradient fields of magnetic resonance imaging (MRI) systems is proposed. Eddy current and secondary magnetic flux density distributions are calculated for a numerical model composed of a z-gradient coil and a cylindrical conductor. An MRI pulse sequence is developed for the experimental evaluation of ICMREIT on a 3T MRI scanner. A relationship between the secondary magnetic flux density and the low-frequency (LF) MR phase is formulated. Characteristics of the LF phase, the eddy current, and the reconstructed conductivity distributions based on the simulated and the physical measurements are in agreement. Geometric shifts, which may contaminate the LF phase measurements, are not observed in the MR magnitude images. Low sensitivity of the LF phase measurements is a major limitation of ICMREIT towards clinical applications. The reconstructed conductivity images are rough estimates of true conductivity distribution of the experimental phantoms. Although the experimental results show that ICMREIT is safe and potentially applicable, its measurement sensitivity and reconstruction accuracy need to be optimized in order to improve the technique towards clinical applications.

Gradient and shim technologies for ultra high field MRI

Ultra High Field (UHF) MRI requires improved gradient and shim performance to fully realize the promised gains (SNR as well as spatial, spectral, diffusion resolution) that higher main magnetic fields offer. Both the more challenging UHF environment by itself, as well as the higher currents used in high performance coils, require a deeper understanding combined with sophisticated engineering modeling and construction, to optimize gradient and shim hardware for safe operation and for highest image quality. This review summarizes the basics of gradient and shim technologies, and outlines a number of UHF-related challenges and solutions. In particular, Lorentz forces, vibroacoustics, eddy currents, and peripheral nerve stimulation are discussed. Several promising UHF-relevant gradient concepts are described, including insertable gradient coils aimed at higher performance neuroimaging.

Predicting Magnetostimulation Thresholds in the Peripheral Nervous System using Realistic Body Models

Rapid switching of applied magnetic fields in the kilohertz frequency range in the human body induces electric fields powerful enough to cause Peripheral Nerve Stimulation (PNS). PNS has become one of the main constraints on the use of high gradient fields for fast imaging with the latest MRI gradient technology. In recent MRI gradients, the applied fields are powerful enough that PNS limits their application in fast imaging sequences like echo-planar imaging. Application of Magnetic Particle Imaging (MPI) to humans is similarly PNS constrained. Despite its role as a major constraint, PNS considerations are only indirectly incorporated in the coil design process, mainly through using the size of the linear region as a proxy for PNS thresholds or by conducting human experiments after constructing coil prototypes. We present for the first time, a framework to simulate PNS thresholds for realistic coil geometries to directly address PNS in the design process. Our PNS model consists of an accurate body model for electromagnetic field simulations, an atlas of peripheral nerves, and a neurodynamic model to predict the nerve responses to imposed electric fields. With this model, we were able to reproduce measured PNS thresholds of two leg/arm solenoid coils with good agreement.

Non-conductive and miniature fiber-optic imaging system for real-time detection of neuronal activity in time-varying electromagnetic fields

Establishing an appropriate threshold value for neuronal modulation by time-varying electromagnetic field (EMF) exposure is important for developing international guidelines to protect against the potential health effects, and to design a variety of medical devices. However, it is technically difficult to achieve real-time detection of neuronal activity under repetitive and long-term exposure to EMF. For this purpose, we developed a non-conductive, miniature, and flexible fiber-optic imaging system that does not affect the electromagnetic noise, induction heating, or vibration in a high-intensity and repetitive time-varying EMF exposure. Using the proposed system, we succeeded at real-time detection of spontaneous Ca²⁺ oscillations in single neuronal and glial cells, as well as synchronized bursting activities of multiple neuronal networks at a micrometer-scale and millisecond-order spatiotemporal resolution during long-term EMF exposure (sinusoidal wave, 20kHz, 8.6mT, >30min). The results indicated that short-term (<5min) exposure-related neuronal modulation was not detectable; however, long-term (15-30min) exposure was observed to depress neuronal activities. In addition, the simultaneous and real-time recording of neuronal activity and the environmental temperature revealed that the neuronal modulation was accompanied by a 0.5-1°C rise in the temperature of the culture medium induced by the heat generation of exposure coils. These findings suggest that our real-time imaging system can be used for precise evaluation of the threshold values and clarification of the mechanisms of neuronal modulation induced by time-varying EMF exposure.

The coil array method for creating a dynamic imaging volume

PURPOSE

Gradient strength and speed are limited by peripheral nerve stimulation (PNS) thresholds. The coil array method allows the gradient field to be moved across the imaging area. This can help reduce PNS and provide faster imaging for image-guided therapy systems such as the magnetic resonance imaging-guided linear accelerator (MRI-linac).

THEORY

The coil array is designed such that many coils produce magnetic fields, which combine to give the desired gradient profile. The design of the coil array uses two methods: either the singular value decomposition (SVD) of a set of field profiles or the electromagnetic modes of the coil surface.

METHODS

Two whole-body coils and one experimental coil were designed to investigate the method. The field produced by the experimental coil was compared to simulated results.

RESULTS

The experimental coil region of uniformity (ROU) was moved along the z axis as shown in simulation. The highest observed field deviation was 16.9% at the edge of the ROU with a shift of 35 mm. The whole-body coils showed a median field deviation across all offsets below 5% with an eight-coil basis when using the SVD design method.

CONCLUSION

Experimental results show the feasibility of a moving imaging region within an MRI with a low number of coils in the array. Magn Reson Med 78:784-793, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Toward 20 T magnetic resonance for human brain studies: opportunities for discovery and neuroscience rationale

An initiative to design and build magnetic resonance imaging (MRI) and spectroscopy (MRS) instruments at 14 T and beyond to 20 T has been underway since 2012. This initiative has been supported by 22 interested participants from the USA and Europe, of which 15 are authors of this review. Advances in high temperature superconductor materials, advances in cryocooling engineering, prospects for non-persistent mode stable magnets, and experiences gained from large-bore, high-field magnet engineering for the nuclear fusion endeavors support the feasibility of a human brain MRI and MRS system with 1 ppm homogeneity over at least a 16-cm diameter volume and a bore size of 68 cm. Twelve neuroscience opportunities are presented as well as an analysis of the biophysical and physiological effects to be investigated before exposing human subjects to the high fields of 14 T and beyond.

Effects of pulse duration on magnetostimulation thresholds

PURPOSE

Medical imaging techniques such as magnetic resonance imaging and magnetic particle imaging (MPI) utilize time-varying magnetic fields that are subject to magnetostimulation limits, which often limit the speed of the imaging process. Various human-subject experiments have studied the amplitude and frequency dependence of these thresholds for gradient or homogeneous magnetic fields. Another contributing factor was shown to be number of cycles in a magnetic pulse, where the thresholds decreased with longer pulses. The latter result was demonstrated on two subjects only, at a single frequency of 1.27 kHz. Hence, whether the observed effect was due to the number of cycles or due to the pulse duration was not specified. In addition, a gradient-type field was utilized; hence, whether the same phenomenon applies to homogeneous magnetic fields remained unknown. Here, the authors investigate the pulse duration dependence of magnetostimulation limits for a 20-fold range of frequencies using homogeneous magnetic fields, such as the ones used for the drive field in MPI.

METHODS

Magnetostimulation thresholds were measured in the arms of six healthy subjects (age: 27 ± 5 yr). Each experiment comprised testing the thresholds at eight different pulse durations between 2 and 125 ms at a single frequency, which took approximately 30-40 min/subject. A total of 34 experiments were performed at three different frequencies: 1.2, 5.7, and 25.5 kHz. A solenoid coil providing homogeneous magnetic field was used to induce stimulation, and the field amplitude was measured in real time. A pre-emphasis based pulse shaping method was employed to accurately control the pulse durations. Subjects reported stimulation via a mouse click whenever they felt a twitching/tingling sensation. A sigmoid function was fitted to the subject responses to find the threshold at a specific frequency and duration, and the whole procedure was repeated at all relevant frequencies and pulse durations.

RESULTS

The magnetostimulation limits decreased with increasing pulse duration (T(pulse)). For T(pulse) < 18 ms, the thresholds were significantly higher than at the longest pulse durations (p < 0.01, paired Wilcoxon signed-rank test). The normalized magnetostimulation threshold (B(Norm)) vs duration curve at all three frequencies agreed almost identically, indicating that the observed effect is independent of the operating frequency. At the shortest pulse duration (T(pulse) ≈ 2 ms), the thresholds were approximately 24% higher than at the asymptotes. The thresholds decreased to within 4% of their asymptotic values for T(pulse) > 20 ms. These trends were well characterized (R(2) = 0.78) by a stretched exponential function given by B(Norm)=1+αe(-T(pulse)/β(γ)) , where the fitted parameters were α = 0.44, β = 4.32, and γ = 0.60.

CONCLUSIONS

This work shows for the first time that the magnetostimulation thresholds decrease with increasing pulse duration, and that this effect is independent of the operating frequency. Normalized threshold vs duration trends are almost identical for a 20-fold range of frequencies: the thresholds are significantly higher at short pulse durations and settle to within 4% of their asymptotic values for durations longer than 20 ms. These results emphasize the importance of matching the human-subject experiments to the imaging conditions of a particular setup. Knowing the dependence of the safety limits to all contributing factors is critical for increasing the time-efficiency of imaging systems that utilize time-varying magnetic fields.

Magnetic resonance safety

Magnetic resonance imaging (MRI) has a superior soft-tissue contrast compared to other radiological imaging modalities and its physiological and functional applications have led to a significant increase in MRI scans worldwide. A comprehensive MRI safety training to protect patients and other healthcare workers from potential bio-effects and risks of the magnetic fields in an MRI suite is therefore essential. The knowledge of the purpose of safety zones in an MRI suite as well as MRI appropriateness criteria is important for all healthcare professionals who will work in the MRI environment or refer patients for MRI scans. The purpose of this article is to give an overview of current magnetic resonance safety guidelines and discuss the safety risks of magnetic fields in an MRI suite including forces and torque of ferromagnetic objects, tissue heating, peripheral nerve stimulation, and hearing damages. MRI safety and compatibility of implanted devices, MRI scans during pregnancy, and the potential risks of MRI contrast agents will also be discussed, and a comprehensive MRI safety training to avoid fatal accidents in an MRI suite will be presented.

Implementation of a comprehensive MR safety course for medical students

This review article proposes the design of an educational magnetic resonance (MR) safety course for instructing medical students about basic MR and patient-related safety. The MR safety course material can be implemented as a traditional didactic or interactive lecture in combination with hands-on safety demonstrations. The goal of the course is to ensure that medical students receive a basic understanding of MR principles and safety considerations. This course will prepare medical students for patient screening and safety consultations when ordering MR studies. A multiple-choice exam can be used to document the proficiency in MR safety of the medical students. The course can be used by various medical school programs and may help to ensure consistent quality of teaching materials and MR safety standards.

Advances in cardiac magnetic resonance imaging of congenital heart disease

Due to advances in cardiac surgery, survival of patients with congenital heart disease has increased considerably during the past decades. Many of these patients require repeated cardiovascular magnetic resonance imaging to assess cardiac anatomy and function. In the past decade, technological advances have enabled faster and more robust cardiovascular magnetic resonance with improved image quality and spatial as well as temporal resolution. This review aims to provide an overview of advances in cardiovascular magnetic resonance hardware and acquisition techniques relevant to both pediatric and adult patients with congenital heart disease and discusses the techniques used to assess function, anatomy, flow and tissue characterization.

Magnetostimulation limits in magnetic particle imaging

For magnetic particle imaging (MPI), specific absorption rate (SAR) and more critically magnetostimulation (i.e., dB/dt) safety limits will determine the optimal scan parameters, such as the drive field strength and frequency. These parameters will impact the scanning speed, field-of-view (FOV) and signal-to-noise ratio in MPI. Understanding the potential safety hazards of the drive field is critical for scaling MPI for human use. In this work, we demonstrate that magnetostimulation is the primary magnetic safety consideration in MPI, and we describe the first human-subject magnetostimulation threshold experiments for MPI using homogeneous coils. Our experiments, performed on the arm and leg, indicate that magnetostimulation thresholds monotonically decrease with increasing frequency. Additionally, we show for the first time that a strong inverse correlation exists between the threshold and the body part size. The chronaxie time, on the other hand, did not vary with body part size. We conclude with an estimation of the magnetostimulation thresholds for a full-body MPI scanner: a mean asymptotic threshold of 14.3 mT-pp (peak-to-peak) with a mean chronaxie time of 289 μs, which correspond to a magnetostimulation threshold of about 15 mT-pp for frequencies between 25 and 50 kHz. These findings will have a great impact on the optimization of MPI parameters, especially in determining the number of partial FOVs required to cover a region of interest.

SQUID-detected ultra-low field MRI

MRI remains the premier method for non-invasive imaging of soft-tissue. Since the first demonstration of ULF MRI the trend has been towards ever higher magnetic fields. This is because the signal, and efficiency of Faraday detectors, increases with ever higher magnetic fields and corresponding Larmor frequencies. Nevertheless, there are many compelling reasons to continue to explore MRI at much weaker magnetic fields, the so-called ultra-low field or (ULF) regime. In the past decade many excellent proof-of-concept demonstrations of ULF MRI have been made. These include combined MRI and magnetoencephalography, imaging in the presence of metal, unique tissue contrast, and implementation in situations where a high magnetic field is simply impractical. These demonstrations have routinely used pulsed pre-polarization (at magnetic fields from ~10 to 100 mT) followed by read-out in a much weaker (1-100 μT) magnetic fields using the ultra-sensitive Superconducting Quantum Interference Device (SQUID) sensor. Even with pre-polarization and SQUID detection, ULF MRI suffers from many challenges associated with lower magnetization (i.e. signal) and inherently long acquisition times compared to conventional >1 T MRI. These are fundamental limitations imposed by the low measurement and gradient fields used. In this review article we discuss some of the techniques, potential applications, and inherent challenges of ULF MRI.

SQUID-detected ultra-low field MRI

MRI remains the premier method for non-invasive imaging of soft-tissue. Since the first demonstration of ULF MRI the trend has been towards ever higher magnetic fields. This is because the signal, and efficiency of Faraday detectors, increases with ever higher magnetic fields and corresponding Larmor frequencies. Nevertheless, there are many compelling reasons to continue to explore MRI at much weaker magnetic fields, the so-called ultra-low field or (ULF) regime. In the past decade many excellent proof-of-concept demonstrations of ULF MRI have been made. These include combined MRI and magnetoencephalography, imaging in the presence of metal, unique tissue contrast, and implementation in situations where a high magnetic field is simply impractical. These demonstrations have routinely used pulsed pre-polarization (at magnetic fields from ∼10 to 100mT) followed by read-out in a much weaker (1-100μT) magnetic fields using the ultra-sensitive Superconducting Quantum Interference Device (SQUID) sensor. Even with pre-polarization and SQUID detection, ULF MRI suffers from many challenges associated with lower magnetization (i.e. signal) and inherently long acquisition times compared to conventional >1T MRI. These are fundamental limitations imposed by the low measurement and gradient fields used. In this review article we discuss some of the techniques, potential applications, and inherent challenges of ULF MRI.

MRI temporal acceleration techniques

In recent years, there has been an explosive growth of magnetic resonance imaging (MRI) techniques that allow faster scan speed by exploiting temporal or spatiotemporal redundancy of the images. These techniques improve the performance of dynamic imaging significantly across multiple clinical applications, including cardiac functional examinations, perfusion imaging, blood flow assessment, contrast-enhanced angiography, functional MRI, and interventional imaging, among others. The scan acceleration permits higher spatial resolution, increased temporal resolution, shorter scan duration, or a combination of these benefits. Along with the exciting developments is a dizzying proliferation of acronyms and variations of the techniques. The present review attempts to summarize this rapidly growing topic and presents conceptual frameworks to understand these techniques in terms of their underlying mechanics and connections. Techniques from view sharing, keyhole, k-t, to compressed sensing are covered.

Increasing the oscillation frequency of strong magnetic fields above 101 kHz significantly raises peripheral nerve excitation thresholds

PURPOSE

A time-varying magnetic field can cause unpleasant peripheral nerve stimulation (PNS) when the maximum excursion of the magnetic field (ΔB) is above a frequency-dependent threshold level [P. Mansfield and P. R. Harvey, Magn. Reson. Med. 29, 746-758 (1993)]. Clinical and research magnetic resonance imaging (MRI) gradient systems have been designed to avoid such bioeffects by adhering to regulations and guidelines established on the basis of clinical trials. Those trials, generally employing sinusoidal waveforms, tested human responses to magnetic fields at frequencies between 0.5 and 10 kHz [W. Irnich and F. Schmitt, Magn. Reson. Med. 33, 619-623 (1995), T. F. Budinger et al., J. Comput. Assist. Tomogr. 15, 909-914 (1991), and D. J. Schaefer et al., J. Magn. Reson. Imaging 12, 20-29 (2000)]. PNS thresholds for frequencies higher than 10 kHz had been extrapolated, using physiological models [J. P. Reilly et al., IEEE Trans. Biomed. Eng. BME-32(12), 1001-1011 (1985)]. The present study provides experimental data on human PNS thresholds to oscillating magnetic field stimulation from 2 to 183 kHz. Sinusoidal waveforms were employed for several reasons: (1) to facilitate comparison with earlier reports that used sine waves, (2) because prior designers of fast gradient hardware for generalized waveforms (e.g., including trapezoidal pulses) have employed quarter-sine-wave resonant circuits to reduce the rise- and fall-times of pulse waveforms, and (3) because sinusoids are often used in fast pulse sequences (e.g., spiral scans) [S. Nowak, U.S. patent 5,245,287 (14 September 1993) and K. F. King and D. J. Schaefer, J. Magn. Reson. Imaging 12, 164-170 (2000)].

METHODS

An IRB-approved prospective clinical trial was performed, involving 26 adults, in which one wrist was exposed to decaying sinusoidal magnetic field pulses at frequencies from 2 to 183 kHz and amplitudes up to 0.4 T. Sham exposures (i.e., with no magnetic fields) were applied to all subjects.

RESULTS

For 0.4 T pulses at 2, 25, 59, 101, and 183 kHz, stimulation was reported by 22 (84.6%), 24 (92.3%), 15 (57.7%), 2 (7.7%), and 1 (3.8%) subjects, respectively.

CONCLUSIONS

The probability of PNS due to brief biphasic time-varying sinusoidal magnetic fields with magnetic excursions up to 0.4 T is shown to decrease significantly at and above 101 kHz. This phenomenon may have particular uses in dynamic scenarios (e.g., cardiac imaging) and in studying processes with short decay times (e.g., electron paramagnetic resonance imaging, bone and solids imaging). The study suggests the possibility of new designs for human and preclinical MRI systems that may be useful in clinical practice and scientific research.

Echo planar imaging before and after fMRI: a personal history

Echo-planar imaging (EPI) plays a crucial role in functional MRI. Focusing especially on the period from 1988 to 1992, the authors offer personal recollections, on the development of practical means of deploying EPI, the people that participated, and its impact on MRI in general.

Low-power MRI by Frank-sequence excitation

Recently, a new NMR method employing an rf excitation scheme with strongly reduced power has been introduced, which is based on modulating rf pulses according to Frank sequences. For many applications, a reduction of rf power is essential, e.g. to eliminate bulky rf pre-amplifiers or in medical high-field MRI to preserve patient safety. Another benefit of the new scheme are very short dead times allowing for measurements of samples with short relaxation times. In this work, Frank-sequence excitation is used for low-power imaging for the first time. Results of one-, two-, and three-dimensional imaging experiments are presented and compared to conventional images.

Sensory and motor stimulation thresholds of the ulnar nerve from electric and magnetic field stimuli: implications to gradient coil operation

Rapidly changing magnetic fields from gradient coils induce electric fields in the individual being imaged, which can potentially result in peripheral nerve stimulation (PNS). This is a safety concern in MRI. Nerves exposed to either electric fields or time-varying magnetic fields are presumed to display equivalent stimulation threshold characteristics. This assumption has motivated the use of electric stimulation literature to be applied to gradient field safety standards. The consistency of peripheral nerve stimulation thresholds were compared by measuring chronaxie times for electric and magnetic stimulation for both motor and sensory fibers in the ulnar nerve for a group of healthy volunteers. Thresholds were determined with both electromyography and also by having the subjects report stimulation onset. Chronaxie times measured between motor and sensory fibers were statistically different. However, this difference does not account for the substantial discrepancy reported between measured electric and magnetic stimulation chronaxie times. We further establish that sensation threshold as defined perceptually by the subject volunteer is adequate as a simple and reliable measurement tool. Based on these observations, significant adjustments may need to be made to nerve parameters taken from the electric field stimulation literature prior to applying them directly to gradient induced stimulation in MRI.

Experimental determination of human peripheral nerve stimulation thresholds in a 3-axis planar gradient system

In MRI, strong, rapidly switched gradient fields are desirable because they can be used to reduce imaging time, obtain images with better resolution, or improve image signal-to-noise ratios. Improvements in gradient strength can be made by either increasing the gradient amplifier strength or by enhancing gradient efficiency. Unfortunately, many MRI pulse sequences, in combination with high-performance amplifiers and existing gradient hardware, can cause peripheral nerve stimulation (PNS). This makes improvements in gradient amplifiers ineffective at increasing safely usable gradient strength. Customized gradient coils are one way to achieve significant improvements in gradient performance. One specific gradient configuration, a planar gradient system, promises improved gradient strength and switching time for cardiac imaging. The PNS thresholds for planar gradients were characterized through human stimulation experiments on all three gradient axes. The specialized gradient was shown to have significantly higher stimulation thresholds than traditional cylindrical designs (y-axis SR(min) = 210 +/- 18 mT/m/ms and DeltaG(min) = 133 +/- 13 mT/m; x-axis SR(min) = 222 +/- 24 mT/m/ms and DeltaG(min) = 147 +/- 17 mT/m; z-axis SR(min) = 252 +/- 26 mT/m/ms and DeltaG(min) = 218 +/- 26 mT/m). This system could be operated at gradient strengths 2 to 3 times higher than cylindrical configurations without causing stimulation.

Interaction of MRI field gradients with the human body

In this review, the effects of low-frequency electromagnetic fields encountered specifically during magnetic resonance imaging (MRI) are examined. The primary biological effect at frequencies of between 100 and 5000 Hz (typical of MRI magnetic field gradient switching) is peripheral nerve stimulation, the result of which can be a mild tingling and muscle twitching to a sensation of pain. The models for nerve stimulation and how they are related to the rate of change of magnetic field are examined. The experimental measurements, and analytic and computational modelling work in this area are reviewed. The review concludes with a discussion of current regulation in this area and current practice as both are applied to MRI.

Numerical field evaluation of healthcare workers when bending towards high-field MRI magnets

In MRI, healthcare workers may be exposed to strong static and dynamic magnetic fields outside of the imager. Body motion through the strong, non-uniform static magnetic field generated by the main superconducting magnet and exposure to gradient-pulsed magnetic fields can result in the induction of electric fields and current densities in the tissue. The interaction of these fields and occupational workers has attracted an increasing awareness. To protect occupational workers from overexposure, the member states of the European Union are required to incorporate the Physical Agents Directive (PAD) 2004/40/EC into their legislation. This study presents numerical evaluations of electric fields and current densities in anatomically equivalent male and female human models (healthcare workers) as they lean towards the bores of three superconducting magnet models (1.5, 4, and 7 T) and x-, y-, and z- gradient coils. The combined effect of the 1.5 T superconducting magnet and the three gradient coils on the body models is compared with the contributions of the magnet and gradient coils in separation. The simulation results indicate that it is possible to induce field quantities of physiological significance, especially when the MRI operator is bending close towards the main magnet and all three gradient coils are switched simultaneously.

Exposure of workers to pulsed gradients in MRI

PURPOSE

To numerically evaluate the electric field/current density magnitudes and spatial distributions in healthcare workers when they are standing close to the gradient coil windings near the magnetic resonance imaging (MRI) scanner ends.

MATERIALS AND METHODS

Anatomically realistic, whole-body male and female voxel phantoms are engaged to model the workers at various positions near the ends of three cylindrical gradient coils (x-, y-, and z-axis gradients). The numerical calculations of induced fields are based on an efficient, quasistatic finite-difference method.

RESULTS

The simulations show that it is possible to induce electric fields/current densities above levels recommended by the International Commission for Non-ionizing Radiation Protection (ICNIRP) and the Institute of Electrical and Electronics Engineers (IEEE) standards when the workers are standing close to the gradient coils and when two or three gradients are switched simultaneously, as is often the case.

CONCLUSION

The longitudinal gradient tends to induce more fields in workers than the transverse coils. The strongest levels of field exposure are observed when all three gradients are operated simultaneously and can be above regulations when the healthcare worker is close to the gradient coils. Other postures such as bending into the magnet shall be investigated in further studies.

PROPELLER-EPI with parallel imaging using a circularly symmetric phased-array RF coil at 3.0 T: application to high-resolution diffusion tensor imaging

A technique integrating multishot periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) and parallel imaging is presented for diffusion echo-planar imaging (EPI) at high spatial resolution. The method combines the advantages of parallel imaging to achieve accelerated sampling along the phase-encoding direction, and PROPELLER acquisition to further decrease the echo train length (ETL) in EPI. With an eight-element circularly symmetric RF coil, a parallel acceleration factor of 4 was applied such that, when combined with PROPELLER acquisition, a reduction of geometric distortions by a factor substantially greater than 4 was achieved. The resulting phantom and human brain images acquired with a 256 x 256 matrix and an ETL of only 16 were visually identical in shape to those acquired using the fast spin-echo (FSE) technique, even without field-map corrections. It is concluded that parallel PROPELLER-EPI is an effective technique that can substantially reduce susceptibility-induced geometric distortions at high field strength.

Multiple-region gradient arrays for extended field of view, increased performance, and reduced nerve stimulation in magnetic resonance imaging

This article presents a novel design for magnetic resonance imaging (MRI) gradient systems. This design may allow the development of MRI scanners that are capable of imaging large regions with high performance while minimizing the potential for nerve stimulation. The general concept of the gradient system is that spatial oscillation is incorporated such that each gradient coil creates multiple, approximately linear gradient regions that oscillate in gradient polarity. Separate radiofrequency (RF) coil arrays are designed to be sensitive to the signals within each linear region and thus allow signal measurements to be obtained separately from each region. Enabling image acquisition in the transition region that separates each pair of adjacent linear regions requires a second gradient system with imaging regions that overlap and coincide with the transition regions of the first gradient system. Imaging the extended field of view (FOV) is accomplished by interleaved operation of the two gradient systems. Simulated annealing is used to create designs for both longitudinal and transverse gradient systems with two imaging regions.

Decibel Attenuation of Pulsed Electromagnetic Field (PEMF) in Blood and Cortical Bone Determined Experimentally and from the Theory of Ohmic Losses

We studied the PEMF power attenuation in tissues representative of clinical applications (blood and cortical bone) to determine the amount of power available for PEMF purported biological effects. The experimental system consisted of a pair of nearly circular, parallel and coaxial coils separated by a distance of one coil diameter. The power attenuation was measured using a small search coil connected to a digital oscilloscope. The coils were powered by a voltage switch operating at two different frequencies (3.8 and 63 kHz) producing bursts of pulses (numbering 21 and 1619) and triggered at two different frequencies (1.5 and 15 Hz, respectively). The tissue samples were placed inside the coils so as to expose them to either transverse electric field (at the center of coils) or the transverse magnetic field (at the coil wire). The cylindrical coil geometry yielded closed-form expressions for power attenuation based on magnetic diffusion equation and ohmic losses due to bulk tissue magnetic permeability and electrical conductivity. The measured power attenuation at these PEMF frequencies of not more than one decibel (1 dB) was well explained by the theory for the 3.8 kHz but less so for the 63 kHz frequency PEMF. The results provide important insights regarding physical mechanism of weak PEMF power dissipation in tissues.

Consideration of magnetically-induced and conservative electric fields within a loaded gradient coil

We present a method to calculate the electric (E)-fields within and surrounding a human body in a gradient coil, including E-fields induced by the changing magnetic fields and "conservative" E-fields originating with the scalar electrical potential in the coil windings. In agreement with previous numerical calculations, it is shown that magnetically-induced E-fields within the human body show no real concentration near the surface of the body, where nerve stimulation most often occurs. Both the magnetically-induced and conservative E-fields are shown to be considerably stronger just outside the human body than inside it, and under some circumstances the conservative E-fields just outside the body can be much larger than the magnetically-induced E-fields there. The order of gradient winding and the presence of conductive RF shield can greatly affect the conservative E-field distribution in these cases. Though the E-fields against the outer surface of the body are not commonly considered, understanding gradient E-fields may be important for reasons other than peripheral nerve stimulation (PNS), such as potential interaction with electrical equipment.

Bilateral neurostimulation systems used for deep brain stimulation: in vitro study of MRI-related heating at 1.5 T and implications for clinical imaging of the brain

Deep brain stimulation (DBS) is used increasingly in the field of movement disorders. The implanted electrodes create not only a prior risk to patient safety during MRI, but also a unique opportunity in the collection of functional MRI data conditioned by direct neural stimulation. We evaluated MRI-related heating for bilateral neurostimulation systems used for DBS with an emphasis on assessing clinically relevant imaging parameters. Magnetic resonance imaging was performed using transmit body radiofrequency (RF) coil and receive-only head RF coil at various specific absorption rates (SARs) of RF power. In vitro testing was performed using a gel-filled phantom with temperatures recorded at the electrode tips. Each DBS electrode was positioned with a single extension loop around each pulse generator and a single loop at the "head" end of the phantom. Various pulse sequences were used for MRI including fast spin-echo, echo-planar imaging, magnetization transfer contrast and gradient-echo techniques. The MRI sequences had calculated whole-body averaged SARs and local head SARs ranging from 0.1 to 1.6 W/kg and 0.1 to 3.2 W/kg, respectively. Temperature elevations of less than 1.0 degrees C were found with the fast spin-echo, magnetization transfer contrast, gradient-echo and echo-planar clinical imaging sequences. Using the highest SAR levels, whole-body averaged, 1.6 W/kg, local exposed-body, 3.2 W/kg, and local head, 2.9 W/kg, the temperature increase was 2.1 degrees C. These results showed that temperature elevations associated with clinical sequences were within an acceptable physiologically safe range for the MR conditions used in this evaluation, especially for the use of relatively low SAR levels. Notably, these findings are highly specific to the neurostimulation systems, device positioning technique, MR system and imaging conditions used in this investigation.

Risque IRM : règles de sécurité, incidents et accidents

It is now accepted that MR imaging does not present any biological risk for humans, even in cases of repeated exposure. However, several of the MR components (magnetic field, gradients, RF pulses, electrodes...) may cause some inconveniences to patients, most of them being reversible. However, severe accidents have been reported. Even though screening of patients for MR imaging eligibility is performed to identify patients with contra-indications to MRI, the lack of vigilance or the ignorance of certain basic safety requirements could lead to serious adverse effects, including death. The goal of this article is to review the various accidents reported with MRI, to explain their mechanism, and to describe means of prevention.

Peripheral nerve stimulation by gradient switching fields in magnetic resonance imaging

A heterogeneous model of the human body and the scalar potential finite difference method are used to compute electric fields induced in tissue by magnetic field exposures. Two types of coils are considered that simulate exposure to gradient switching fields during magnetic resonance imaging (MRI). These coils producing coronal (y axis) and axial (z axis) magnetic fields have previously been used in experiments with humans. The computed fields can, therefore, be directly compared to human response data. The computed electric fields in subcutaneous fat and skin corresponding to peripheral nerve stimulation (PNS) thresholds in humans in simulated MRI experiments range from 3.8 to 5.8 V/m for the fields exceeded in 0.5% of tissue volume (skin and fat of the torso). The threshold depends on coil type and position along the body, and on the anatomy and resolution of the human body model. The computed values are in agreement with previously established thresholds for neural stimulation.

Increased Time Rate of Change of Gradient Fields: Effect on Peripheral Nerve Stimulation at Clinical MR Imaging

PURPOSE

To increase gradient stimulation from 100% to a fixed 120% level and to assess patient acceptance of the degree of peripheral nerve stimulation (PNS) at magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Two hundred ten patients underwent MR imaging of various body regions according to clinical indications. An additional three-dimensional fast low-angle shot sequence with the 120% stimulation level was performed. A patient questionnaire was distributed after MR imaging to document the presence, degree, and location of PNS. Degree was measured with an 11-point scale (score range, 0-10). Age was analyzed between the sexes for significant statistical differences. Furthermore, correlation between location of examination and location and degree of stimulation was performed. To determine stimulation discomfort relative to other factors typically present at MR imaging, the degree of discomfort due to room temperature, size of magnet bore, acoustic noise, examination time, and heating sensation was determined for comparison, as well.

RESULTS

Thirty-five (16.7%) patients reported a stimulation sensation during imaging in one or more locations, while six (2.9%) felt very uncomfortable local stimulation (score of 8-10). No significant difference between male and female patients regarding age, sex, and appearance or degree of stimulation sensation could be detected. No significant correlation between location of examination and location and degree of stimulation was recorded. Compared with other side effects, PNS was considered relatively unimportant.

CONCLUSION

The 120% gradient stimulation level seems acceptable for routine clinical imaging with this gradient system, since only 2.9% of patients experienced very uncomfortable local stimulation.