1. Dr. Fung OHSU Body Radiology

2. Patient Preparation Education Approximate duration of the exam Breath-holding Stress importance Expiration If cannot sustain BH, slowly inhale over time Practice with patient Describe sensations of Gd infusion 2L NC O 2 No O 2 if patient has COPD/emphysema: ASK! Patient Position Supine Feet first Cushion under knees to relieve back pressure Arms at sides Coil Position 3 fingers below xyphoid process Ensure parallel positioning Other Ear plugs Emergency button Anxiolytic Music

3. 3-Plane Localizer Ensure coil is placed properly for optimized liver imaging. Run calibration (reference) sequence for ASSET/SENSE. 2 with BH Exp, 2 Free Breath If patient moves or coil position is changed, rerun calibration scan. Clinical Quick eval of spine

4. Ax/Cor Single Shot TSE Coronal SSFSE/SSTSE T2 FOV <48 cm SLT/gap: 8 mm/0 ASSET/SENSE: none BH (Arms Up if Possible) Axial SSFSE/SSTSE T2 FOV <34 cm SLT/gap: 8 mm/0 ASSET/SENSE: none BH Liver through kidneys Two acquisitions if necessary Overlap acquisitions NO INTERLEAVE Clinical Overview of anatomy Fluid-filled structures Liver size

5. Coronal 3D FIESTA/B-TFE Parameters FOV: 38 cm SLT/gap: 3-4 mm/reconstructed to 1-2 mm ASSET/SENSE: min BH Liver through pancreas Arms Up if possible- Fold over Clinical Poor man’s MRCP Decreases dephasing in patients with significant ascites

6. Axial 2D FIESTA/B-FFE Parameters FOV: <34 cm SLT/gap: 5 mm ASSET/SENSE: min BH: (resp-trig uncooperative patient) Liver through bottom of kidneys Clinical Vascular patency: important if unable to adequately BH during post-Gd sequences

7. Axial Dual Echo SPGR (In/Out Phase) Parameters FOV: <34 cm SLT/gap: 7 mm/1 ASSET/SENSE: none BH Two acquisitions if necessary Overlap acquisitions NO INTERLEAVE Repeat as necessary to optimize image quality Run 3D Dixon on MR1 for In/Out Phase imaging Clinical Detect lipid and iron Evaluate kidneys T1 appearance of lesions

8. Axial Resp-Trig FSE T2 Fat Sat Parameters FOV: <34 cm SLT/gap: 7 mm/1 ASSET/SENSE: None Respiratory Triggered Liver through bottom of kidneys Position gating trigger on dome of diaphragm half in lung field/half in liver Clinical Increased lesion conspicuity T2 characteristics Lymphadenopathy

9. Axial 3D LAVA/THRIVE/DIXON Parameters FOV <34 cm SLT/gap: 4-5 mm/reconstructed to 2 mm ASSET/SENSE: 1.5, max BH Liver through bottom of kidneys Breath-holding Expiration Practice breathing with patient Watch respiratory graph so breathing cycle not interrupted Stress importance of these images If can’t hold breath long enough, slowly and steadily inhale (as had practiced before the exam) Precontrast Ensure : Adequate coverage Adequate fat suppression Patient understands BH No artifacts through liver

10. Axial 3D Dynamic Timing Post-Contrast Arterial: 25s after start of injection – MOST INPORTANT SCAN prior to scanning this sequence, please remind patient of the importance of this sequence Arterial Phase is for Hepatic Artery uptake, NOT early arterial (30sec k0 time) This time depends on k0 time, injection rate, cardiac output, hemodynamics We may be switching back to bolus tracking because of these variables. Portal: 60s after start of injection Late Portal: 100s after start of injection Equilibrium: 180s after start of injection 10-min Delay (FSPGR) Please send images to PACS in proper fashion (Philips)! Clinical Lesion detection and characterization

11. Axial 3D DIXON (Water Images) Parameters FOV <34 cm SLT/gap: 4-5 mm/reconstructed to 2 mm BH Liver through bottom of kidneys Breath-holding Faster scan and better fat sat than THRIVE ONLY available on MR1 Philips 3D Dixon will also replace In/Out Phase on MR-1 Ensure : Adequate coverage Adequate fat suppression Patient understands BH No artifacts through liver

12. 10min Delay Axial FSPGR Fat Sat Parameters FOV <34 cm SLT/gap: 7 mm/1 ASSET/SENSE: None BH Liver through Aortic Bifurcation Two acquisitions if necessary Overlap acquisitions NO INTERLEAVE Repeat as necessary to optimize image quality Clinical Evaluate for delayed contrast enhancement

13. Additional Optional Sequences DWI Parameters: as specified on the Philips Scanner Through the liver Please be sure to perform ADC map Clinical: Lesion detection, esp. for metastatic lesions to liver EOVIST Protocol Axial Post-contrast LAVA/THRIVE at 5 min’s and 20 min’s Axial and coronal Pre- and Post-contrast “STEALTH” as required by the radiologist oncologists Clinical: Lesion detection

14. MRCP To be performed after contrast sequences Default is MRCP + liver mass protocol Rad will specify if study to be done without contrast MRCP 3D Axial FOV: <34 cm SLT/gap: 1.4 mm/0 ASSET/SENSE: minimum Respiratory Triggered Through bottom 2/3 of liver, including pancreas

15. MRCP Thin Slice Parameters: FOV: 32 cm SLT/gap: 4-5 mm/0 Slices: 15, each ASSET/SENSE: None BH Off Axial image, select image showing CBD through pancreatic head Coronal Image posterior to CBD as it passes through the pancreatic head to anterior to the porta hepatis Whole gallbladder should be included although can be sacrificed to image whole CBD RAO Coronal Oblique Rotate 20-30⁰ counterclockwise Include CBD Gallbladder not necessarily included LAO Coronal Oblique Rotate 20-30⁰ clockwise from straight coronal Center on CBD Entire gallbladder included RAO CoronalLAO

16. MRCP Thick Slab, Radial Parameters: FOV: 32 cm SLT/gap: 40 mm/0 Slices: 12 ASSET/SENSE: None BH Off Axial image, select image showing Pancreatic Duct (Pancreatic Head) Multiple slabs off different angles (15-30⁰ intervals) Adequate pause to eliminate crosstalk RADIAL