mri of acute abdominal pain in pregnancy...mri of acute abdominal pain in pregnancy ivan pedrosa,...
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MRI of Acute Abdominal Pain in Pregnancy
I v a n Pe d ro s a , M . D.C h i e f o f M R I
J a c k R ey n o l d s M D C h a i r i n R a d i o l o g yA s s o c i a t e P ro f e s s o r o f R a d i o l o g yU T S o u t h we s t e r n M e d i c a l C e n t e r
A d v a n c e d I m a g i n g R e s e a rc h C e n t e rWednesday, October 3, 2012
NON SURGICALLigamentous Laxity
Hemorrhagic Corpus Luteum
Degenerating Fibroids
GU tract
GI tract
SURGICALAcute Appendicitis
Ectopic Pregnancy
Ovarian TorsionWednesday, October 3, 2012
Location of the Appendix
Baer et al. JAMA 1932
Wednesday, October 3, 2012
Location of the Appendix
Baer et al. JAMA 1932 Pedrosa et al. Radiology 2006Oto et al. AJR 2006
Spearman Rank Correlation:0.44 (P-value: 0.003)
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Location of the Appendix
C
Wednesday, October 3, 2012
Tilting of the Cecum
Lee K. et al. Radiology 2008Wednesday, October 3, 2012
Tilting of the Cecum
α
Lee K. et al. Radiology 2008Wednesday, October 3, 2012
Tilting of the Cecum
α
Lee K. et al. Radiology 2008Wednesday, October 3, 2012
Tilting of the Cecum
α
Lee K. et al. Radiology 2008Wednesday, October 3, 2012
Tilting of the Cecum
α
Lee K. et al. Radiology 2008Wednesday, October 3, 2012
Tilting of the Cecum
α
specificity 98%
Lee K. et al. Radiology 2008Wednesday, October 3, 2012
MRI Protocol
Wednesday, October 3, 2012
MRI ProtocolUS prior to MRI
Wednesday, October 3, 2012
MRI ProtocolUS prior to MRI
1.5T (No 3T)
Wednesday, October 3, 2012
MRI ProtocolUS prior to MRI
1.5T (No 3T)
No Gadolinium
Wednesday, October 3, 2012
MRI ProtocolUS prior to MRI
1.5T (No 3T)
No Gadolinium
Supine, Phase Array Body Coil
Wednesday, October 3, 2012
MRI ProtocolUS prior to MRI
1.5T (No 3T)
No Gadolinium
Supine, Phase Array Body Coil
Oral prep (1.5 hours)450 mL Gastromark (Mallinckrodt Medical Inc., St. Louis, MO)[iron oxide]
300 mL Readi-cat 2 (EZEM Canada Inc., Westbury, NY)[barium sulfate]
Liebig, T et al. Mag Reson Med 1993
Wednesday, October 3, 2012
MRI ProtocolUS prior to MRI
1.5T (No 3T)
No Gadolinium
Supine, Phase Array Body Coil
Oral prep (1.5 hours)450 mL Gastromark (Mallinckrodt Medical Inc., St. Louis, MO)[iron oxide]
300 mL Readi-cat 2 (EZEM Canada Inc., Westbury, NY)[barium sulfate]
Liebig, T et al. Mag Reson Med 1993
Wednesday, October 3, 2012
MRI Protocol
Wednesday, October 3, 2012
T2W SSFSE / HASTE (T2-WI)AxialCoronalSagittal
MRI Protocol
Wednesday, October 3, 2012
T2W SSFSE / HASTE (T2-WI)AxialCoronalSagittal
Axial T2W Fat-Sat SSFSE / HASTE
MRI Protocol
Wednesday, October 3, 2012
T2W SSFSE / HASTE (T2-WI)AxialCoronalSagittal
Axial T2W Fat-Sat SSFSE / HASTEAxial 2D T2* TOF
MRI Protocol
Wednesday, October 3, 2012
T2W SSFSE / HASTE (T2-WI)AxialCoronalSagittal
Axial T2W Fat-Sat SSFSE / HASTEAxial 2D T2* TOFAxial T1W GRE in- and out-of-phase
MRI Protocol
Wednesday, October 3, 2012
T2W SSFSE / HASTE (T2-WI)AxialCoronalSagittal
Axial T2W Fat-Sat SSFSE / HASTEAxial 2D T2* TOFAxial T1W GRE in- and out-of-phaseAxial DWI (b=850)
MRI Protocol
Wednesday, October 3, 2012
Wednesday, October 3, 2012
Wednesday, October 3, 2012
Wednesday, October 3, 2012
Normal Appendix
Collapsed Intraluminal AirWednesday, October 3, 2012
Normal Appendix
Collapsed Intraluminal AirWednesday, October 3, 2012
Normal Appendix
Collapsed Intraluminal AirWednesday, October 3, 2012
Is the Appendix Obstructed?
Normal/Abnormal? AppendicitisNormal
T2-W SSFSE Bailey et al. Applied Radiology 2012Wednesday, October 3, 2012
Air-Filled Appendix
T2W SSFSE (spin echo) TOF (GRE)
Wednesday, October 3, 2012
Air-Filled Appendix
T2W SSFSE (spin echo) TOF (GRE)
Wednesday, October 3, 2012
Air-Filled Appendix
T2W SSFSE (spin echo) TOF (GRE)
Wednesday, October 3, 2012
Air-Filled Appendix
T2W SSFSE (spin echo) TOF (GRE)
Blooming Effect = Intraluminal AirWednesday, October 3, 2012
Air-Filled Appendix
T2W SSFSE (spin echo) TOF (GRE)
Blooming Effect = Intraluminal AirWednesday, October 3, 2012
Air-Filled Appendix
T2W SSFSE (spin echo) TOF (GRE)
Blooming Effect = Intraluminal AirWednesday, October 3, 2012
Appendix vs. Gonadal Varices
SSFSE
Wednesday, October 3, 2012
Appendix vs. Gonadal Varices
SSFSE
Wednesday, October 3, 2012
TOF
Appendix vs. Gonadal Varices
SSFSE
Wednesday, October 3, 2012
TOF
Appendix vs. Gonadal Varices
SSFSE
Wednesday, October 3, 2012
TOF
Appendix vs. Gonadal Varices
SSFSE
Intraluminal Air (Blooming)Collapsed (intermediate signal)
Wednesday, October 3, 2012
Appendicitis: MR Criteria
Wednesday, October 3, 2012
Appendicitis: MR Criteria
NormalDiameter ≤ 6 mmAir in its lumen (blooming effect on T2* TOF)
Wednesday, October 3, 2012
Appendicitis: MR Criteria
NormalDiameter ≤ 6 mmAir in its lumen (blooming effect on T2* TOF)
AbnormalDiameter > 7 mmFluid-filled lumenPeriappendiceal fat strandingRLQ abscess/phlegmon
Wednesday, October 3, 2012
Appendicitis: MR Criteria
NormalDiameter ≤ 6 mmAir in its lumen (blooming effect on T2* TOF)
AbnormalDiameter > 7 mmFluid-filled lumenPeriappendiceal fat strandingRLQ abscess/phlegmon
InconclusiveDiameter between 6-7 mm without ancillary findings
Wednesday, October 3, 2012
Mild Appendicitis
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Mild Appendicitis
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Mild Appendicitis
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Mild Appendicitis
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Appendicitis + Appendicolith
Wednesday, October 3, 2012
Appendicitis + Appendicolith
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Appendicitis + Appendicolith
Wednesday, October 3, 2012
Appendicitis + Appendicolith
Wednesday, October 3, 2012
Appendicitis + Appendicolith
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Suppurative Appendicitis
Wednesday, October 3, 2012
Suppurative Appendicitis
Wednesday, October 3, 2012
Suppurative Appendicitis
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Suppurative Appendicitis
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Fat Saturation in Mild Acute Appendicitis
SSFSE SSFSE + FSWednesday, October 3, 2012
Fat Saturation in Mild Acute Appendicitis
SSFSE SSFSE + FSWednesday, October 3, 2012
Fat Saturation in Mild Acute Appendicitis
SSFSE SSFSE + FSWednesday, October 3, 2012
Fat Saturation in Mild Acute Appendicitis
SSFSE SSFSE + FSWednesday, October 3, 2012
Fat Saturation in Mild Acute Appendicitis
SSFSE SSFSE + FSWednesday, October 3, 2012
Appendiceal Phlegmon
27 wks
Wednesday, October 3, 2012
Appendiceal Phlegmon
27 wks
C
Wednesday, October 3, 2012
Appendiceal Phlegmon
27 wks
C
Wednesday, October 3, 2012
Appendiceal Phlegmon
32 wks27 wks
C
Wednesday, October 3, 2012
Appendiceal Phlegmon
32 wks27 wks
C
Wednesday, October 3, 2012
Appendiceal Phlegmon
32 wks27 wks
C
Wednesday, October 3, 2012
DWI in Appendicitis
SSFSE DWI (b=1000)Wednesday, October 3, 2012
DWI in Appendicitis
SSFSE DWI (b=1000)Wednesday, October 3, 2012
DWI in Appendicitis
SSFSE DWI (b=1000)Wednesday, October 3, 2012
DWI in Appendicitis
SSFSE DWI (b=1000) FusedWednesday, October 3, 2012
Inconclusive Result
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Inconclusive Result
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Inconclusive Result
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Initial Experience
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Initial Experience
Prospective diagnosis (51 pts): 4 TP, 3FP, 0 FN, 44 TN
Pedrosa I et al. Radiology 2006Wednesday, October 3, 2012
Initial Experience
Prospective diagnosis (51 pts): 4 TP, 3FP, 0 FN, 44 TN
Sensitivity 100%, NPV 100%
Pedrosa I et al. Radiology 2006Wednesday, October 3, 2012
Initial Experience
Prospective diagnosis (51 pts): 4 TP, 3FP, 0 FN, 44 TN
Sensitivity 100%, NPV 100%
1 CT / 51 patients to confirm tip appendicitis
Pedrosa I et al. Radiology 2006Wednesday, October 3, 2012
“Ruling-out” Acute Appendicitis
Wednesday, October 3, 2012
“Ruling-out” Acute Appendicitis
MR → normal appendix seen:
Wednesday, October 3, 2012
“Ruling-out” Acute Appendicitis
MR → normal appendix seen:
89% (20/23) Oto et al. Radiology 2005
Wednesday, October 3, 2012
“Ruling-out” Acute Appendicitis
MR → normal appendix seen:
89% (20/23) Oto et al. Radiology 2005
87% (116/134) Pedrosa et al. Radiology 2009
Wednesday, October 3, 2012
“Ruling-out” Acute Appendicitis
MR → normal appendix seen:
89% (20/23) Oto et al. Radiology 2005
87% (116/134) Pedrosa et al. Radiology 2009
US → normal appendix typically not seenNegative Result = Ambiguous result
Wednesday, October 3, 2012
“Ruling-out” Acute Appendicitis
MR → normal appendix seen:
89% (20/23) Oto et al. Radiology 2005
87% (116/134) Pedrosa et al. Radiology 2009
US → normal appendix typically not seenNegative Result = Ambiguous result
Do we need an US?
Wednesday, October 3, 2012
Surgical Conditions
Ectopic Pregnancy
Ovarian Torsion
Wednesday, October 3, 2012
Ovarian Torsion
MR Findings
Tubal thickening
Ovarian enlargement
Hyperintense ovarian stroma on T2-W (probably related to edema)
Ghossain MA et al. JMRI 2004
Swirled vascular pedicle
Wednesday, October 3, 2012
Ovarian Torsion
Wednesday, October 3, 2012
Ovarian Torsion
Wednesday, October 3, 2012
Ovarian Torsion
Wednesday, October 3, 2012
Ovarian Torsion
Wednesday, October 3, 2012
Hemorrhagic Corpus Luteum
Degenerated Fibroids
GU tract pathology
GI tract pathology
Right ovarian vein varices
Non-Surgical Conditions
Wednesday, October 3, 2012
Fibroid degeneration
T2-WI T1-WIWednesday, October 3, 2012
Fibroid degeneration
T2-WI T1-WIWednesday, October 3, 2012
Fibroid degeneration
T2-WI T1-WIWednesday, October 3, 2012
T2W SSFSE
DWI in Fibroid degeneration
Wednesday, October 3, 2012
T2W SSFSE
DWI in Fibroid degeneration
Wednesday, October 3, 2012
T2W SSFSE
DWI in Fibroid degeneration
Wednesday, October 3, 2012
DWI (b=850)
T2W SSFSE
DWI in Fibroid degeneration
Wednesday, October 3, 2012
DWI (b=850)
T2W SSFSE
DWI in Fibroid degeneration
Wednesday, October 3, 2012
DWI (b=850)
T2W SSFSE
DWI in Fibroid degeneration
Wednesday, October 3, 2012
Hydronephrosis
Pregnancy hydronephrosis
Passed Ureteral StoneRoy C. Magn Reson Imaging 1995
Wednesday, October 3, 2012
Hydronephrosis
Pregnancy hydronephrosis
Passed Ureteral StoneRoy C. Magn Reson Imaging 1995
Wednesday, October 3, 2012
Hydronephrosis
Pregnancy hydronephrosis
Passed Ureteral StoneRoy C. Magn Reson Imaging 1995
Wednesday, October 3, 2012
Hydronephrosis
Pregnancy hydronephrosis
Passed Ureteral StoneRoy C. Magn Reson Imaging 1995
Wednesday, October 3, 2012
Hydronephrosis
Pregnancy hydronephrosis
Passed Ureteral StoneRoy C. Magn Reson Imaging 1995
Wednesday, October 3, 2012
Ureteral StoneWednesday, October 3, 2012
Ureteral StoneWednesday, October 3, 2012
Ureteral StoneWednesday, October 3, 2012
Ureteral Stone Pseudo-stoneWednesday, October 3, 2012
Ureteral Stone Pseudo-stoneWednesday, October 3, 2012
Ureteral Stone Pseudo-stoneWednesday, October 3, 2012
Ureteral Stone Pseudo-stoneWednesday, October 3, 2012
Ureteral Stone
B
Wednesday, October 3, 2012
Ureteral Stone
B
Wednesday, October 3, 2012
Ureteral Stone
B
Wednesday, October 3, 2012
Fat Sat SSFSE
Ureteral Stone
B
Wednesday, October 3, 2012
Fat Sat SSFSE
Ureteral Stone
B
Wednesday, October 3, 2012
Fat Sat SSFSE
3D FIESTA
Ureteral Stone
B
Wednesday, October 3, 2012
Fat Sat SSFSE
3D FIESTA
Ureteral Stone
B
Wednesday, October 3, 2012
Fat Sat SSFSE
3D FIESTA
Ureteral Stone
B
Wednesday, October 3, 2012
Pyelonephritis
T2 FSE FS
Dipstick Urinanalysis: -Wednesday, October 3, 2012
Pyelonephritis
T2 FSE FS
Dipstick Urinanalysis: -Wednesday, October 3, 2012
Pyelonephritis
T2 FSE FS DWI (b=1000)
Dipstick Urinanalysis: -Wednesday, October 3, 2012
Pyelonephritis
T2 FSE FS DWI (b=1000)
Dipstick Urinanalysis: -Wednesday, October 3, 2012
Pyelonephritis
T2 FSE FS DWI (b=1000)
Dipstick Urinanalysis: -Wednesday, October 3, 2012
Pyelonephritis
T2 FSE FS DWI (b=1000)
Dipstick Urinanalysis: - Final culture: Gram +Wednesday, October 3, 2012
Clinical Outcomes (2002-07)
148 ptsAll
patientsEstimated
(MRI negative) Literature
Negative Laparotomy
Rate30% 7% 20-52%
Perforation Rate
21% 21% 55%
Pedrosa et al. Radiology 2009
Wednesday, October 3, 2012
Conclusion
Wednesday, October 3, 2012
Dx of Surgical and Non-surgical dz
Conclusion
Wednesday, October 3, 2012
Dx of Surgical and Non-surgical dz
Anatomic changes in right colon
Conclusion
Wednesday, October 3, 2012
Dx of Surgical and Non-surgical dz
Anatomic changes in right colon
MRI Protocol - short but comprehensive
Conclusion
Wednesday, October 3, 2012
Dx of Surgical and Non-surgical dz
Anatomic changes in right colon
MRI Protocol - short but comprehensive
MRI findings in acute appy, other GI dz, ovarian torsion, degenerating fibroids, ureteral stone vs pregnancy-hydro
Conclusion
Wednesday, October 3, 2012
[email protected] Wednesday, October 3, 2012