BASIC PRINCIPLES OF MR IMAGING

J ohn R. Hesselink, MD, FACR

Magnetic resonance (MR) is a dynamic
and flexible technology that allows one to
tailor the imaging study to the anatomic
part of interest and to the disease process
being studied. With its dependence on the
more biologically variable parameters of
proton density, longitudinal relaxation time
(T1), and transverse relaxation time (T2),
variable image contrast can be achieved by
using different pulse sequences and by
changing the imaging parameters. Signal
intensities on T1, T2, and proton density-
weighted images relate to specific tissue
characteristics. For example, the changing
chemistry and physical structure of
hematomas over time directly affects the signal intensity on MR images, providing information about
the age of the hemorrhage. Moreover, with MR's multiplanar capability, the imaging plane can be
optimized for the anatomic area being studied, and the relationship of lesions to eloquent areas of the
brain can be defined more accurately. Flow-sensitive pulse sequences and MR angiography yield data
about blood flow, as well as displaying the vascular anatomy. Even brain function can be investigated
by having a subject perform specific mental tasks and noting changes in regional cerebral blood flow
and oxygenation. Finally, MR spectroscopy has enormous potential for providing information about
the biochemistry and metabolism of tissues. As an imaging technology, MR has advanced
considerably the past 10 years, but it continues to evolve and new capabilities will likely be developed.

PHYSICAL PRINCIPLES

An MR system consists of the following components: 1) a large magnet to generate the magnetic
field, 2) shim coils to make the magnetic field as homogeneous as possible, 3) a radiofrequency (RF)
coil to transmit a radio signal into the body part being imaged, 4) a receiver coil to detect the returning
radio signals, 5) gradient coils to provide spatial localization of the signals, and 6) a computer to
reconstruct the radio signals into the final image.
The signal intensity on the MR image is determined by four basic parameters: 1) proton density, 2)
T1 relaxation time, 3) T2 relaxation time, and 4) flow. Proton density is the concentration of protons in
the tissue in the form of water and macromolecules (proteins, fat, etc). The T1 and T2 relaxation times
define the way that the protons revert back to their resting states after the initial RF pulse. The most
common effect of flow is loss of signal from rapidly flowing arterial blood.
The contrast on the MR image can be
manipulated by changing the pulse sequence parameters. A pulse sequence sets the specific number,
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strength, and timing of the RF and gradient
pulses. The two most important parameters
are the repetition time (TR) and the echo
time (TE). The TR is the time between
consecutive 90 degree RF pulse. The TE is
the time between the initial 90 degree RF
pulse and the echo.
The most common pulse sequences are
the T1- weighted and T2-weighted spin-
echo sequences. The T1-weighted sequence
uses a short TR and short TE (TR <
1000msec, TE <30msec). The T2-
weighted sequence uses a long
TR and long TE (TR >
2000msec, TE >80msec). The
T2-weighted sequence can be
employed as a dual echo
sequence. The first or shorter
echo (TE <30msec) is proton
density (PD) weighted or a
mixture of T1 and T2. This
image is very helpful for
evaluating periventricular
pathology, such as multiple
sclerosis, because the
hyperintense plaques are contrasted against the lower signal CSF. More recently, the FLAIR (Fluid
Attenuated Inversion Recovery) sequence has replaced the PD image. FLAIR images are T2-weighted
with the CSF signal suppressed.
The TR, matrix size and NEX are the only
parameters that affect scan time. Increasing any one of these parameters increases the minimum scan
time. Spatial resolution is determined by matrix size, FOV and slice thickness. Increasing matrix size
or decreasing FOV and slice thickness increases spatial resolution, but at the expense of either
decreased signal-to-noise or increased scan time. To obtain images of high resolution with high signal-
to-noise requires longer scan times. All of the scan parameters affect signal-to-noise. The signal within
an image can be improved by increasing TR, FOV, slice thickness and NEX or by decreasing TE and
matrix size. The most direct way to increase signal is by increasing NEX, but one must keep in mind
that increasing NEX from two to four, for example, doubles the scan time, but increases the signal by
only the square root of two. Finally, TE does not affect scan time, however, it does determine the
maximum number of slices in multislice mode. Increasing the TE or shortening TR decreases the
number of slices that can be obtained with one pulse sequence.
Specialized techniques for reducing motion and artifacts on the images also have applications for brain
imaging. Gradient moment rephasing or flow compensation techniques effectively reduce ghost
artifacts resulting from CSF flow. They should be used for T2-weighted spin-echo and gradient-echo
acquisitions, but not with T1-weighted imaging because they increase the signal from CSF. Flow
compensation techniques do not contribute to SAR (a measure of power deposition), but the extra
gradient pulses lengthen the minimum TE, and gradient heating may limit the number of slices, the
minimum FOV and slice thickness. Cardiac gating also reduces artifacts from CSF pulsations,
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resulting in superior object contrast and resolving power in the temporal lobes, basal ganglia and brain
stem.
Saturation (SAT) techniques use extra
RF pulses to eliminate artifacts from
moving tissues outside the imaging
volume, such as swallowing or
respiratory artifacts, and from
unsaturated protons that enter the
imaging volume through vascular
channels. SAT should be used for T1-
weighted imaging of the sella, internal
auditory canals, and the spine. The extra
RF pulses cost SAR and take time,
lengthening the minimum TR or
decreasing the maximum number of
slices in a multislice mode.
Methods for eliminating wrap-
around or aliasing should be prescribed
when imaging small anatomic areas,
such as the sella and internal auditory
canals, with smaller FOR's. The "no
phase wrap" option is most effective in the anterior-posterior direction for sagittal and axial scans. On
newer MR systems, many of theses specialized techniques are automatically added to the appropriate
sequences.

MR IMAGE CONTRAST

When reviewing an MR image, the easiest way to determine which pulse sequence was used, or the
"weighting" of the image, is to look at the cerebrospinal fluid (CSF). If the CSF is bright (high signal),
then it must be a T2-weighted imaged. If the CSF is dark, it is a T1-weighted image. Next look at the
signal intensity of the brain structures.
On MR images of the brain,
the primary determinants of
signal intensity and contrast are
the T1 and T2 relaxation times.
The contrast is distinctly
different on T1 and T2-weighted
images. Also, brain pathologies
have some common signal
characteristics.
Pathologic lesions can be
separated into five major groups
by their specific signal
characteristics on the three basic
images: T2- weighted, proton
density-weighted (PD)/FLAIR,
and T1-weighted.

BRAIN IMAGING PROTOCOL

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Since studies have shown that T2-weighted images are most sensitive for detecting brain
pathology, patients with suspected intracranial disease should be screened with T2-weighted spin-echo
and FLAIR images. The axial plane is commonly used because of our familiarity with the anatomy
from CT. The other scan parameters include a 256 x 256 matrix, 1 NEX, 22 cm FOR and 5 mm slice
thickness for a scan time of less than 4 minutes and a voxel size of 5 x 0.86 x 0.86 mm. A 1-2 mm
interslice gap prevents RF interference between slices.

If an abnormality is found, additional
scans help characterize the lesion.
Noncontrast T1-weighted images are needed
only if the preliminary scans suggest
hemorrhage, lipoma, or dermoid. Otherwise,
contrast-enhanced scans are recommended.
Gadolinium-based contrast agents for MR
are paramagnetic and have demonstrated
excellent biologic tolerance. No significant
complications or side effects have been
reported. It is injected intravenously at a
dose rate of 0.1 mmol/kg. The gadolinium
contrast agents do not cross the intact blood-
brain barrier (BBB). If the BBB is disrupted
by a disease process, the contrast agent
diffuses into the interstitial space and shortens the T1 relaxation time of the tissue, resulting in
increased signal intensity on T1-weighted images. The scans should be acquired between 3 and 30
minutes postinjection for optimal results.
Contrast enhancement is especially helpful for extra-axial tumors because they tend to be
isointense to brain on plain scans, but it also identifies areas of BBB breakdown associated with intra-
axial lesions. Gadolinium enhancement is essential for detecting leptomeningeal inflammatory and
neoplastic processes. Contrast scans are obtained routinely in patients with symptoms of pituitary
adenoma (elevated prolactin, growth hormone, and so forth) or acoustic neuroma (sensorineural
hearing loss). To screen for brain metastases in patients with a known primary, contrast-enhanced T1-
weighted scans alone are probably sufficient.
Gadolinium does not enhance rapidly-flowing blood. If vascular structures are not adequately seen
on plain scan, the positive contrast provided by gradient-echo techniques or MR angiography may be
helpful to confirm or disprove a suspected carotid occlusion or cerebral aneurysm, to evaluate the
integrity of the venous sinuses, and to assess the vascularity of lesions. Gradient-echo imaging also
enhances the magnetic susceptibility effects of acute and chronic hemorrhage, making them easily
observable, even on low and mid-field MR systems.
Although the axial plane is the primary plane for imaging the brain, the multiplanar capability of
MR allows one to select the optimal plane to visualize the anatomy of interest. Coronal views are good
for parasagittal lesions near the vertex and lesions immediately above or below the lateral ventricles
(corpus callosum or thalamus), temporal lobes, sella, and internal auditory canals. The coronal plane
can be used as the primary plane of imaging in patients with temporal lobe seizures. Sagittal views are
useful for midline lesions (sella, third ventricle, corpus callosum, pineal region), and for the brain stem
and cerebellar vermis.
Scan techniques are slightly different for the sella and cerebellopontine angle. For the sella, the
plain and contrast enhanced scans are obtained in the coronal and sagittal planes using a smaller FOR
and thin (3mm or less) contiguous or overlapping sections. For patients with a sensorineural hearing
loss or suspected acoustic neuroma, contrast enhanced scans with T1-weighting are obtained through
the internal auditory canals, again using thin overlapping sections.

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CLINICAL INDICATIONS

As imaging techniques of the brain, MR and CT are both competitive and complimentary. In
general, CT performs better in cases of trauma and emergent situations. It provides better bone detail
and has high sensitivity for acute hemorrhage. Support equipment and personnel can be brought
directly into the scan room. CT scanning is fast. Single scans can be done in 1 second, so that even
with uncooperative patients, adequate scans usually can be obtained. CT is more sensitive than MR for
subarachnoid hemorrhage. CT is also more sensitive for detecting intracranial calcifications.
MR, on the other hand, functions best as an elective outpatient procedure. Proper screening of
patients, equipment, and personnel for ferromagnetic materials, pacemakers, etc. is mandatory to avoid
possible catastrophe in the magnet room. If proper precautions are in place, emergency studies can be
done, but the set-up time is longer, and the imaging also requires more time. With conventional MR
systems, most pulse sequences take a minimum of 2 minutes. Echo-planar capability has become
standard on most MR systems, and this advanced technology can acquire sub-second MR scans.
Due to its high sensitivity for brain water, MR is generally more sensitive for detecting brain
abnormalities during the early stages of disease. For example, in cases of cerebral infarction, brain
tumors or infections, the MR scan will become positive earlier than CT. When early diagnosis
is critical for favorable patient outcome, such as in suspected herpes encephalitis, MR is the
imaging procedure of choice. MR is exquisitely sensitive for white matter disease, such as
multiple sclerosis, progressive multifocal leukoencephalopathy, leukodystrophy, and post-
infectious encephalitis. Patients with obvious white matter abnormalities on MR may have an
entirely normal CT scan. Other clinical situations where MR will disclose abnormalities earlier
and more definitively are temporal lobe epilepsy, nonhemorrhagic brain contusions and
traumatic shear injuries.
In general, nonenhancing disease processes are much more apparent on MR than CT. When the
blood-brain barrier is damaged, enhancement occurs with both gadolinium and iodinated contrast
agents on MR and CT, respectively. As a rule, the degree of enhancement is greater on MR scans.
For evaluating posterior fossa disease, MR is preferable to CT. The CT images are invariable
degraded by streaking artifacts from the bones at the skull base. In conjunction with gadolinium
enhancement, MR can reliably detect intracanalicular acoustic neuromas and other schwannomas
arising along the cranial nerves within the basal cisterns and foramina of the skull base. Similarly, MR
has largely supplanted CT for imaging the sella turcica and pituitary gland.
The value of MR for defining congenital malformations is unquestioned. The multiplanar display
of anatomy gives important information about the corpus callosum and posterior fossa structures.
The superior gray/white contrast allows accurate assessment of myelination.
The phenomenon of flow void within arteries on spin-echo images, the high sensitivity for
hemorrhage and hemosiderin deposition, and the capability of MR angiography give MR distinct
advantages over CT for imaging vascular disease. Vascular stenoses or occlusions, aneurysms,
and arteriovenous malformations can be imaged without intravenous contrast media. In
cases of cryptic vascular malformations and cavernous angiomas, where the angiogram and CT
scan are often negative, MR may reveal small deposits of hemosiderin from prior small
hemorrhages. Diffusion-weighted sequences are highly sensitive for restricted diffusion and
cytotoxic edema associated with acute cerebral infarction. By combining conventional MR
images with diffusion and perfusion-weighted imaging and MR angiography, a complete
workup of vascular disease can be accomplished.
Along with the function of MR as a primary imaging procedure, there are indications for MR as a
secondary procedure after the pathology has already been demonstrated by CT. In patients with
solitary lesions on CT, in whom the diagnosis of metastatic disease, abscess, or multiple sclerosis
would be strengthened by finding additional lesions, MR may resolve the issue. Similarly, in a patient
with brain metastases in whom none of the lesions account for the patient's signs or symptoms, MR
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can help evaluate the particular anatomic area of interest. A potential problem in both of these
circumstances is the nonspecificity of white matter hyperintensities, and contrast MR may be
necessary to clarify the situation.

References

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