Магнитно-резонансная томография: принципы и применение.

Medical imaging technique
magnetic resonance imaging

Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves to generate images of the organs in the body. MRI does not involve X rays or the use of ionizing radiation, which distinguishes it from computed tomography (CT) and positron emission tomography (PET) scans. MRI is a medical application of nuclear magnetic resonance (NMR) which can also be used for imaging in other NMR applications, such as NMR spectroscopy. MRI is widely used in hospitals and clinics for medical diagnosis, staging and follow up of disease. Compared to CT, MRI provides better contrast in images of soft tissues, e. g. in the brain or abdomen. However, it may be perceived as less comfortable by patients, due to the usually longer and louder measurements with the subject in a long, confining tube, although "open" MRI designs mostly relieve this. Additionally, implants and other non removable metal in the body can pose a risk and may exclude some patients from undergoing an MRI examination safely. MRI was originally called NMRI (nuclear magnetic resonance imaging), but "nuclear" was dropped to avoid negative associations. Certain atomic nuclei are able to absorb radio frequency (RF) energy when placed in an external magnetic field; the resultant evolving spin polarization can induce a RF signal in a radio frequency coil and thereby be detected. In clinical and research MRI, hydrogen atoms are most often used to generate a macroscopic polarization that is detected by antennas close to the subject being examined.

In most medical applications, hydrogen nuclei, which consist solely of a proton, that are in tissues create a signal that is processed to form an image of the body in terms of the density of those nuclei in a specific region. Given that the protons are affected by fields from other atoms to which they are bonded, it is possible to separate responses from hydrogen in specific compounds. To perform a study, the person is positioned within an MRI scanner that forms a strong magnetic field around the area to be imaged. First, energy from an oscillating magnetic field is temporarily applied to the patient at the appropriate resonance frequency. Scanning with X and Y gradient coils causes a selected region of the patient to experience the exact magnetic field required for the energy to be absorbed. The atoms are excited by a RF pulse and the resultant signal is measured by a receiving coil. The RF signal may be processed to deduce position information by looking at the changes in RF level and phase caused by varying the local magnetic field using gradient coils. As these coils are rapidly switched during the excitation and response to perform a moving line scan, they create the characteristic repetitive noise of an MRI scan as the windings move slightly due to magnetostriction. The contrast between different tissues is determined by the rate at which excited atoms return to the equilibrium state. Exogenous contrast agents may be given to the person to make the image clearer. The major components of an MRI scanner are the main magnet, which polarizes the sample, the shim coils for correcting shifts in the homogeneity of the main magnetic field, the gradient system which is used to localize the region to be scanned and the RF system, which excites the sample and detects the resulting NMR signal. The whole system is controlled by one or more computers. MRI requires a magnetic field that is both strong and uniform to a few parts per million across the scan volume. The field strength of the magnet is measured in teslas – and while the majority of systems operate at 1.5 T, commercial systems are available between 0.2 and 7 T. Whole body MRI systems for research applications operate in e. g. 9.4T, 10.5T, 11.7T. Even higher field whole body MRI systems e. g. 14 T and beyond are in conceptual proposal or in engineering design. Most clinical magnets are superconducting magnets, which require liquid helium to keep them at low temperatures. Lower field strengths can be achieved with permanent magnets, which are often used in "open" MRI scanners for claustrophobic patients. Lower field strengths are also used in a portable MRI scanner approved by the FDA in 2020. Recently, MRI has been demonstrated also at ultra low fields, i. e., in the microtesla to millitesla range, where sufficient signal quality is made possible by prepolarization (on the order of 10–100 mT) and by measuring the Larmor precession fields at about 100 microtesla with highly sensitive superconducting quantum interference devices (SQUIDs).

MRI is the investigative tool of choice for neurological cancers over CT, as it offers better visualization of the posterior cranial fossa, containing the brainstem and the cerebellum. The contrast provided between grey and white matter makes MRI the best choice for many conditions of the central nervous system, including demyelinating diseases, dementia, cerebrovascular disease, infectious diseases, Alzheimer's disease and epilepsy. Since many images are taken milliseconds apart, it shows how the brain responds to different stimuli, enabling researchers to study both the functional and structural brain abnormalities in psychological disorders. MRI also is used in guided stereotactic surgery and radiosurgery for treatment of intracranial tumors, arteriovenous malformations, and other surgically treatable conditions using a device known as the N localizer. New tools that implement artificial intelligence in healthcare have demonstrated higher image quality and morphometric analysis in neuroimaging with the application of a denoising system. The record for the highest spatial resolution of a whole intact brain (postmortem) is 100 microns, from Massachusetts General Hospital. The data was published in NATURE on 30 October 2019.

Cardiac MRI is complementary to other imaging techniques, such as echocardiography, cardiac CT, and nuclear medicine. It can be used to assess the structure and the function of the heart. Its applications include assessment of myocardial ischemia and viability, cardiomyopathies, myocarditis, iron overload, vascular diseases, and congenital heart disease.

Applications in the musculoskeletal system include spinal imaging, assessment of joint disease, and soft tissue tumors. Also, MRI techniques can be used for diagnostic imaging of
systemic muscle diseases including genetic muscle diseases. Swallowing movement of throat and oesophagus can cause motion artifact over the imaged spine. Therefore, a saturation pulse applied over this region the throat and oesophagus can help to avoid this artifact. Motion artifact arising due to pumping of the heart can be reduced by timing the MRI pulse according to heart cycles. Blood vessels flow artifacts can be reduced by applying saturation pulses above and below the region of interest.

Hepatobiliary MR is used to detect and characterize lesions of the liver, pancreas, and bile ducts. Focal or diffuse disorders of the liver may be evaluated using diffusion weighted, opposed phase imaging and dynamic contrast enhancement sequences. Extracellular contrast agents are used widely in liver MRI, and newer hepatobiliary contrast agents also provide the opportunity to perform functional biliary imaging. Anatomical imaging of the bile ducts is achieved by using a heavily T2 weighted sequence in magnetic resonance cholangiopancreatography (MRCP). Functional imaging of the pancreas is performed following administration of secretin. MR enterography provides non invasive assessment of inflammatory bowel disease and small bowel tumors. MR colonography may play a role in the detection of large polyps in patients at increased risk of colorectal cancer.

Magnetic resonance angiography (MRA) generates pictures of the arteries to evaluate them for stenosis (abnormal narrowing) or aneurysms (vessel wall dilatations, at risk of rupture). MRA is often used to evaluate the arteries of the neck and brain, the thoracic and abdominal aorta, the renal arteries, and the legs (called a "run off"). A variety of techniques can be used to generate the pictures, such as administration of a paramagnetic contrast agent (gadolinium) or using a technique known as "flow related enhancement" (e. g., 2D and 3D time of flight sequences), where most of the signal on an image is due to blood that recently moved into that plane (see also FLASH MRI). Techniques involving phase accumulation (known as phase contrast angiography) can also be used to generate flow velocity maps easily and accurately. Magnetic resonance venography (MRV) is a similar procedure that is used to image veins. In this method, the tissue is now excited inferiorly, while the signal is gathered in the plane immediately superior to the excitation plane—thus imaging the venous blood that recently moved from the excited plane.

MRI for imaging anatomical structures or blood flow do not require contrast agents since the varying properties of the tissues or blood provide natural contrasts. However, for more specific types of imaging, exogenous contrast agents may be given intravenously, orally, or intra articularly. In general, these agents have proved safer than the iodinated contrast agents used in X ray radiography or CT. Anaphylactoid reactions are rare, occurring in approx. 0.03–0.1%. Of particular interest is the lower incidence of nephrotoxicity, compared with iodinated agents, when given at usual doses—this has made contrast enhanced MRI scanning an option for patients with renal impairment, who would otherwise not be able to undergo contrast enhanced CT.

Gadolinium based contrast reagents are typically octadentate complexes of gadolinium(III). The complex is very stable (log K > 20) so that, in use, the concentration of the un complexed Gd3+ ions should be below the toxicity limit. The 9th place in the metal ion's coordination sphere is occupied by a water molecule which exchanges rapidly with water molecules in the reagent molecule's immediate environment, affecting the magnetic resonance relaxation time. For details see MRI contrast agent. In December 2017, the Food and Drug Administration (FDA) in the United States announced in a drug safety communication that new warnings were to be included on all gadolinium based contrast agents (GBCAs). The FDA also called for increased patient education and requiring gadolinium contrast vendors to conduct additional animal and clinical studies to assess the safety of these agents. Although gadolinium agents have proved useful for patients with kidney impairment, in patients with severe kidney failure requiring dialysis there is a risk of a rare but serious illness, nephrogenic systemic fibrosis, which may be linked to the use of certain gadolinium containing agents. The most frequently linked is gadodiamide, but other agents have been linked too. Although a causal link has not been definitively established, current guidelines in the United States are that dialysis patients should only receive gadolinium agents where essential and that dialysis should be performed as soon as possible after the scan to remove the agent from the body promptly. In Europe, where more gadolinium containing agents are available, a classification of agents according to potential risks has been released. In 2008, a new contrast agent named gadoxetate, brand name Eovist (US) or Primovist (EU), was approved for diagnostic use: This has the theoretical benefit of a dual excretion path.

An MRI sequence is a particular setting of radiofrequency pulses and gradients, resulting in a particular image appearance. The T1 and T2 weighting can also be described as MRI sequences.

Magnetic resonance spectroscopy (MRS) is used to measure the levels of different metabolites in body tissues, which can be achieved through a variety of single voxel or imaging based techniques. The MR signal produces a spectrum of resonances that corresponds to different molecular arrangements of the isotope being "excited". This signature is used to diagnose certain metabolic disorders, especially those affecting the brain, and to provide information on tumor metabolism. Magnetic resonance spectroscopic imaging (MRSI) combines both spectroscopic and imaging methods to produce spatially localized spectra from within the sample or patient. The spatial resolution is much lower (limited by the available SNR), but the spectra in each voxel contains information about many metabolites. Because the available signal is used to encode spatial and spectral information, MRSI requires high SNR achievable only at higher field strengths (3 T and above). The high procurement and maintenance costs of MRI with extremely high field strengths inhibit their popularity. However, recent compressed sensing based software algorithms (e. g., SAMV) have been proposed to achieve super resolution without requiring such high field strengths.

Real time MRI refers to the continuous imaging of moving objects (such as the heart) in real time. One of the many different strategies developed since the early 2000s is based on radial FLASH MRI, and iterative reconstruction. This gives a temporal resolution of 20–30 ms for images with an in plane resolution of 1.5–2.0 mm. Balanced steady state free precession (bSSFP) imaging has a better image contrast between the blood pool and myocardium than the FLASH MRI, yet it will produce severe banding artifact when the B0 inhomogeneity is strong. Real time MRI is likely to add important information on diseases of the heart and the joints, and in many cases may make MRI examinations easier and more comfortable for patients, especially for the patients who cannot hold their breathings or who have arrhythmia.

The lack of harmful effects on the patient and the operator make MRI well suited for interventional radiology, where the images produced by an MRI scanner guide minimally invasive procedures. Such procedures use no ferromagnetic instruments. A specialized growing subset of interventional MRI is intraoperative MRI, in which an MRI is used in surgery. Some specialized MRI systems allow imaging concurrent with the surgical procedure. More typically, the surgical procedure is temporarily interrupted so that MRI can assess the success of the procedure or guide subsequent surgical work.

In guided therapy, high intensity focused ultrasound (HIFU) beams are focused on a tissue, that are controlled using MR thermal imaging. Due to the high energy at the focus, the temperature rises to above 65 °C (150 °F) which completely destroys the tissue. This technology can achieve precise ablation of diseased tissue. MR imaging provides a three dimensional view of the target tissue, allowing for the precise focusing of ultrasound energy. The MR imaging provides quantitative, real time, thermal images of the treated area. This allows the physician to ensure that the temperature generated during each cycle of ultrasound energy is sufficient to cause thermal ablation within the desired tissue and if not, to adapt the parameters to ensure effective treatment.

Hydrogen has the most frequently imaged nucleus in MRI because it is present in biological tissues in great abundance, and because its high gyromagnetic ratio gives a strong signal. However, any nucleus with a net nuclear spin could potentially be imaged with MRI. Such nuclei include helium 3, lithium 7, carbon 13, fluorine 19, oxygen 17, sodium 23, phosphorus 31 and xenon 129. 23Na and 31P are naturally abundant in the body, so they can be imaged directly. Gaseous isotopes such as 3He or 129Xe must be hyperpolarized and then inhaled as their nuclear density is too low to yield a useful signal under normal conditions. 17O and 19F can be administered in sufficient quantities in liquid form (e. g. 17O water) that hyperpolarization is not a necessity. Using helium or xenon has the advantage of reduced background noise, and therefore increased contrast for the image itself, because these elements are not normally present in biological tissues. Moreover, the nucleus of any atom that has a net nuclear spin and that is bonded to a hydrogen atom could potentially be imaged via heteronuclear magnetization transfer MRI that would image the high gyromagnetic ratio hydrogen nucleus instead of the low gyromagnetic ratio nucleus that is bonded to the hydrogen atom. In principle, heteronuclear magnetization transfer MRI could be used to detect the presence or absence of specific chemical bonds. Multinuclear imaging is primarily a research technique at present. However, potential applications include functional imaging and imaging of organs poorly seen on 1H MRI (e. g., lungs and bones) or as alternative contrast agents. Inhaled hyperpolarized 3He can be used to image the distribution of air spaces within the lungs. Injectable solutions containing 13C or stabilized bubbles of hyperpolarized 129Xe have been studied as contrast agents for angiography and perfusion imaging. 31P can potentially provide information on bone density and structure, as well as functional imaging of the brain. Multinuclear imaging holds the potential to chart the distribution of lithium in the human brain, this element finding use as an important drug for those with conditions such as bipolar disorder.

MRI has the advantages of having very high spatial resolution and is very adept at morphological imaging and functional imaging. MRI does have several disadvantages though. First, MRI has a sensitivity of around 10−3 mol/L to 10−5 mol/L, which, compared to other types of imaging, can be very limiting. This problem stems from the fact that the population difference between the nuclear spin states is very small at room temperature. For example, at 1.5 teslas, a typical field strength for clinical MRI, the difference between high and low energy states is approximately 9 molecules per 2 million. Improvements to increase MR sensitivity include increasing magnetic field strength and hyperpolarization via optical pumping or dynamic nuclear polarization. There are also a variety of signal amplification schemes based on chemical exchange that increase sensitivity. To achieve molecular imaging of disease biomarkers using MRI, targeted MRI contrast agents with high specificity and high relaxivity (sensitivity) are required. To date, many studies have been devoted to developing targeted MRI contrast agents to achieve molecular imaging by MRI. Commonly, peptides, antibodies, or small ligands, and small protein domains, such as HER 2 affibodies, have been applied to achieve targeting. To enhance the sensitivity of the contrast agents, these targeting moieties are usually linked to high payload MRI contrast agents or MRI contrast agents with high relaxivities. A new class of gene targeting MR contrast agents has been introduced to show gene action of unique mRNA and gene transcription factor proteins. These new contrast agents can trace cells with unique mRNA, microRNA and virus; tissue response to inflammation in living brains. The MR reports change in gene expression with positive correlation to TaqMan analysis, optical and electron microscopy.

It takes time to gather MRI data using sequential applications of magnetic field gradients. Even for the most streamlined of MRI sequences, there are physical and physiologic limits to the rate of gradient switching. Parallel MRI circumvents these limits by gathering some portion of the data simultaneously, rather than in a traditional sequential fashion. This is accomplished using arrays of radiofrequency (RF) detector coils, each with a different 'view' of the body. A reduced set of gradient steps is applied, and the remaining spatial information is filled in by combining signals from various coils, based on their known spatial sensitivity patterns. The resulting acceleration is limited by the number of coils and by the signal to noise ratio (which decreases with increasing acceleration), but two to four fold accelerations may commonly be achieved with suitable coil array configurations, and substantially higher accelerations have been demonstrated with specialized coil arrays. Parallel MRI may be used with most MRI sequences. After a number of early suggestions for using arrays of detectors to accelerate imaging went largely unremarked in the MRI field, parallel imaging saw widespread development and application following the introduction of the SiMultaneous Acquisition of Spatial Harmonics (SMASH) technique in 1996–7. The SENSitivity Encoding (SENSE) and Generalized Autocalibrating Partially Parallel Acquisitions (GRAPPA) techniques are the parallel imaging methods in most common use today. The advent of parallel MRI resulted in extensive research and development in image reconstruction and RF coil design, as well as in a rapid expansion of the number of receiver channels available on commercial MR systems. Parallel MRI is now used routinely for MRI examinations in a wide range of body areas and clinical or research applications.

Traditional MRI generates poor images of lung tissue because there are fewer water molecules with protons that can be excited by the magnetic field. Using hyperpolarized gas an MRI scan can identify ventilation defects in the lungs. Before the scan, a patient is asked to inhale hyperpolarized xenon mixed with a buffer gas of helium or nitrogen. The resulting lung images are much higher quality than with traditional MRI.

MRI is, in general, a safe technique, although injuries may occur as a result of failed safety procedures or human error. Contraindications to MRI include most cochlear implants and cardiac pacemakers, shrapnel, and metallic foreign bodies in the eyes. Magnetic resonance imaging in pregnancy appears to be safe, at least during the second and third trimesters if done without contrast agents. Since MRI does not use any ionizing radiation, its use is generally favored in preference to CT when either modality could yield the same information. Some patients experience claustrophobia and may require sedation or shorter MRI protocols. Amplitude and rapid switching of gradient coils during image acquisition may cause peripheral nerve stimulation. MRI uses powerful magnets and can therefore cause magnetic materials to move at great speeds, posing a projectile risk, and may cause fatal accidents. However, as millions of MRIs are performed globally each year, fatalities are extremely rare. MRI machines can produce loud noise, up to 120 dB(A). This can cause hearing loss, tinnitus and hyperacusis, so appropriate hearing protection is essential for anyone inside the MRI scanner room during the examination.

Medical societies issue guidelines for when physicians should use MRI on patients and recommend against overuse. MRI can detect health problems or confirm a diagnosis, but medical societies often recommend that MRI not be the first procedure for creating a plan to diagnose or manage a patient's complaint. A common case is to use MRI to seek a cause of low back pain; the American College of Physicians, for example, recommends against imaging (including MRI) as unlikely to result in a positive outcome for the patient.

[[File:MRI with motion artifacts. jpg|thumb|Motion artifact (T1 coronal study of cervical vertebrae)

MRI is used industrially mainly for routine analysis of chemicals. The nuclear magnetic resonance technique is also used, for example, to measure the ratio between water and fat in foods, monitoring of flow of corrosive fluids in pipes, or to study molecular structures such as catalysts. It is also applied to veterinary radiology for diagnostic purposes. Outside this, its use in zoology is limited due to the high cost; but it can be used on many species. In palaeontology it is used to examine the structure of fossils. Forensic imaging provides graphic documentation of an autopsy, which manual autopsy does not. CT scanning provides quick whole body imaging of skeletal and parenchymal alterations, whereas MR imaging gives better representation of soft tissue pathology. All that being said, MRI is more expensive, and more time consuming to utilize.

In 1971 at Stony Brook University, Paul Lauterbur applied magnetic field gradients in all three dimensions and a back projection technique to create NMR images. He published the first images of two tubes of water in 1973 in the journal Nature, followed by the picture of a living animal, a clam, and in 1974 by the image of the thoracic cavity of a mouse. Lauterbur called his imaging method zeugmatography, a term which was replaced by (N)MR imaging. Raymond Damadian’s work into nuclear magnetic resonance (NMR) has been incorporated into MRI, having built one of the first scanners. Advances in semiconductor technology were crucial to the development of practical MRI, which requires a large amount of computational power. This was made possible by the rapidly increasing number of transistors on a single integrated circuit chip. Mansfield and Lauterbur were awarded the 2003 Nobel Prize in Physiology or Medicine for their "discoveries concerning magnetic resonance imaging".