General

Easier to include more sequences up front because easier than bringing patient back

Emergency Room

Please Indicate the following Tier in the comment section for each ER scan.

Tier 1: Table clearing event scan to begin within 30mins

Immediate response is needed.

The MRI should begin immediately or within 30 minutes of being ordered and properly screened prior to MRI.
The patient must be monitored and accompanied by an RN/MD.
The results will drive major changes in the medical management of the patient, with the intention of treatment.
MRI screening form must be done prior to patient arriving to MRI or cleared by imaging.

The MRI department coordinates when the patient is to be brought over as the table should be clear.

It is required that there be communication from the ED provider and the radiologist or resident to approve and protocol this as a Tier 1 exam which should be confirmed in Epic before the MRI is attempted.

Qualifying examples:

Brain attack – qualifies for TPA/clot retrieval
Traumatic - paraplegia or quadriplegia
Atraumatic paraplegia or quadriplegia that is rapidly progressive.

Tier 2: Scan to begin within 2 hours

Rapid response is needed.

The MRI should be expected to begin within 2 hours of being ordered and properly screened prior to MRI.
The results will drive major changes in the medical management of the patient, with the intention of treatment.

It is required that there be communication from the ED provider and the radiologist or resident to approve and protocol this as a Tier 2 exam which should be confirmed in Epic before the MRI is attempted.

Qualifying examples:

The patient needs an MRI to clear their C-spine and continues to be in C-spine precautions.
A trauma patient with an abnormal CT of the spine requires further work-up.
A trauma patient with an abnormal neurological exam.
Concern for epidural abscess in a toxic appearing patient with back pain.

Tier 3: Scan to begin within 6 hours

Urgent response is needed.

The MRI should be expected to begin within 6 hours of being ordered and properly screened prior to MRI.

Qualifying examples:

Focal neurological deficits that are not TPA candidates.
ER Fast Brain protocol
Back pain with mild neurologic symptoms
Non - toxic appearing back pain with concern for epidural abscess WITHOUT focal neurological findings.
Elevated CRP in a setting of back pain.

Brain

Brain protocols have the most options. They all include Routine Brain as a base, and then add various sequences depending on the clinical question.

Routine brain (I-)

Standard for most head basic sequences including DWI.

Brain with gado (I+)Adds T1 post: axial and triplanar volumetric. Good assessment for metastatic disease.

Pituitary

Adds coronals for extra sella views

Seizure / Temporal lobes

Adds focused view of temporal lobes, also gad to evaluate for lesions.

Multiple sclerosis (MS)

Look for demyelinating disease. Adds sagittal FLAIR and gado.

Internal auditory canal (IAC)

For dizziness vertigo if suspect IAC etiology such as schwannoma, includes thin slices through IAC

Trigeminal Nerve for cranial nerve V (trigeminal) evaluation for facial numbness or pain

Facial Nerve (I+)e.g. for facial muscle weakness

MRI/MRA head/neck (prefer I+)

Typical look at brain and vascular. COW can be without contrast. Neck can be with or without, but better image quality with

MRA cow (I- tof)

If just need look at intracranial vessels. No gado needed (time-of-flight technique).

MRV (prefer I+)Evaluate patency of dural sinuses. Can do I- if necessary but I+ higher quality.

Dissection Adds T1 and/or PD with fat saturation.

Spine

Routine (I-)

Good for standard evaluation, nerve roots, degenerative changes, etc.

With gado

If mass, lumbar post-operative, or history of cancer

Demyelinating/MS (I+)for demyelinating disease including multiple sclerosis or neuromyelitis optica, includes post-contrast

Cord compression Sag T2s of whole spine - good for cord compression but not detailed nerve root anatomy

Musculoskeletal

Routine (I-)

Standard for any joint (knee, shoulder, etc)

Arthrogram (intra-articular gad)

Procedural injection of gadolinium into the joint, typically used for labral tears in the shoulder/hip.

Soft Tissue Mass (w/ gad)

Evaluate mass. Should include T1 with fat saturation both pre and post contrast. Place indicator at site indicated by patient (e.g. vitamin D pill). Focus field of view to pertinent anatomy.

Long Bone (w/ gad)

Looking for osteomyelitis, with gado

Brachial plexus

Temporomandibular joint (TMJ)

Hip Fracture

Extremities can be subdivided into small fields of view as possible, e.g.

shoulder, long bone, elbow, wrist, hand, thumb, finger
hip, long bone upper or lower, knee, ankle, mid foot, fore foot, toe

Chest

Dissection MRA

PE MRA Possible but not as good as CTA

General thorax

Often for mass characterization

Cardiac

Basic sequences, then add-on specifics -

Cardiomyopathy/viability Hemochromatosis, sarcoidosis, deposition

ARVD Focus to right ventricle

Myocarditis Mass Valve/shunt Pericarditis Tag lines (but software not available at MAH)Post ablation/pulmonary veins? Regurgitation

? Aortic stenosis

Abdomen

Liver (I+)

Generally perform with and without regular gadolinium contrast (e.g. Gadavist).

In certain situations it is helpful to use hepatobiliary-specific contrast (Eovist). Specifically use Eovist if suspect:

Focal nodular hyperplasia (FNH)
Metastatic disease

Usually includes MRCP

Pancreas (I+)

Good for characterizing and following pancreatic lesions.

Usually includes MRCP.

Enterography (AH)

Eval Crohns
Different types of oral contrast can be administered

Adrenals (G+)

Nodule characterization

Kidneys (G+)

Renal mass characterization

Pelvis

Bony pelvis

general musculoskeletal stuff, wide field of view but can see majority of pelvis, sacrum, some assessment of hips

Hip

more focused exam to a hip of concern, such as when radiographs are negative or equivocal

Uterus triplanar along uterine axis, evaluate uterine anomalies, lesions

Cervix for cervical cancer staging. seems like uterus but specific subset with planes along axis of cervix to assess extension of tumor

Dynamic pelvic floor (PS)e.g. to evaluate for pelvic floor weakness

Urethera diverticulum versus skene or other cyst

Breast

Breast Routine (I+)

Standard most common option, evaluation for breast cancer (high-risk screening or other diagnostic use). Must use contrast.

Implants

Evaluate for silicone implant rupture.