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Angiography - Thoracic MRA

a) SCMR official document standardized acquisition guidelines – relevant extract

1. Localizer, 3 orientations
2. Half-fourier single shot fast spin echo or SSFP (one breathhold, entire thorax) Transaxial orientation.
3. Transaxial T1-weighted fast spin echo through aorta (for intramural hematoma, dissection)
4. SSFP cine imaging in parasagittal plane parallel to aorta Option – use 3-point piloting
5. Evaluate aortic valve as per valvular protocol
6. Contrast timing
   a. Option 1 -Transaxial test bolus at level of distal abdominal aorta. 2 ml injection of gadolinium, followed by 20ml saline. Determine time to peak enhancement following injection.
   b. Option 2 – Bolus triggering technique to time start of scan
   c. Option 3 – Rapid multiphase 3D acquisitions without timing
7. 3D gadolinium enhanced MRA (0.1–0.2 mmol/kg) (optional – ECG-gated acquisition)
   a. Use spatial resolution of at least 1–1.5 mm
   b. Parallel acquisition if availablec. At least 2 acquisitions after contrast injection
Optional – transaxial T2-weighted gradient echo or T1-weighted gradient-echo post-contrast for aortitis
8. Analysis – MPR-Reconstruction, MIP and thin slab MIP

b) SCMR official document reporting recommendations – relevant extract

Aorta:
Dimensions including (4 recommended, 1 optional):
a. Aortic annulus (recommended)
b. Sinuses of Valsalva (recommended)
c. Sinotubular junction (recommended)
d. Ascending and descending diameters at the level of the pulmonary artery (recommended)
e. Comment regarding whether the aorta is right or left-sided may be provided (optional).
Findings when present (7 recommended, 1 optional):
a.  Comment on sinotubular effacement (recommended)
b.  Comment on tortuosity (recommended)
c.  Aortic  atherosclerosis  (recommended):  description  of  location, mobility  and extent, estimate %-stenosis when advanced 
d.  Aortic aneurysm (recommended):
size (AP x LR x CC),
morphology (saccular versus fusiform),
location in the aorta,
relation to branch vessels,
presence of mural thrombus,
visceral compressive effects (effacement expansion of the aorta against surrounding structures),
post-contrast appearance (if these sequence were acquired),
presence of periaortic, mediastinal, pericardial, or pleural fluid.
e.  Aortic dissection (recommended):  dissection classification (either DeBakey or Stanford), presence of intimal flap, location of tear or areas of communication   (if possible), description of the size and extent of the true and false lumens, presence of murmal thrombus or blood in false lumen, branch vessel involvement, presence of periaortic, mediastinal, pericardial, or pleural fluid, 
i. Intramural hematoma (IH): in cases of IH and penetrating aortic ulcer, the CMR practitioner should describe carefully the morphologic findings in much the same way as an aortic dissection paying careful attention to select wording to convey a diagnosis of limited ulceration or dissection.
ii. Post-operative appearance:  this should be described in accordance with (a-e) above noting additional graft insertion points and dimensions.
f.  Inflammatory diseases of the aorta (recommended):
aortic wall thickness, multispectral appearance on different pulse sequences, contrast enhancement pattern, branch vessel involvement, presence of periaortic, pleural, or pericardial fluid 
g.  Congenital disease involving the aorta and ventriculoarterial connections: see recommended congenital report below. 
h.  Aortic flow (optional): On CMR scans of the aorta in which PC-MR measures are obtained, the direction and magnitude of flow should be provided.

c) Standardized web based images

Coarctation case
Case notes: Case from the Heart Hospital, London.
This case has
1. Localizer, 3 orientations Series_2
2. Half-fourier single shot fast spin echo Series_4 or SSFP (one breathhold, entire thorax) Series_55  Transaxial orientation.
3. Transaxial T1-weighted fast spin echo through aorta (for intramural hematoma, dissection) Series_56 and _57
4. SSFP cine imaging in parasagittal plane parallel to aorta Option – use 3-point piloting Series_39
5. Evaluate aortic valve as per valvular protocol Series_32,_34,_41
6. Contrast timing
a. Option 1 -Transaxial test bolus at level of distal abdominal aorta. 2 ml injection of gadolinium, followed by 20ml saline. Determine time to peak enhancement following injection. Series_25
b. Option 2 – Bolus triggering technique to time start of scan Not done
c. Option 3 – Rapid multiphase 3D acquisitions without timing  Not done
7. 3D gadolinium enhanced MRA (0.1–0.2 mmol/kg) (optional – ECG-gated acquisition) Series_26
8. Optional – transaxial T2-weighted gradient echo or T1-weighted gradient-echo post-contrast for aortitis Not done
9. Analysis – MPR-Reconstruction, MIP and thin slab MIP Not displayed

Other cases examples
Marfans aneurysm

d) Case of the Week example(s)

Number 08-04: Where is the murmur from?
History: A 20 year-old Hispanic male with a murmur since childhood presented with worsening exertional chest pressure and dyspnea. CMR was ordered for further evaluation.

Number 08-06: Coarctation & aortic stenosis?
History: A 46 year old male with 6 months breathlessness. Previous patch repair of “adult type” CoA.

Number 08-10: Interrupted Aortic Arch
History: 2 day old female, mild respiratory distress

Number 08-12: Congenital Bicuspid Aortic Valve with Ascending Aortic Dilatation
History: 35 year old man. Known congenital bicuspid aortic valve. Recently noted ascending aortic dilatation on routine echocardiogram. Referred for a cardiac MRI for LV functional and morphologic assessment and contrast MRA for aortic evaluation.

e) Expert opinion – ‘How we do’

"How I do CMR of the Aorta" (Saul Myerson, Oxford CMR unit)

f) Relevant Online Talks

Free talks

Vascular: Aorta and pulmonary circulation
By Raad Mohiaddin
Recorded at EuroCMR 2008

Angiography
By Georg Bongartz
Recorded at EuroCMR 2008

CE MRA
By Daniel Thomas
Recorded at SCMR 2008: Technicians Workshop

Members only talks - general

Arterial sclerosis and endothelial function
By F Alpendurada
Recorded at EuroCMR 2008

Members only talks - cutting edge

Low Dose Gadolinium MRA
By J Paul Finn - David Geffen School of Medicine at UCLA
Recorded at SCMR 2009 Nephrogenic Systemic Fibrosis Era - Contrast enhanced vs Non-contrast enhanced

NSF - Is this an overblown risk?
By Brett Elicker - UCSF Medical Centre
Recorded at SCMR 2009 Nephrogenic Systemic Fibrosis Era - Contrast enhanced vs Non-contrast enhanced

Non-contrast MRA - Abdominal Aora, Renal Arteries and Peripheral
By Robert Edelman - Evanston Hospital
Recorded at SCMR 2009 Nephrogenic Systemic Fibrosis Era - Contrast enhanced vs Non-contrast enhanced

Time Resolved Contrast-Enhanced MRA
By James Carr - Northwestern Memorial Hospital
Recorded at SCMR 2009 Nephrogenic Systemic Fibrosis Era - Contrast enhanced vs Non-contrast enhanced

 

g) Relevant papers (starting point):

Bogaert J, Kuzo R, Dymarkowski S et al. Follow-up of patients with previous treatment for coarctation of the thoracic aorta: comparison between contrast-enhanced MR angiography and fast spin-echo MR imaging. Eur Radiol 2000;10:1847–54.

Sutter R, Nanz D, Lutz AM, Pfammatter T, Seifert B, Struwe A, Heilmaier C, Weishaupt D, Marincek B, Willmann JK. Assessment of aortoiliac and renal arteries: MR angiography with parallel acquisition versus conventional MR angiography and digital subtraction angiography. Radiology. 2007 Oct;245(1):276-84.

Kraft KA, Arena R, Arrowood JA, Fei DY. High aerobic capacity does not attenuate aortic stiffness in hypertensive subjects. Am Heart J. 2007 Nov;154(5):976-82.