LISTS: (dont know if lists are current)

• BU WX HTPN MR Body Unread 

• ARA Body MRI list in Clario [Body MRI 1, on T/Th also TMI Rosedale Body MRI T, Th, Sa list] 

LOCATION: 

• Sammons 7th floor. Go left from the elevators. Walk past the bathrooms on your left. Touchstone MRI office will be on your right. Reading room code is 12345. Receptionist is Nelda. Attending sits in the room with 2 workstations on an L-shaped desk configuration. Residents sit in the other room: upper level closest to the door and lower level switches between the other 2 workstations (1 for Baylor, 1 for ARA).  

WORKFLOW

• This rotation SHOULD have a lower and upper level/fellow on at all times though if you're like me you are all alone. You'll read cases on Clario/InteleViewer for the outpatient world and also read the inpatient body MR cases (which includes extremities e.g. for osteomyelitis evaluation, not detailed tendon evaluation like you'll do on MSK). The "bone box" is another list that gets extremity CTs rarely as well. 

• Prioritize Inpatient exams (BUMC side) first, then Clario (unless there's a stat Clario). Then try and make sure to read Dr. Goldstein's patients in Clario (nurses no longer bring a sheet of his clinic patients around so dont expect to every know who his current clinic day patients are until he pops in).  

TEMPLATES

• Curtis:

  • Likes you to free dictate for MR abdomens but probs wont tell you this. Otherwise use the MR abdomen template everyone uses. Its easy to forget to delete vascular section on noncon studies so you can avoid it if you free dictate.

• Dockery: Occasionally changes his templates and more recently MRI/MRCP.. He'll tell you

• Hazel: only wants you to use her templates. Her templates start with "preferred"

• Others: kind of all over the place so just pick a recommended template and find what you like. 

STUDY / TOPICS

• Focus on MR abdomen, MRCPs and everything liver in the first week. 

  • Become fluent in LIRADS: use radiology assistant or RSNA article for basic knowledge and then learn on base.

  • Understand post treatment change. Goldstein makes same day appts for his patients to get their MRI and see him. He will pay you a visit throughout the day and demand an immediate assessment as the patients are sometimes already there and are waiting on an answer.

  • Can look at body MRI specific ppts to learn protocol info from Curtis as well as RSNA in MRI section. MRIMASTER.com is a great website too.

  • Know liver lesions: memorize "MR characterization of focal liver lesion" article for golden pearls. I also have 2 google docs that cover the approach and specific lesion details. 

• Second week: start prostate MRIs and pelvis or anything else you want. Leave rectal CA for last weeks unless you just cant help yourself.

• Other 

  • Prostate: use radassist modules in the MALE GU tab to get initial info. Typically one of the easier studies you can read. First determine prostate volume on sag/axial T2 using the prostate volume calculator -> assess DWI/ADC for peripheral zone -> T2 sequences for transitional zone -> compare findings with dynamic contrast sequences

    • Everyone typically has the same template except for Hazel. 

  • Pancreas cyst F/U: dont comment on new ones unless they're ~>4mm. Otherwise assess change and use the ACR algorithm guidelines for follow up. 

  • Elastography: look at ppt in HEPATOBILIARY page for QC and assessment tips. 

    • Rads on the base have VERY different opinions on elastography and multiscans and you will just have to learn their idiosyncrasies. Reference values are included in the template footer for the clinicians. There are 2 studies that the research came from and some docs prefer one table over the other.

  • MR pelvic floor dysfunction studies: use MRI dynamic defecography ppt in rectum/anus page for help

  • Enterography: radassist module walkthrough in GI tract inflammatory bowel dz section

  • Rectal CA cases: More high level and can wait until you are comfortable with hepatobiliary info UNLESS you are presenting at rectal conference then you can learn it early (Stephens will make you present). 

    • If new diagnosis without prior MRI check who the referring physician is and if they are one of the surgeons listed on the sheet in the attendings room. If listed, the study can ONLY be sent to the rads (Page or Stephens) who is presenting at the upcoming conference (its an accreditation thing). So you'll review it with you current staff then send it to the conference rads. If its a follow up or new dx w/o one of those rectal surgeons listed then you can send the study to the attendee you're working with that day.

    • Study materials: radassist modules in rectum/anus page for pre and post treatment change. Radiology assistant is great for first time reading. 

    • For post treatment change look at the TRG chart in rectal CA ppt to give tumor response grading in the impression. Not too hard. Look at T2 for change in tumor characteristics (T2 darkness is good) and DWI/ADC for restricted diffusion (viable tumor) or T2 shine through (could be granulation tissue).

    • You must use the template dePrisco or somebody made. It will walk you through search pattern and assessment. 

  • TMJ: use ppt in MRI page

  • Female pelvis: i have random ppts and modules in the UTERUS/VAGINA and OVARIES pages that can help.

  • Plexus studies: body reads brachial and lumbosacral plexus studies. No real great template for it and the studies typically suck with tons of streak artifact. 

MR SEQUENCE 

• Diffusion: Abdominal lymphadenopathy 

• In/out of phase (usually "2D Dual Echo"): 

• Out of phase images have organs surrounded by "India Ink" artifact (dark thick lines) 

  • If the signal drops (hypointense) on out of phase, the lesion contains fat (e.g. hepatic steatosis, AML, adrenal adenoma) 

  • If the signal drops (hypointense) on in phase, there is metal deposition (think hemochromatosis, maybe Wilson's) 

• Post-contrast: Enhancing lesions and how they behave over time (to characterize in LI-RADS, for example) 

PROTOCOL TIPS (https://mrimaster.com/planning/)

• Liver – T2, In/Out, T1 Pre, T1 post arterial, venous, 3-minute, and delayed (some centers do 5, 8, or 10 minutes, have to have 10 minutes if cholangiocarcinoma) 

• If Eovist – Used for FNH 

• Same, only the delayed will be 20 minutes 

• Biliary – Same as liver, only they add MRCP 

• Pancreas – Same as biliary 

• Kidneys – Same as liver, except sometimes they do the in/out as coronal (to see kidneys better), and sometimes do a single post coronal 

• Adrenal – T2, In/Out, T1 pre, T1 post arterial, venous, 3 minute (although most of the time don't even need the contrast, just using in/out for adenoma evaluation) 

• Pelvis: 

  • Protocols available: MSK, female pelvis (assesses anterior/middle compartment), rectal (specific for 

CHEST