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Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah, MD Brian Hamilton, MD Jochen Gaa, MD

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Page 1: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Portal MR Venography

with slides borrowed from

Tom Grist, MDJorg Debatin, MDQian Dong, MDRuth Carlos, MDDavid Stafford-Johnson, MDMohammed Neimatallah, MDBrian Hamilton, MDJochen Gaa, MD

Page 2: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Arterial phase Portal venous phase

Page 3: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Coronal 3D Gd MRA of Portal Vein• Coronal Plane

• Field of view = width of patient (28-32 cm)

• Thick slices: 3-5 mm

• Zero padding

• Fast enough for breath holding• TR < 10 msec• TE < 3 msec• Partial Fourier imaging (0.5 NEX)• Adjust phase encoding steps (128-224)

• Three phases• Arterial • Portal venous• Equilibrium

Page 4: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Mesenteric Portal Protocol

Sequence Time

• Sag SSFSE 0:56

•Axial T1 5:32

• Axial T2 & fat sat 6:04

• MRCP (optional)

• Coronal 3D Gd (3 phases) 0:30 x 3

• Axial 2D TOF (optional)

Total imaging time ~15-25 minutes

Page 5: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Arterial Phase

Venous Phase

Page 6: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Venous Phase

Hepatoma

Page 7: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Fig. 7.7. Hepatoma.Clinical Scenario: 54-year-old female with abdominal pain and elevated AFP. Technique: Coronal Acquisition, TR/TE/Flip = 8.1/2.1/45°, Field-of-View = 320 x 320 x 96 mm, Matrix 256 x 160 x 32, Centric Ordering of k-space, Acquisition Time = 29 s, 40 ml gadolinium contrast infused at 2 ml/s, and timed empirically.Interpretation: A coronal MIP from the portal venous-phase of the contrast bolus shows an enhancing mass in the dome of the liver with heterogenously enhancing tumor invading the right portal vein and extending down to the confluence of right and left portal veins. The main and left portal veins are widely patent.Diagnosis: Hepatoma with invasion of right portal vein.Submitted by Martin R. Prince, M.D., Ph.D., Ann Arbor, MI.

Page 8: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Main Portal Vein

MIP of Entire 3D Volume

Main Portal Vein

SMV

Sub-Volume MIP

Axial Reformation

Page 9: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

MIP of Entire 3D Volume

Axial Reformation

Sub-Volume MIP

Right Hepatic vein

Right Hepatic vein

Page 10: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Portal hypertension with varices

Page 11: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

55 year old female prior to TIPS

Coronal 3D Gd MRA MIP during venous phase

Page 12: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Thick MIP Thin MIP

Varices

Page 13: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Portal hypertension

Page 14: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Spleno-renal shunt

Anterior MIP Posterior MIP

Page 15: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Fig. 7.3. MRA of Portocaval Shunt.Clinical Scenario: 42-year-old male, status post-portocaval shunt with worsening ascites.Technique: Coronal Acquisition, TR/TE/Flip = 7.2/1.2/45°, Field-of-View = 300 x 300, Matrix = 256 x 128, Centric Ordering of k-space, Acquisition Time = 32 s, 1 NEX, 40 ml of gadolinium infused at 2 ml/s, and timed empirically. Interpretation: Coronal subvolume MIP (a) and magnification view (b) shows a widely patent portocaval shunt (arrows). Note also gastric varices (arrowheads). During this equilibrium phase image, there is comparable enhancement of the portal vein, IVC, and aorta.Diagnosis: Patent portocaval shunt.Submitted by David Stafford-Johnson, M.D., Ann Arbor, MI.Reprinted with permission from Investigative Radiology Sept. Oct. 1998.

Page 16: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

56 year old female with abdominal pain

Maximum intensity projection

Minimun intensity projections

Page 17: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Portal and hepatic vein thrombosus

Maximum intensity projection

Minimun intensity projections

Page 18: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Acute thrombosis of portal vein (arrows) with perithrombus enhancement (arrowheads)

Maximum Intensity Projection

Page 19: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Cavernous Transformation

Page 20: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

32-year-old female with abdominal pain

Page 21: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Budd Chiari

Page 22: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Fig. 7.4. Liver Transplant.Clinical Scenario: Status post liver transplant with increased liver function tests.Technique: Coronal Acquisition, TR/TE/Flip = 7/2.1/45°, Field-of-View = 320 x 320 x 84 mm, Matrix = 256 x 128 x 28, Sequential Ordering of k-space, Acquisition Time = 27 s, 40 ml gadolinium contrast infused at 2 ml/ s, and timed empirically.Interpretation: Coronal oblique subvolume MIP shows a widely patent splenic and portal veins. There is minor narrowing (arrows) at the site of anastomosis between the native and donor portal veins.Diagnosis: Widely patent transplant portal vein.Submitted by Martin R. Prince, M.D., Ph.D., Ann Arbor, MI. v

Page 23: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

IVC anastomotic narrowing

Page 24: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

13 year old female post liver and kidney transplant

Arterial Phase Portal-venous Phase

Page 25: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Post Liver Transplant

Page 26: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Post Liver Transplant with

abcess narrowing portal vein

Page 27: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Pancreatic mass encasing celiac and spleno-portal confluence

Page 28: Portal MR Venography with slides borrowed from Tom Grist, MD Jorg Debatin, MD Qian Dong, MD Ruth Carlos, MD David Stafford-Johnson, MD Mohammed Neimatallah,

Summary• Normal flow: Gd not necessary

• Slow flow: Gd essential

• Coronal 3D: thick slices & breathholding

• Useful for evaluating• Varices • Shunts• Tumor encasement • Tumor invasion• Thrombosis• Cavernous transformation• Budd Chiari• Liver transplant


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