Magnetic resonance imaging

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Magnetic_resonance_imaging

 

Magnetic resonance imaging
Play media Para-sagittal MRI of the head, with aliasing artifacts (nose and forehead appear at the back of the head)
Synonyms	nuclear magnetic resonance imaging (NMRI), magnetic resonance tomography (MRT)
ICD-9-CM	88.91
MeSH	D008279
MedlinePlus	003335

Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of 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 CT and 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.

While the hazards of ionizing radiation are now well controlled in most medical contexts, an MRI may still be seen as a better choice than a CT scan. MRI is widely used in hospitals and clinics for medical diagnosis and staging and follow-up of disease without exposing the body to radiation. An MRI may yield different information compared with CT. Risks and discomfort may be associated with MRI scans. Compared with CT scans, MRI scans typically take longer and are louder, and they usually need the subject to enter a narrow, confining tube. In addition, people with some medical implants or other non-removable metal inside the body may be unable to undergo 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 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 antennae close to the subject being examined. Hydrogen atoms are naturally abundant in humans and other biological organisms, particularly in water and fat. For this reason, most MRI scans essentially map the location of water and fat in the body. Pulses of radio waves excite the nuclear spin energy transition, and magnetic field gradients localize the polarization in space. By varying the parameters of the pulse sequence, different contrasts may be generated between tissues based on the relaxation properties of the hydrogen atoms therein.

Since its development in the 1970s and 1980s, MRI has proven to be a versatile imaging technique. While MRI is most prominently used in diagnostic medicine and biomedical research, it also may be used to form images of non-living objects. Diffusion MRI and Functional MRI extends the utility of MRI to capture neuronal tracts and blood flow respectively in the nervous system, in addition to detailed spatial images. The sustained increase in demand for MRI within health systems has led to concerns about cost effectiveness and overdiagnosis.

Mechanism

Construction and physics

Schematic of construction of a cylindrical superconducting MR scanner

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 excited atoms emit a radio frequency (RF) signal, which 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.

A mobile MRI unit visiting Glebefields Health Centre, Tipton, England

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. Most clinical magnets are superconducting magnets, which require liquid helium to keep them very cold. 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).

T1 and T2

Effects of TR and TE on MR signal

 

Examples of T1-weighted, T2-weighted and PD-weighted MRI scans

Each tissue returns to its equilibrium state after excitation by the independent relaxation processes of T1 (spin-lattice; that is, magnetization in the same direction as the static magnetic field) and T2 (spin-spin; transverse to the static magnetic field). To create a T1-weighted image, magnetization is allowed to recover before measuring the MR signal by changing the repetition time (TR). This image weighting is useful for assessing the cerebral cortex, identifying fatty tissue, characterizing focal liver lesions, and in general, obtaining morphological information, as well as for post-contrast imaging. To create a T2-weighted image, magnetization is allowed to decay before measuring the MR signal by changing the echo time (TE). This image weighting is useful for detecting edema and inflammation, revealing white matter lesions, and assessing zonal anatomy in the prostate and uterus.

The standard display of MRI images is to represent fluid characteristics in black and white images, where different tissues turn out as follows:

Signal	T1-weighted	T2-weighted
High	Fat Subacute hemorrhage Melanin Protein-rich fluid Slowly flowing blood Paramagnetic or diamagnetic substances, such as gadolinium, manganese, copper Cortical pseudolaminar necrosis Anatomy	More water content, as in edema, tumor, infarction, inflammation and infection Extracellularly located methemoglobin in subacute hemorrhage Fat Pathology
Inter- mediate	Gray matter darker than white matter	White matter darker than grey matter
Low	Bone Urine CSF Air More water content, as in edema, tumor, infarction, inflammation, infection, hyperacute or chronic hemorrhage Low proton density as in calcification	Bone Air Low proton density, as in calcification and fibrosis Paramagnetic material, such as deoxyhemoglobin, intracelullar methemoglobin, iron, ferritin, hemosiderin, melanin Protein-rich fluid

Diagnostics

Usage by organ or system

Patient being positioned for MR study of the head and abdomen

MRI has a wide range of applications in medical diagnosis and more than 25,000 scanners are estimated to be in use worldwide. MRI affects diagnosis and treatment in many specialties although the effect on improved health outcomes is disputed in certain cases.

MRI is the investigation of choice in the preoperative staging of rectal and prostate cancer and has a role in the diagnosis, staging, and follow-up of other tumors, as well as for determining areas of tissue for sampling in biobanking.

Neuroimaging

MRI diffusion tensor imaging of white matter tracts

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.

Cardiovascular

MR angiogram in congenital heart disease

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.

Musculoskeletal

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.

Liver and gastrointestinal

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.

Angiography

Magnetic resonance angiography

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.

Contrast agents

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. The most commonly used intravenous contrast agents are based on chelates of gadolinium. 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 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.

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.

Sequences

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.

Overview table

This table does not include uncommon and experimental sequences.

Group	Sequence	Abbr.	Physics	Main clinical distinctions	Example
Spin echo	T1 weighted	T1	Measuring spin–lattice relaxation by using a short repetition time (TR) and echo time (TE).	Lower signal for more water content, as in edema, tumor, infarction, inflammation, infection, hyperacute or chronic hemorrhage. High signal for fat High signal for paramagnetic substances, such as MRI contrast agents Standard foundation and comparison for other sequences
	T2 weighted	T2	Measuring spin–spin relaxation by using long TR and TE times	Higher signal for more water content Low signal for fat − Note that this only applies to standard Spin Echo (SE) sequences and not the more modern Fast Spin Echo (FSE) sequence (also referred to as Turbo Spin Echo, TSE), which is the most commonly used technique today. In FSE/TSE, fat will have a high signal. Low signal for paramagnetic substances Standard foundation and comparison for other sequences
	Proton density weighted	PD	Long TR (to reduce T1) and short TE (to minimize T2).	Joint disease and injury. High signal from meniscus tears. (pictured)
Gradient echo (GRE)	Steady-state free precession	SSFP	Maintenance of a steady, residual transverse magnetisation over successive cycles.	Creation of cardiac MRI videos (pictured).
	Effective T2 or "T2-star"	T2*	Spoiled gradient recalled echo (GRE) with a long echo time and small flip angle	Low signal from hemosiderin deposits (pictured) and hemorrhages.
	Susceptibility-weighted	SWI	Spoiled gradient recalled echo (GRE), fully flow compensated, long echo time, combines phase image with magnitude image	Detecting small amounts of hemorrhage (diffuse axonal injury pictured) or calcium.
Inversion recovery	Short tau inversion recovery	STIR	Fat suppression by setting an inversion time where the signal of fat is zero.	High signal in edema, such as in more severe stress fracture. Shin splints pictured:
	Fluid-attenuated inversion recovery	FLAIR	Fluid suppression by setting an inversion time that nulls fluids	High signal in lacunar infarction, multiple sclerosis (MS) plaques, subarachnoid haemorrhage and meningitis (pictured).
	Double inversion recovery	DIR	Simultaneous suppression of cerebrospinal fluid and white matter by two inversion times.	High signal of multiple sclerosis plaques (pictured).
Diffusion weighted (DWI)	Conventional	DWI	Measure of Brownian motion of water molecules.	High signal within minutes of cerebral infarction (pictured).
	Apparent diffusion coefficient	ADC	Reduced T2 weighting by taking multiple conventional DWI images with different DWI weighting, and the change corresponds to diffusion.	Low signal minutes after cerebral infarction (pictured).
	Diffusion tensor	DTI	Mainly tractography (pictured) by an overall greater Brownian motion of water molecules in the directions of nerve fibers.	Evaluating white matter deformation by tumors Reduced fractional anisotropy may indicate dementia.
Perfusion weighted (PWI)	Dynamic susceptibility contrast	DSC	Measures changes over time in susceptibility-induced signal loss due to gadolinium contrast injection.	Provides measurements of blood flow In cerebral infarction, the infarcted core and the penumbra have decreased perfusion and delayed contrast arrival (pictured).
	Arterial spin labelling	ASL	Magnetic labeling of arterial blood below the imaging slab, which subsequently enters the region of interest. It does not need gadolinium contrast.
	Dynamic contrast enhanced	DCE	Measures changes over time in the shortening of the spin–lattice relaxation (T1) induced by a gadolinium contrast bolus.	Faster Gd contrast uptake along with other features is suggestive of malignancy (pictured).
Functional MRI (fMRI)	Blood-oxygen-level dependent imaging	BOLD	Changes in oxygen saturation-dependent magnetism of hemoglobin reflects tissue activity.	Localizing brain activity from performing an assigned task (e.g. talking, moving fingers) before surgery, also used in research of cognition.
Magnetic resonance angiography (MRA) and venography	Time-of-flight	TOF	Blood entering the imaged area is not yet magnetically saturated, giving it a much higher signal when using short echo time and flow compensation.	Detection of aneurysm, stenosis, or dissection
	Phase-contrast magnetic resonance imaging	PC-MRA	Two gradients with equal magnitude, but opposite direction, are used to encode a phase shift, which is proportional to the velocity of spins.	Detection of aneurysm, stenosis, or dissection (pictured).	(VIPR)

Other specialized configurations

Magnetic resonance spectroscopy

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

Play media

Real-time MRI of a human heart at a resolution of 50 ms

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.

Interventional MRI

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.

Magnetic resonance guided focused ultrasound

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.

Multinuclear imaging

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, hetereonuclear 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.

Molecular imaging by MRI

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.

Parallel MRI

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.

Safety

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. 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.

Overuse

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 this procedure as unlikely to result in a positive outcome for the patient.

Artifacts

Motion artifact (T1 coronal study of cervical vertebrae)

An MRI artifact is a visual artifact, that is, an anomaly during visual representation. Many different artifacts can occur during magnetic resonance imaging (MRI), some affecting the diagnostic quality, while others may be confused with pathology. Artifacts can be classified as patient-related, signal processing-dependent and hardware (machine)-related.

Non-medical use

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.

Being non-invasive and non-damaging, MRI can be used to study the anatomy of plants, their water transportation processes and water balance. 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 MRI imaging gives better representation of soft tissue pathology. But MRI is more expensive, and more time-consuming to utilize. Moreover, the quality of MR imaging deteriorates below 10 °C.

History

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. In the late 1970s, physicists Peter Mansfield and Paul Lauterbur developed MRI-related techniques, like the echo-planar imaging (EPI) technique.

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".

Medical imaging

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Medical_imaging

 

Medical imaging
A CT scan image showing a ruptured abdominal aortic aneurysm
ICD-10-PCS	B
ICD-9	87-88
MeSH	003952 D 003952
OPS-301 code	3
MedlinePlus	007451

Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to reveal internal structures hidden by the skin and bones, as well as to diagnose and treat disease. Medical imaging also establishes a database of normal anatomy and physiology to make it possible to identify abnormalities. Although imaging of removed organs and tissues can be performed for medical reasons, such procedures are usually considered part of pathology instead of medical imaging.

As a discipline and in its widest sense, it is part of biological imaging and incorporates radiology, which uses the imaging technologies of X-ray radiography, magnetic resonance imaging, ultrasound, endoscopy, elastography, tactile imaging, thermography, medical photography, nuclear medicine functional imaging techniques as positron emission tomography (PET) and single-photon emission computed tomography (SPECT).

Measurement and recording techniques that are not primarily designed to produce images, such as electroencephalography (EEG), magnetoencephalography (MEG), electrocardiography (ECG), and others, represent other technologies that produce data susceptible to representation as a parameter graph vs. time or maps that contain data about the measurement locations. In a limited comparison, these technologies can be considered forms of medical imaging in another discipline.

As of 2010, 5 billion medical imaging studies had been conducted worldwide. Radiation exposure from medical imaging in 2006 made up about 50% of total ionizing radiation exposure in the United States. Medical imaging equipment are manufactured using technology from the semiconductor industry, including CMOS integrated circuit chips, power semiconductor devices, sensors such as image sensors (particularly CMOS sensors) and biosensors, and processors such as microcontrollers, microprocessors, digital signal processors, media processors and system-on-chip devices. As of 2015, annual shipments of medical imaging chips amount to 46 million units and $1.1 billion.

Medical imaging is often perceived to designate the set of techniques that noninvasively produce images of the internal aspect of the body. In this restricted sense, medical imaging can be seen as the solution of mathematical inverse problems. This means that cause (the properties of living tissue) is inferred from effect (the observed signal). In the case of medical ultrasound, the probe consists of ultrasonic pressure waves and echoes that go inside the tissue to show the internal structure. In the case of projectional radiography, the probe uses X-ray radiation, which is absorbed at different rates by different tissue types such as bone, muscle, and fat.

The term "noninvasive" is used to denote a procedure where no instrument is introduced into a patient's body, which is the case for most imaging techniques used.

Types

(a) The results of a CT scan of the head are shown as successive transverse sections. (b) An MRI machine generates a magnetic field around a patient. (c) PET scans use radiopharmaceuticals to create images of active blood flow and physiologic activity of the organ or organs being targeted. (d) Ultrasound technology is used to monitor pregnancies because it is the least invasive of imaging techniques and uses no electromagnetic radiation.

In the clinical context, "invisible light" medical imaging is generally equated to radiology or "clinical imaging" and the medical practitioner responsible for interpreting (and sometimes acquiring) the images is a radiologist. "Visible light" medical imaging involves digital video or still pictures that can be seen without special equipment. Dermatology and wound care are two modalities that use visible light imagery. Diagnostic radiography designates the technical aspects of medical imaging and in particular the acquisition of medical images. The radiographer or radiologic technologist is usually responsible for acquiring medical images of diagnostic quality, although some radiological interventions are performed by radiologists.

As a field of scientific investigation, medical imaging constitutes a sub-discipline of biomedical engineering, medical physics or medicine depending on the context: Research and development in the area of instrumentation, image acquisition (e.g., radiography), modeling and quantification are usually the preserve of biomedical engineering, medical physics, and computer science; Research into the application and interpretation of medical images is usually the preserve of radiology and the medical sub-discipline relevant to medical condition or area of medical science (neuroscience, cardiology, psychiatry, psychology, etc.) under investigation. Many of the techniques developed for medical imaging also have scientific and industrial applications.

Radiography

Two forms of radiographic images are in use in medical imaging. Projection radiography and fluoroscopy, with the latter being useful for catheter guidance. These 2D techniques are still in wide use despite the advance of 3D tomography due to the low cost, high resolution, and depending on the application, lower radiation dosages with 2D technique. This imaging modality utilizes a wide beam of x rays for image acquisition and is the first imaging technique available in modern medicine.

• Fluoroscopy produces real-time images of internal structures of the body in a similar fashion to radiography, but employs a constant input of x-rays, at a lower dose rate. Contrast media, such as barium, iodine, and air are used to visualize internal organs as they work. Fluoroscopy is also used in image-guided procedures when constant feedback during a procedure is required. An image receptor is required to convert the radiation into an image after it has passed through the area of interest. Early on this was a fluorescing screen, which gave way to an Image Amplifier (IA) which was a large vacuum tube that had the receiving end coated with cesium iodide, and a mirror at the opposite end. Eventually the mirror was replaced with a TV camera.
• Projectional radiographs, more commonly known as x-rays, are often used to determine the type and extent of a fracture as well as for detecting pathological changes in the lungs. With the use of radio-opaque contrast media, such as barium, they can also be used to visualize the structure of the stomach and intestines – this can help diagnose ulcers or certain types of colon cancer.

Magnetic resonance imaging

A brain MRI representation

A magnetic resonance imaging instrument (MRI scanner), or "nuclear magnetic resonance (NMR) imaging" scanner as it was originally known, uses powerful magnets to polarize and excite hydrogen nuclei (i.e., single protons) of water molecules in human tissue, producing a detectable signal which is spatially encoded, resulting in images of the body. The MRI machine emits a radio frequency (RF) pulse at the resonant frequency of the hydrogen atoms on water molecules. Radio frequency antennas ("RF coils") send the pulse to the area of the body to be examined. The RF pulse is absorbed by protons, causing their direction with respect to the primary magnetic field to change. When the RF pulse is turned off, the protons "relax" back to alignment with the primary magnet and emit radio-waves in the process. This radio-frequency emission from the hydrogen-atoms on water is what is detected and reconstructed into an image. The resonant frequency of a spinning magnetic dipole (of which protons are one example) is called the Larmor frequency and is determined by the strength of the main magnetic field and the chemical environment of the nuclei of interest. MRI uses three electromagnetic fields: a very strong (typically 1.5 to 3 teslas) static magnetic field to polarize the hydrogen nuclei, called the primary field; gradient fields that can be modified to vary in space and time (on the order of 1 kHz) for spatial encoding, often simply called gradients; and a spatially homogeneous radio-frequency (RF) field for manipulation of the hydrogen nuclei to produce measurable signals, collected through an RF antenna.

Like CT, MRI traditionally creates a two-dimensional image of a thin "slice" of the body and is therefore considered a tomographic imaging technique. Modern MRI instruments are capable of producing images in the form of 3D blocks, which may be considered a generalization of the single-slice, tomographic, concept. Unlike CT, MRI does not involve the use of ionizing radiation and is therefore not associated with the same health hazards. For example, because MRI has only been in use since the early 1980s, there are no known long-term effects of exposure to strong static fields (this is the subject of some debate; see 'Safety' in MRI) and therefore there is no limit to the number of scans to which an individual can be subjected, in contrast with X-ray and CT. However, there are well-identified health risks associated with tissue heating from exposure to the RF field and the presence of implanted devices in the body, such as pacemakers. These risks are strictly controlled as part of the design of the instrument and the scanning protocols used.

Because CT and MRI are sensitive to different tissue properties, the appearances of the images obtained with the two techniques differ markedly. In CT, X-rays must be blocked by some form of dense tissue to create an image, so the image quality when looking at soft tissues will be poor. In MRI, while any nucleus with a net nuclear spin can be used, the proton of the hydrogen atom remains the most widely used, especially in the clinical setting, because it is so ubiquitous and returns a large signal. This nucleus, present in water molecules, allows the excellent soft-tissue contrast achievable with MRI.

A number of different pulse sequences can be used for specific MRI diagnostic imaging (multiparametric MRI or mpMRI). It is possible to differentiate tissue characteristics by combining two or more of the following imaging sequences, depending on the information being sought: T1-weighted (T1-MRI), T2-weighted (T2-MRI), diffusion weighted imaging (DWI-MRI), dynamic contrast enhancement (DCE-MRI), and spectroscopy (MRI-S). For example, imaging of prostate tumors is better accomplished using T2-MRI and DWI-MRI than T2-weighted imaging alone. The number of applications of mpMRI for detecting disease in various organs continues to expand, including liver studies, breast tumors, pancreatic tumors, and assessing the effects of vascular disruption agents on cancer tumors.

Nuclear medicine

Nuclear medicine encompasses both diagnostic imaging and treatment of disease, and may also be referred to as molecular medicine or molecular imaging and therapeutics. Nuclear medicine uses certain properties of isotopes and the energetic particles emitted from radioactive material to diagnose or treat various pathology. Different from the typical concept of anatomic radiology, nuclear medicine enables assessment of physiology. This function-based approach to medical evaluation has useful applications in most subspecialties, notably oncology, neurology, and cardiology. Gamma cameras and PET scanners are used in e.g. scintigraphy, SPECT and PET to detect regions of biologic activity that may be associated with a disease. Relatively short-lived isotope, such as ^99mTc is administered to the patient. Isotopes are often preferentially absorbed by biologically active tissue in the body, and can be used to identify tumors or fracture points in bone. Images are acquired after collimated photons are detected by a crystal that gives off a light signal, which is in turn amplified and converted into count data.

• Scintigraphy ("scint") is a form of diagnostic test wherein radioisotopes are taken internally, for example, intravenously or orally. Then, gamma cameras capture and form two-dimensional images from the radiation emitted by the radiopharmaceuticals.
• SPECT is a 3D tomographic technique that uses gamma camera data from many projections and can be reconstructed in different planes. A dual detector head gamma camera combined with a CT scanner, which provides localization of functional SPECT data, is termed a SPECT-CT camera, and has shown utility in advancing the field of molecular imaging. In most other medical imaging modalities, energy is passed through the body and the reaction or result is read by detectors. In SPECT imaging, the patient is injected with a radioisotope, most commonly Thallium 201TI, Technetium 99mTC, Iodine 123I, and Gallium 67Ga. The radioactive gamma rays are emitted through the body as the natural decaying process of these isotopes takes place. The emissions of the gamma rays are captured by detectors that surround the body. This essentially means that the human is now the source of the radioactivity, rather than the medical imaging devices such as X-ray or CT.
• Positron emission tomography (PET) uses coincidence detection to image functional processes. Short-lived positron emitting isotope, such as ¹⁸F, is incorporated with an organic substance such as glucose, creating F18-fluorodeoxyglucose, which can be used as a marker of metabolic utilization. Images of activity distribution throughout the body can show rapidly growing tissue, like tumor, metastasis, or infection. PET images can be viewed in comparison to computed tomography scans to determine an anatomic correlate. Modern scanners may integrate PET, allowing PET-CT, or PET-MRI to optimize the image reconstruction involved with positron imaging. This is performed on the same equipment without physically moving the patient off of the gantry. The resultant hybrid of functional and anatomic imaging information is a useful tool in non-invasive diagnosis and patient management.

Fiduciary markers are used in a wide range of medical imaging applications. Images of the same subject produced with two different imaging systems may be correlated (called image registration) by placing a fiduciary marker in the area imaged by both systems. In this case, a marker which is visible in the images produced by both imaging modalities must be used. By this method, functional information from SPECT or positron emission tomography can be related to anatomical information provided by magnetic resonance imaging (MRI). Similarly, fiducial points established during MRI can be correlated with brain images generated by magnetoencephalography to localize the source of brain activity.

Ultrasound

Ultrasound representation of Urinary bladder (black butterfly-like shape) and hyperplastic prostate

Medical ultrasound uses high frequency broadband sound waves in the megahertz range that are reflected by tissue to varying degrees to produce (up to 3D) images. This is commonly associated with imaging the fetus in pregnant women. Uses of ultrasound are much broader, however. Other important uses include imaging the abdominal organs, heart, breast, muscles, tendons, arteries and veins. While it may provide less anatomical detail than techniques such as CT or MRI, it has several advantages which make it ideal in numerous situations, in particular that it studies the function of moving structures in real-time, emits no ionizing radiation, and contains speckle that can be used in elastography. Ultrasound is also used as a popular research tool for capturing raw data, that can be made available through an ultrasound research interface, for the purpose of tissue characterization and implementation of new image processing techniques. The concepts of ultrasound differ from other medical imaging modalities in the fact that it is operated by the transmission and receipt of sound waves. The high frequency sound waves are sent into the tissue and depending on the composition of the different tissues; the signal will be attenuated and returned at separate intervals. A path of reflected sound waves in a multilayered structure can be defined by an input acoustic impedance (ultrasound sound wave) and the Reflection and transmission coefficients of the relative structures. It is very safe to use and does not appear to cause any adverse effects. It is also relatively inexpensive and quick to perform. Ultrasound scanners can be taken to critically ill patients in intensive care units, avoiding the danger caused while moving the patient to the radiology department. The real-time moving image obtained can be used to guide drainage and biopsy procedures. Doppler capabilities on modern scanners allow the blood flow in arteries and veins to be assessed.

Elastography

3D tactile image (C) is composed from 2D pressure maps (B) recorded in the process of tissue phantom examination (A).

Elastography is a relatively new imaging modality that maps the elastic properties of soft tissue. This modality emerged in the last two decades. Elastography is useful in medical diagnoses, as elasticity can discern healthy from unhealthy tissue for specific organs/growths. For example, cancerous tumours will often be harder than the surrounding tissue, and diseased livers are stiffer than healthy ones. There are several elastographic techniques based on the use of ultrasound, magnetic resonance imaging and tactile imaging. The wide clinical use of ultrasound elastography is a result of the implementation of technology in clinical ultrasound machines. Main branches of ultrasound elastography include Quasistatic Elastography/Strain Imaging, Shear Wave Elasticity Imaging (SWEI), Acoustic Radiation Force Impulse imaging (ARFI), Supersonic Shear Imaging (SSI), and Transient Elastography. In the last decade a steady increase of activities in the field of elastography is observed demonstrating successful application of the technology in various areas of medical diagnostics and treatment monitoring.

Photoacoustic imaging

Photoacoustic imaging is a recently developed hybrid biomedical imaging modality based on the photoacoustic effect. It combines the advantages of optical absorption contrast with an ultrasonic spatial resolution for deep imaging in (optical) diffusive or quasi-diffusive regime. Recent studies have shown that photoacoustic imaging can be used in vivo for tumor angiogenesis monitoring, blood oxygenation mapping, functional brain imaging, and skin melanoma detection, etc.

Tomography

Basic principle of tomography: superposition free tomographic cross sections S₁ and S₂ compared with the (not tomographic) projected image P

Tomography is the imaging by sections or sectioning. The main such methods in medical imaging are:

• X-ray computed tomography (CT), or Computed Axial Tomography (CAT) scan, is a helical tomography technique (latest generation), which traditionally produces a 2D image of the structures in a thin section of the body. In CT, a beam of X-rays spins around an object being examined and is picked up by sensitive radiation detectors after having penetrated the object from multiple angles. A computer then analyses the information received from the scanner's detectors and constructs a detailed image of the object and its contents using the mathematical principles laid out in the Radon transform. It has a greater ionizing radiation dose burden than projection radiography; repeated scans must be limited to avoid health effects. CT is based on the same principles as X-Ray projections but in this case, the patient is enclosed in a surrounding ring of detectors assigned with 500–1000 scintillation detectors (fourth-generation X-Ray CT scanner geometry). Previously in older generation scanners, the X-Ray beam was paired by a translating source and detector. Computed tomography has almost completely replaced focal plane tomography in X-ray tomography imaging.
• Positron emission tomography (PET) also used in conjunction with computed tomography, PET-CT, and magnetic resonance imaging PET-MRI.
• Magnetic resonance imaging (MRI) commonly produces tomographic images of cross-sections of the body. (See separate MRI section in this article.)

Echocardiography

When ultrasound is used to image the heart it is referred to as an echocardiogram. Echocardiography allows detailed structures of the heart, including chamber size, heart function, the valves of the heart, as well as the pericardium (the sac around the heart) to be seen. Echocardiography uses 2D, 3D, and Doppler imaging to create pictures of the heart and visualize the blood flowing through each of the four heart valves. Echocardiography is widely used in an array of patients ranging from those experiencing symptoms, such as shortness of breath or chest pain, to those undergoing cancer treatments. Transthoracic ultrasound has been proven to be safe for patients of all ages, from infants to the elderly, without risk of harmful side effects or radiation, differentiating it from other imaging modalities. Echocardiography is one of the most commonly used imaging modalities in the world due to its portability and use in a variety of applications. In emergency situations, echocardiography is quick, easily accessible, and able to be performed at the bedside, making it the modality of choice for many physicians.

Functional near-infrared spectroscopy

FNIR Is a relatively new non-invasive imaging technique. NIRS (near infrared spectroscopy) is used for the purpose of functional neuroimaging and has been widely accepted as a brain imaging technique.

Magnetic particle imaging

Using superparamagnetic iron oxide nanoparticles, magnetic particle imaging (MPI) is a developing diagnostic imaging technique used for tracking superparamagnetic iron oxide nanoparticles. The primary advantage is the high sensitivity and specificity, along with the lack of signal decrease with tissue depth. MPI has been used in medical research to image cardiovascular performance, neuroperfusion, and cell tracking.

In pregnancy

CT scanning (volume rendered in this case) confers a radiation dose to the developing fetus.

Medical imaging may be indicated in pregnancy because of pregnancy complications, a pre-existing disease or an acquired disease in pregnancy, or routine prenatal care. Magnetic resonance imaging (MRI) without MRI contrast agents as well as obstetric ultrasonography are not associated with any risk for the mother or the fetus, and are the imaging techniques of choice for pregnant women. Projectional radiography, CT scan and nuclear medicine imaging result some degree of ionizing radiation exposure, but have with a few exceptions much lower absorbed doses than what are associated with fetal harm. At higher dosages, effects can include miscarriage, birth defects and intellectual disability.

Maximizing imaging procedure use

The amount of data obtained in a single MR or CT scan is very extensive. Some of the data that radiologists discard could save patients time and money, while reducing their exposure to radiation and risk of complications from invasive procedures. Another approach for making the procedures more efficient is based on utilizing additional constraints, e.g., in some medical imaging modalities one can improve the efficiency of the data acquisition by taking into account the fact the reconstructed density is positive.

Creation of three-dimensional images

Volume rendering techniques have been developed to enable CT, MRI and ultrasound scanning software to produce 3D images for the physician. Traditionally CT and MRI scans produced 2D static output on film. To produce 3D images, many scans are made and then combined by computers to produce a 3D model, which can then be manipulated by the physician. 3D ultrasounds are produced using a somewhat similar technique. In diagnosing disease of the viscera of the abdomen, ultrasound is particularly sensitive on imaging of biliary tract, urinary tract and female reproductive organs (ovary, fallopian tubes). As for example, diagnosis of gallstone by dilatation of common bile duct and stone in the common bile duct. With the ability to visualize important structures in great detail, 3D visualization methods are a valuable resource for the diagnosis and surgical treatment of many pathologies. It was a key resource for the famous, but ultimately unsuccessful attempt by Singaporean surgeons to separate Iranian twins Ladan and Laleh Bijani in 2003. The 3D equipment was used previously for similar operations with great success.

Other proposed or developed techniques include:

• Diffuse optical tomography
• Elastography
• Electrical impedance tomography
• Optoacoustic imaging
• Ophthalmology
  • A-scan
  • B-scan
  • Corneal topography
  • Optical coherence tomography
  • Scanning laser ophthalmoscopy

Some of these techniques are still at a research stage and not yet used in clinical routines.

Non-diagnostic imaging

Neuroimaging has also been used in experimental circumstances to allow people (especially disabled persons) to control outside devices, acting as a brain computer interface.

Many medical imaging software applications are used for non-diagnostic imaging, specifically because they don't have an FDA approval and not allowed to use in clinical research for patient diagnosis. Note that many clinical research studies are not designed for patient diagnosis anyway.

Archiving and recording

Used primarily in ultrasound imaging, capturing the image produced by a medical imaging device is required for archiving and telemedicine applications. In most scenarios, a frame grabber is used in order to capture the video signal from the medical device and relay it to a computer for further processing and operations.

DICOM

The Digital Imaging and Communication in Medicine (DICOM) Standard is used globally to store, exchange, and transmit medical images. The DICOM Standard incorporates protocols for imaging techniques such as radiography, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and radiation therapy.

Compression of medical images

Medical imaging techniques produce very large amounts of data, especially from CT, MRI and PET modalities. As a result, storage and communications of electronic image data are prohibitive without the use of compression. JPEG 2000 image compression is used by the DICOM standard for storage and transmission of medical images. The cost and feasibility of accessing large image data sets over low or various bandwidths are further addressed by use of another DICOM standard, called JPIP, to enable efficient streaming of the JPEG 2000 compressed image data.

Medical imaging in the cloud

There has been growing trend to migrate from on-premise PACS to a cloud-based PACS. A recent article by Applied Radiology said, "As the digital-imaging realm is embraced across the healthcare enterprise, the swift transition from terabytes to petabytes of data has put radiology on the brink of information overload. Cloud computing offers the imaging department of the future the tools to manage data much more intelligently."

Use in pharmaceutical clinical trials

Medical imaging has become a major tool in clinical trials since it enables rapid diagnosis with visualization and quantitative assessment.

A typical clinical trial goes through multiple phases and can take up to eight years. Clinical endpoints or outcomes are used to determine whether the therapy is safe and effective. Once a patient reaches the endpoint, he or she is generally excluded from further experimental interaction. Trials that rely solely on clinical endpoints are very costly as they have long durations and tend to need large numbers of patients.

In contrast to clinical endpoints, surrogate endpoints have been shown to cut down the time required to confirm whether a drug has clinical benefits. Imaging biomarkers (a characteristic that is objectively measured by an imaging technique, which is used as an indicator of pharmacological response to a therapy) and surrogate endpoints have shown to facilitate the use of small group sizes, obtaining quick results with good statistical power.

Imaging is able to reveal subtle change that is indicative of the progression of therapy that may be missed out by more subjective, traditional approaches. Statistical bias is reduced as the findings are evaluated without any direct patient contact.

Imaging techniques such as positron emission tomography (PET) and magnetic resonance imaging (MRI) are routinely used in oncology and neuroscience areas,. For example, measurement of tumour shrinkage is a commonly used surrogate endpoint in solid tumour response evaluation. This allows for faster and more objective assessment of the effects of anticancer drugs. In Alzheimer's disease, MRI scans of the entire brain can accurately assess the rate of hippocampal atrophy, while PET scans can measure the brain's metabolic activity by measuring regional glucose metabolism, and beta-amyloid plaques using tracers such as Pittsburgh compound B (PiB). Historically less use has been made of quantitative medical imaging in other areas of drug development although interest is growing.

An imaging-based trial will usually be made up of three components:

1. A realistic imaging protocol. The protocol is an outline that standardizes (as far as practically possible) the way in which the images are acquired using the various modalities (PET, SPECT, CT, MRI). It covers the specifics in which images are to be stored, processed and evaluated.
2. An imaging centre that is responsible for collecting the images, perform quality control and provide tools for data storage, distribution and analysis. It is important for images acquired at different time points are displayed in a standardised format to maintain the reliability of the evaluation. Certain specialised imaging contract research organizations provide end to end medical imaging services, from protocol design and site management through to data quality assurance and image analysis.
3. Clinical sites that recruit patients to generate the images to send back to the imaging centre.

Shielding

Lead is the main material used for radiographic shielding against scattered X-rays.

In magnetic resonance imaging, there is MRI RF shielding as well as magnetic shielding to prevent external disturbance of image quality.

Privacy protection

Medical imaging are generally covered by laws of medical privacy. For example, in the United States the Health Insurance Portability and Accountability Act (HIPAA) sets restrictions for health care providers on utilizing protected health information, which is any individually identifiable information relating to the past, present, or future physical or mental health of any individual. While there has not been any definitive legal decision in the matter, at least one study has indicated that medical imaging may contain biometric information that can uniquely identify a person, and so may qualify as PHI.

The UK General Medical Council's ethical guidelines indicate that the Council does not require consent prior to secondary uses of X-ray images.

Industry

Organizations in the medical imaging industry include manufacturers of imaging equipment, freestanding radiology facilities, and hospitals.

The global market for manufactured devices was estimated at $5 billion in 2018. Notable manufacturers as of 2012 included Fujifilm, GE, Siemens Healthineers, Philips, Shimadzu, Toshiba, Carestream Health, Hitachi, Hologic, and Esaote. In 2016, the manufacturing industry was characterized as oligopolistic and mature; new entrants included in Samsung and Neusoft Medical.

In the United States, as estimate as of 2015 places the US market for imaging scans at about $100b, with 60% occurring in hospitals and 40% occurring in freestanding clinics, such as the RadNet chain.

Copyright

United States

As per chapter 300 of the Compendium of U.S. Copyright Office practices, "the Office will not register works produced by a machine or mere mechanical process that operates randomly or automatically without any creative input or intervention from a human author." including "Medical imaging produced by x-rays, ultrasounds, magnetic resonance imaging, or other diagnostic equipment." This position differs from the broad copyright protections afforded to photographs. While the Copyright Compendium is an agency statutory interpretation and not legally binding, courts are likely to give deference to it if they find it reasonable. Yet, there is no U.S. federal case law directly addressing the issue of the copyrightability of x-ray images.

Derivatives

In a derivative of a medical image created in the U.S., added annotations and explanations may be copyrightable, but the medical image itself remains Public Domain.

An extensive definition of the term derivative work is given by the United States Copyright Act in 17 U.S.C. § 101:

A “derivative work” is a work based upon one or more preexisting works, such as a translation... art reproduction, abridgment, condensation, or any other form in which a work may be recast, transformed, or adapted. A work consisting of editorial revisions, annotations, elaborations, or other modifications which, as a whole, represent an original work of authorship, is a “derivative work”.

17 U.S.C. § 103(b) provides:

The copyright in a compilation or derivative work extends only to the material contributed by the author of such work, as distinguished from the preexisting material employed in the work, and does not imply any exclusive right in the preexisting material. The copyright in such work is independent of, and does not affect or enlarge the scope, duration, ownership, or subsistence of, any copyright protection in the preexisting material.

Germany

In Germany, X-ray images as well as MRI, medical ultrasound, PET and scintigraphy images are protected by (copyright-like) related rights or neighbouring rights. This protection does not require creativity (as would be necessary for regular copyright protection) and lasts only for 50 years after image creation, if not published within 50 years, or for 50 years after the first legitimate publication. The letter of the law grants this right to the "Lichtbildner", i.e. the person who created the image. The literature seems to uniformly consider the medical doctor, dentist or veterinary physician as the rights holder, which may result from the circumstance that in Germany many x-rays are performed in ambulatory setting

United Kingdom

Medical images created in the United Kingdom will normally be protected by copyright due to "the high level of skill, labour and judgement required to produce a good quality x-ray, particularly to show contrast between bones and various soft tissues". The Society of Radiographers believe this copyright is owned by employer (unless the radiographer is self-employed—though even then their contract might require them to transfer ownership to the hospital). This copyright owner can grant certain permissions to whoever they wish, without giving up their ownership of the copyright. So the hospital and its employees will be given permission to use such radiographic images for the various purposes that they require for medical care. Physicians employed at the hospital will, in their contracts, be given the right to publish patient information in journal papers or books they write (providing they are made anonymous). Patients may also be granted permission to "do what they like with" their own images.

Sweden

The Cyber Law in Sweden states: "Pictures can be protected as photographic works or as photographic pictures. The former requires a higher level of originality; the latter protects all types of photographs, also the ones taken by amateurs, or within medicine or science. The protection requires some sort of photographic technique being used, which includes digital cameras as well as holograms created by laser technique. The difference between the two types of work is the term of protection, which amounts to seventy years after the death of the author of a photographic work as opposed to fifty years, from the year in which the photographic picture was taken."

Medical imaging may possibly be included in the scope of "photography", similarly to a U.S. statement that "MRI images, CT scans, and the like are analogous to photography."

Health information technology

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Health_information_technology

Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on an often-cited 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands – the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system. According to a 2006 report by the Agency for Healthcare Research and Quality, in an ideal world, broad and consistent utilization of HIT would:

• improve health care quality or effectiveness
• increase health care productivity or efficiency
• prevent medical errors and increase health care accuracy and procedural correctness
• reduce health care costs
• increase administrative efficiencies and healthcare work processes
• decrease paperwork and unproductive or idle work time
• extend real-time communications of health informatics among health care professionals
• expand access to affordable care

Risk-based regulatory framework for health IT

September 4, 2013 the Health IT Policy Committee (HITPC) accepted and approved recommendations from the Food and Drug Administration Safety and Innovation Act (FDASIA) working group for a risk-based regulatory framework for health information technology. The Food and Drug Administration (FDA), the Office of the National Coordinator for Health IT (ONC), and Federal Communications Commission (FCC) kicked off the FDASIA workgroup of the HITPC to provide stakeholder input into a report on a risk-based regulatory framework that promotes safety and innovation and reduces regulatory duplication, consistent with section 618 of FDASIA. This provision permitted the Secretary of Health and Human Services (HHS) to form a workgroup in order to obtain broad stakeholder input from across the health care, IT, patients and innovation spectrum. The FDA, ONC, and FCC actively participated in these discussions with stakeholders from across the health care, IT, patients and innovation spectrum.

HIMSS Good Informatics Practices-GIP is aligned with FDA risk-based regulatory framework for health information technology. GIP development began in 2004 developing risk-based IT technical guidance. Today the GIP peer-review and published modules are widely used as a tool for educating Health IT professionals.

Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including:

• early detection of infectious disease outbreaks around the country;
• improved tracking of chronic disease management;
• evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared

According to an article published in the International Journal of Medical Informatics, health information sharing between patients and providers helps to improve diagnosis, promotes self care, and patients also know more information about their health. The use of electronic medical records (EMRs) is still scarce now but is increasing in Canada, American and British primary care. Healthcare information in EMRs are important sources for clinical, research, and policy questions. Health information privacy (HIP) and security has been a big concern for patients and providers. Studies in Europe evaluating electronic health information poses a threat to electronic medical records and exchange of personal information. Moreover, software's traceability features allow the hospitals to collect detailed information about the preparations dispensed, creating a database of every treatment that can be used for research purposes.

Concepts and definitions

Health information technology (HIT) is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, health data, and knowledge for communication and decision making". Technology is a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT.

Informatics refers to the science of information, the practice of information processing, and the engineering of information systems. Informatics underlies the academic investigation and practitioner application of computing and communications technology to healthcare, health education, and biomedical research. Health informatics refers to the intersection of information science, computer science, and health care. Health informatics describes the use and sharing of information within the healthcare industry with contributions from computer science, mathematics, and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Medical informatics, nursing informatics, public health informatics, pharmacy informatics, and translational bioinformatics are subdisciplines that inform health informatics from different disciplinary perspectives. The processes and people of concern or study are the main variables.

Implementation

The Institute of Medicine's (2001) call for the use of electronic prescribing systems in all healthcare organizations by 2010 heightened the urgency to accelerate United States hospitals' adoption of CPOE systems. In 2004, President Bush signed an Executive Order titled the President's Health Information Technology Plan, which established a ten-year plan to develop and implement electronic medical record systems across the US to improve the efficiency and safety of care. According to a study by RAND Health, the US healthcare system could save more than $81 billion annually, reduce adverse healthcare events and improve the quality of care if it were to widely adopt health information technology.

The American Recovery and Reinvestment Act, signed into law in 2009 under the Obama Administration, has provided approximately $19 billion in incentives for hospitals to shift from paper to electronic medical records. Meaningful Use, as a part of the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) was the incentive that included over $20 billion for the implementation of HIT alone, and provided further indication of the growing consensus regarding the potential salutary effect of HIT. The American Recovery and Reinvestment Act has set aside $2 billion which will go towards programs developed by the National Coordinator and Secretary to help healthcare providers implement HIT and provide technical assistance through various regional centers. The other $17 billion in incentives comes from Medicare and Medicaid funding for those who adopt HIT before 2015. Healthcare providers who implement electronic records can receive up to $44,000 over four years in Medicare funding and $63,750 over six years in Medicaid funding. The sooner that healthcare providers adopt the system, the more funding they receive. Those who do not adopt electronic health record systems before 2015 do not receive any federal funding.

While electronic health records have potentially many advantages in terms of providing efficient and safe care, recent reports have brought to light some challenges with implementing electronic health records. The most immediate barriers for widespread adoption of this technology have been the high initial cost of implementing the new technology and the time required for doctors to train and adapt to the new system. There have also been suspected cases of fraudulent billing, where hospitals inflate their billings to Medicare. Given that healthcare providers have not reached the deadline (2015) for adopting electronic health records, it is unclear what effects this policy will have long term.

One approach to reducing the costs and promoting wider use is to develop open standards related to EHRs. In 2014 there was widespread interest in a new HL7 draft standard, Fast Healthcare Interoperability Resources (FHIR), which is designed to be open, extensible, and easier to implement, benefiting from modern web technologies.

Types of technology

In a 2008 study about the adoption of technology in the United States, Furukawa, and colleagues classified applications for prescribing to include electronic medical records (EMR), clinical decision support (CDS), and computerized physician order entry (CPOE). They further defined applications for dispensing to include bar-coding at medication dispensing (BarD), robot for medication dispensing (ROBOT), and automated dispensing machines (ADM). They defined applications for administration to include electronic medication administration records (eMAR) and bar-coding at medication administration (BarA or BCMA).

Electronic health record (EHR)

US medical groups' adoption of EHR (2005)

Although the electronic health record (EHR), previously known as the electronic medical record (EMR), is frequently cited in the literature, there is no consensus about the definition. However, there is consensus that EMRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures. Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient. Advances in health informatics and widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise (see chart to right). Since 2002, the National Health Service of the United Kingdom has placed emphasis on introducing computers into healthcare. As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT), the NHS component of which is known as the "Connecting for Health Programme". However, recent surveys have shown physicians' deficiencies in understanding the patient safety features of the NPfIT-approved software.

A main problem in HIT adoption is mainly seen by physicians, an important stakeholder to the process of EHR. The Thorn et al. article, elicited that emergency physicians noticed that health information exchange disrupted workflow and was less desirable to use, even though the main goal of EHR is improving coordination of care. The problem was seen that exchanges did not address the needs of end users, e.g. simplicity, user-friendly interface, and speed of systems. The same finding was seen in an earlier article with the focus on CPOE and physician resistance to its use, Bhattacherjee et al.

One opportunity for EHRs is to utilize natural language processing for searches. One systematic review of the literature found that searching and analyzing notes and text that would otherwise be inaccessible for review could be accessed through increasing collaboration between software developers and end-users of natural language processing tools within EHRs.

Clinical point of care technology

Computerized provider (physician) order entry

Prescribing errors are the largest identified source of preventable errors in hospitals. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay. Computerized provider order entry (CPOE), also called computerized physician order entry, can reduce total medication error rates by 80%, and adverse (serious with harm to patient) errors by 55%. A 2004 survey by found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years. In addition to electronic prescribing, a standardized bar code system for dispensing drugs could prevent a quarter of drug errors. Consumer information about the risks of the drugs and improved drug packaging (clear labels, avoiding similar drug names and dosage reminders) are other error-proofing measures. Despite ample evidence of the potential to reduce medication errors, competing systems of barcoding and electronic prescribing have slowed adoption of this technology by doctors and hospitals in the United States, due to concern with interoperability and compliance with future national standards. Such concerns are not inconsequential; standards for electronic prescribing for Medicare Part D conflict with regulations in many US states. And, aside from regulatory concerns, for the small-practice physician, utilizing CPOE requires a major change in practice work flow and an additional investment of time. Many physicians are not full-time hospital staff; entering orders for their hospitalized patients means taking time away from scheduled patients.

Technological innovations, opportunities, and challenges

One of the rapidly growing areas of health care innovation lies in the advanced use of data science and machine learning. The key opportunities here are:

• health monitoring and diagnosis
• medical treatment and patient care
• pharmaceutical research and development
• clinic performance optimization

Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the Institute of Medicine (2000) report. The follow-up IOM (2004) report, Crossing the quality chasm: A new health system for the 21st century, advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. However, many system implementations have experienced costly failures. Furthermore, there is evidence that CPOE may actually contribute to some types of adverse events and other medical errors. For example, the period immediately following CPOE implementation resulted in significant increases in reported adverse drug events in at least one study, and evidence of other errors have been reported. Collectively, these reported adverse events describe phenomena related to the disruption of the complex adaptive system resulting from poorly implemented or inadequately planned technological innovation.

Technological iatrogenesis

Technology may introduce new sources of error. Technologically induced errors are significant and increasingly more evident in care delivery systems. Terms to describe this new area of error production include the label technological iatrogenesis for the process and e-iatrogenic for the individual error. The sources for these errors include:

• prescriber and staff inexperience may lead to a false sense of security; that when technology suggests a course of action, errors are avoided.
• shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses.
• CPOE and automated drug dispensing were identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.
• irrelevant or frequent warnings can interrupt work flow

Healthcare information technology can also result in iatrogenesis if design and engineering are substandard, as illustrated in a 14-part detailed analysis done at the University of Sydney.

Revenue Cycle HIT

The HIMSS Revenue Cycle Improvement Task Force was formed to prepare for the IT changes in the U.S. (e.g. the American Recovery and Reinvestment Act of 2009 (HITECH), Affordable Care Act, 5010 (electronic exchanges), ICD-10). An important change to the revenue cycle is the international classification of diseases (ICD) codes from 9 to 10. ICD-9 codes are set up to use three to five alphanumeric codes that represent 4,000 different types of procedures, while ICD-10 uses three to seven alphanumeric codes increasing procedural codes to 70,000. ICD-9 was outdated because there were more codes than procedures available, and to document for procedures without an ICD-9 code, unspecified codes were utilized which did not fully capture the procedures or the work involved in turn affecting reimbursement. Hence, ICD-10 was introduced to simplify the procedures with unknown codes and unify the standards closer to world standards (ICD-11). One of the main parts of Revenue Cycle HIT is charge capture, it utilizes codes to capture costs for reimbursements from different payers, such as CMS.

International comparisons through HIT

International health system performance comparisons are important for understanding health system complexities and finding better opportunities, which can be done through health information technology. It gives policy makers the chance to compare and contrast the systems through established indicators from health information technology, as inaccurate comparisons can lead to adverse policies.