Review Questions for MRI

Acknowledgements

First, I must thank God for the knowledge to complete this educational offering. Second, and always, I need to thank my family, friends, and my loving husband, Scott, for their support. Next, I would like to include within my thank you list all of hard working personnel, colleagues, and friends from Imaging Education Associates (IEA) including: my associates PJ, Pat R, Amy; my faculty and professional colleagues Joy, Wil, Barb, and the IEA faculty. Finally, I must thank all of the technologists, radiologists, nurses, and corporate personnel that I have had the opportunity to teach. In fact, teaching these healthcare professionals has had a boomerang effect whereby they have actually taught me! It also goes without saying that it has been my privilege to have worked with Bill Faulkner on this and many other projects for over 25 years. I am honored to have been a part of your professional lives. May God bless you as you study for your boards!

Candi

I suppose that with a name like William Faulkner, it was inevitable that it should wind up on the front of a book. That said, since I am William Faulkner, Jr, I want to thank my parents not only for the name, but also for the support, encouragement, and love I still receive. I also want to thank and acknowledge my wife, Tricia, our daughter, Amber, her husband Ricky, and now our beautiful and wonderful granddaughter Zooey Ann for their love and support. (You can only imagine what I’m like to live with.) It would be remiss if I did not thank the unequaled group of radiologists and technologists with whom I have the pleasure of working with over the years. (You can only imagine what I’m like to work with.) In particular, I want to thank the late Dr James Crawley, who offered me my first job in MRI, and Dr Don Mills who then had to work with me while I began learning MRI. Dr Mills gave his time and energy to offer me an education that could not be given a price; I am eternally grateful. I have truly been blessed to meet and work with many wonderful professionals over the course of my career. It should be obvious that my participation in this book would not have been possible without having the great fortune to meet and work with Candi Roth. Every job has its ups and downs and we are not always happy. However, because of these great people and many others, I can say that l have always enjoyed my career. Finally, I want to thank God, for without Him, nothing would be possible.

Bill

Introduction

Magnetic resonance imaging (MRI) is a diagnostic imaging modality that is used to evaluate anatomic structures and pathologic conditions within the body. MRI is known for its exquisite demonstration of soft tissues within the body. For this reason, the majority of MR imaging is performed for the evaluation of hydrogen. Hydrogen atoms behave like a microscopic magnet when exposed to the strong magnetic field associated with MR imaging. For this reason, hydrogen is said to be MR active. In addition, the human body is approximately 75% water. The combination of the relative abundance of hydrogen within the body and the magnetic characteristics of the hydrogen atom explains the utilization of hydrogen for MR imaging. Although other substances can be evaluated with magnetic resonance, hydrogen is typically preferred. It is the hydrogen in water (H2O or two hydrogens bound to one oxygen) and the hydrogen in fat (CH3 or three hydrogens bound to one carbon) that represent the substances typically evaluated by magnetic resonance. This evaluation can be provided by imaging (known as magnetic resonance imaging – MRI) and/or magnetic resonance spectroscopy (MRS). MRI and/or MRS can be performed on a specimen in vivo (within the body) or in vitro (outside the body, e.g. within a test tube).

To acquire MR or MRS images, a complex combination of hardware and software components are required. As the name implies, the MR imager consists of several different types of magnets. Magnets used in MRI include permanent magnets and electromagnets. Electromagnets include resistive and superconducting magnets. Resistive magnets can be used to create the main magnetic field and/or other magnetic system components. Permanent, resistive, and superconducting magnets can create various types of magnetic fields: static magnetic fields and time-varying magnetic fields. Magnets that produce static magnetic fields create magnetic fields that are unchanging. The static magnetic field associated with the main magnet is known as the B0 field. Magnets that produce time-varying magnetic fields (TVMF) create magnetic fields that that vary or change over time. TVMF are associated with RF fields and/or gradient fields. Oscillating magnetic fields, such as the radiofrequency (RF) field, are employed during imaging acquisition, known as excitation. This secondary (oscillating) magnetic field is known as the B1 field. TVMF are also associated with magnetic fields that are switched on and off over time. Gradient magnetic fields produce a linear gradation or slope in the magnetic field that is switched on and off during image acquisition. The primary function of gradient magnetic fields is spatial encoding, allowing for various imaging planes (or views) to be acquired without moving the patient.

Various magnetic components such as RF and gradients are pulsed on and off during MR image acquisition. The sequence of these pulses determines the type of image that is acquired during MR imaging. This is known as a pulse sequence. Computers are programmed to direct the various magnets within the MR imager to coordinate their usage during MR image acquisition. MR images can be acquired with various types of imaging planes (views) and/or with different types of image contrast (known as T1-, T2-, or proton density-weighted images). For example, images can be acquired whereby the fat is bright and water dark (T1-weighted image), or by changing imaging parameters (technique factors), images can be acquired whereby the water is bright and fat darker (T2-weighted image). Each patient is evaluated with several different types of images (various imaging planes or views), and/or acquisitions with different image contrast (different image weighting). The combination of images acquired for a patient is known as a protocol. The protocol consists of images acquired with various views or planes (sagittal, axial, coronal, and/or oblique) with various contrast or weighting (T1-, T2-, proton density-weighting), depending upon the anatomy and pathology to be imaged.

Each type of magnet within the MR imager functions differently. For this reason, each MR system component has unique safety considerations. To date there are no known, long-term biologic effects associated with exposure to the magnetic field. The safety consideration associated with the static magnetic field (specifically the stray field or fringe field located outside the MR imager) is generally associated with forces (translational force and rotational force) resulting in projectiles and torque. Even though MR imaging does not use ionizing radiation, imaging does require radiofrequency (RF) energy that is considered to be low energy or nonionizing radiation. The Food and Drug Administration (FDA) imposes limits on exposure to various components of the MR imager, including the static field, RF field, and gradient magnetic field. Because of these various and unique magnetic field effects, patient care and safety in the MR environment is critical.

The technologist who operates the MR imager should understand all of the aspects of MR imaging. These aspects include: the MR system components (hardware or instrumentation); safety associated with these system components; the substances that can be imaged by MR (hydrogen and other elements); the method by which MR images are acquired (imaging planes and image weighting); and the anatomy (and pathology) to be imaged. In order to evaluate the knowledge of the MRI technologist, the American Registry for Radiologic technologists (ARRT) has developed an advanced-level examination in MRI. This has been divided into four categories:

Patient care in MRI (general patient care and MRI safety)

Imaging procedures (cross-sectional anatomy and clinical applications for MRI and contrast-enhanced MR)

Data acquisition and processing (pulse sequences, parameters, and options for MR image formation)

Physical principles of image formation (MR instrumentation and fundamentals for image acquisition).

To provide the technologist with information about the advanced-level examination in MRI, the ARRT has provided a document known as the content specifications (or content specs). This outlines the topics and subtopics that will be tested in the examination. Essentially, the content specifications hint as to the categories of questions (topics), the information for the questions (subtopics), and the number of questions (per category) that will be included in the advanced-level examination for MRI. The table of contents (and the outline below it) reflects the topics and subtopics associated with the content specs. These documents are updated periodically; therefore, it is always recommended to visit the ARRT website for the most current version of the content specifications (www.arrt.org).

This book is designed to provide the technologist with questions associated with the content specifications provided by the ARRT. This book contains four parts that match the four main topics associated with the content specs. Within each part are subtopics to help technologist prepare for the MRI Boards.

Part A

Patient Care in MRI

Bioeffects, Safety, and Patient Care

Introduction

To date, there are no known long-term biological effects associated with magnetic resonance imaging (MRI). However, there are some aspects of MRI that could potentially result in irreversible and devastating outcomes for the patients and operators. These aspects include the static magnetic fields (potential projectiles and torque), the time-varying magnetic fields associated with the magnetic field gradients (peripheral nerve stimulation and acoustic noise), and the radiofrequency field (thermal injuries, heating, and burns). Part A will provide practice questions to prepare for the safety component of the MRI Boards.

MR image acquisition is very different from radiographic imaging, nuclear medicine, and sonography. The instrumentation used and the physical principles of image formation are unique for MR imaging. For these reasons, safety considerations for patients and personnel in MRI are also unique to the modality. For example, the strength of the magnetic field in the majority of MR imagers is so high (1.5 Tesla or 10 000 Gauss) that terminal velocity of a paperclip is up to 40 miles per hour. A simple paperclip would hit the side of the MR scanner at 40 mph! Furthermore, the velocity with which a metallic object (such as the paperclip) flies toward the scanner is determined by the mass of the object and the distance from the scanner (in addition to the type of metal and strength of the magnetic field). One can only imagine the damage that could be done if an oxygen tank was inadvertently brought into the MR scan room. MR safety can be a life-or-death scenario. Part A will provide practice questions about projectiles (flying metallic objects) as well as other life-threatening safety considerations in MRI.

The Safety Component of the MRI Boards (Post Primary Examination and/or Primary Examination)

Beginning in 1995, the advanced-level examination in MRI was available as a post primary examination. At that time, the post primary examination was only available for the registered technologist in radiography (RT (R) ). To qualify for the MRI (post primary) examination, the technologist had to have a primary certification. The primary examination could include: the radiography examination (RT (R) ), the nuclear medicine examination (RT (N) ), and the radiation therapy examination (RT (T) ) or the sonography examination RT (S) ). The assumption was that the technologist had already learned (and had been tested on) subjects such as general patient care during their primary examination. Therefore, when the MRI Boards were only available as a post primary examination, the safety category of the MRI boards included only MRI safety considerations.

Toward the fall of 2005 the ARRT announced that "the technologist need not be an RT to qualify for the advanced level examination in MRI. In January 2006, the ARRT defined the statement whereby one could qualify for the exam as a primary examination or a post primary examination. To qualify for the post primary examination, the technologist must have a primary certification (explained above). To qualify for the primary examination, the student must attend an accredited MRI educational program. This program can resemble a radiography program, whereby the radiation physics is replaced by MR physics; radiation technique is replaced by MRI scan parameters; and patient care and radiation safety is replaced by patient care and MR safety. Today the MRI Boards are available as a post primary examination (for the RT) and also as a primary examination" (for the non-RT). For this reason, the safety category within the advanced-level examination in MRI includes not only MRI safety but also general patient care.

There are several types of examination for the MRI technologist in North America, including the ARRT examination, the ARMRIT examination, and the CAMRT examination. Each examination has safety questions and these make up roughly 15–20% of the examination.

Part A offers review questions and answers that relate to general patient care and MRI safety considerations. Even though the questions are set with the guidelines from the content specifications from North American Boards in mind, MRI safety is critical for healthcare workers in the MR environment worldwide!

General Patient Care

1. Legal and ethical principles

a. Confirmation of exam requisition

b. Legal issues

c. Patient’s rights

d. ARRT standard of ethics

2. Patient assessment, monitoring, and management

a. Routine monitoring

b. Emergency response

c. Patient transfer and body mechanics

d. Assisting patients with medical equipment

3. Interpersonal communications

a. Modes of communication

b. Challenges in communication

c. Patient education

d. Medical terminology

4. Infection control

a. Terminology and basic concepts

b. Cycle of infection

c. Standard precautions (general patient contact)

d. Additional or transmission-based precautions (e.g. hepatitis B, HIV, tuberculosis)

e. Disposal of contaminated materials

Legal and Ethical Principles

It is important for the MRI technologist to understand legal and ethical issues associated with MR imaging. This information is critical as deviation from these standards can lead to unsafe patient practices, lawsuits, and/or termination of employment. Questions on legal and ethical principles are drawn from the following subject areas:

a. Confirmation of exam requisition

i. Verification of patient identification

ii. Comparison of request to clinical indications

b. Legal issues

i. Common terminology (e.g. negligence, malpractice)

ii. Legal doctrines (e.g. respondeat superior, res ipsa loquitur)

c. Patient’s rights

i. Informed consent (written, oral, implied)

ii. Confidentiality (HIPAA)

iii. Patient’s Bill of Rights (e.g. privacy, access to information, healthcare proxy, research participation)

d. Standard of ethics

i. ARRT

ii. CAMRT

iii. ARMRIT

Questions 1–29 concern legal and ethical principles.

Patient Assessment, Monitoring, and Management

This category has been modified from the original content specifications and includes patient management information. Questions on patient assessment, monitoring, and assessment are drawn from the following subject areas:

a. Routine monitoring

i. Vital signs

ii. Physical signs and symptoms

iii. Sedated patients

iv. Claustrophobic patients

b. Emergency response

i. Reactions to contrast

ii. Other allergic reactions (e.g. latex)

iii. Cardiac/respiratory arrest (CPR)

iv. Physical injury, trauma, or RF burn

v. Other medical disorders (e.g. seizures, diabetic reactions)

vi. Life-threatening situations (e.g. quench, projectiles)

c. Patient transfer and body mechanics

d. Assisting patients with medical equipment

i. Implantable devices (e.g. infusion catheters, pumps, pacemakers, others)

ii. Oxygen delivery systems

iii. Other (e.g. nasogastric tubes, urinary catheters)

Questions 30–104 concern patient assessment, monitoring, and management.

Interpersonal Communications

Since the advanced-level examination offered by the ARRT is now available as a primary examination (for the person who attended an accredited MRI school) or a post primary examination [for the technologist who first studied a primary modality such as radiography RT (R), or nuclear medicine RT (N), or radiation therapy RT (T) ], new patient care information has been added to the content specifications. Questions on communication are drawn from the following subject areas:

a. Modes of communication

i. Verbal, written

ii. Nonverbal (e.g. eye contact, touching)

b. Challenges in communication

i. Patient characteristics (e.g. cultural factors, physical or emotional status)

ii. Strategies to improve understanding

c. Patient education

i. Explanation of procedure (e.g. risks, benefits)

ii. Follow-up instructions

iii. Referral to other services

d. Medical terminology

Questions 105–114 concern interpersonal communications.

Infection Control

Since the advanced-level examination offered by the ARRT is now available as a primary examination (for the person who attended an accredited MRI school) or a post primary examination [for the technologist who first studied a primary modality such as radiography RT (R), or nuclear medicine RT (N), or radiation therapy RT (T) ], new patient care information has been added to the content specifications. Questions on infection control are drawn from the following subject areas:

a. Terminology and basic concepts

i. Types of asepsis

ii. Sterile technique

iii. Pathogens (e.g. fomites, vehicles, vectors)

iv. Nosocomial infections

b. Cycle of infection

i. Pathogen

ii. Source or reservoir of infection